Health Issues in Chinese Contexts [1 ed.] 9781612093857, 9781606926901

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Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved. Health Issues in Chinese Contexts, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook Central,

Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved. Health Issues in Chinese Contexts, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook Central,

Health Issues in Chinese Contexts Series

HEALTH ISSUES IN CHINESE CONTEXTS VOLUME 1

Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved.

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, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook Central,

Health Issues in Chinese Contexts Series

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Health Issues in Chinese Contexts Volume 1 Zenobia C. Y. Chan (Editor) 2009. 978-1-60692-690-1

Health Issues in Chinese Contexts, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook Central,

Health Issues in Chinese Contexts Series

HEALTH ISSUES IN CHINESE CONTEXTS VOLUME 1

ZENOBIA C. Y. CHAN

Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved.

EDITOR

Nova Science Publishers, Inc. New York

Health Issues in Chinese Contexts, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook Central,

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.

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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.

ISBN 978-1-61209-385-7 (E-Book)

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

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CONTENTS About the Editor

vii

Preface

ix

Chapter 1

Chapter 2

Chapter 3

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Chapter 4

Exploratory Study of the Strain on Co-Resident Female Spouses of Male Patients Suffering from Cerebrovascular Accident Mavis Tong and Zenobia C. Y. Chan

1

Influential Factors and Attitudes towards Healthful and Unhealthful Beverages for Adolescents in Hong Kong: A Focus Group Study Ivy Chan and Zenobia C. Y. Chan

27

An Exploratory Study on Working Overtime in a Private Company and Practising a Healthful Diet Ida N. K. Lau and Zenobia C. Y. Chan

43

Stressors among Female Patients Undergoing Thoracic Surgery and Methods of Pre-Operative Education to Reduce Their Stressors: Ten Case Studies from Hong Kong S. H. Fok and Zenobia C. Y. Chan

Chapter 5

Nursing Crisis Management: Fire Safety in Operating Theatres Yvonne Y. Wong and Zenobia C. Y. Chan

Chapter 6

Discussion of Medical Leadership Styles and Roles for a Community Geriatric Consultant Julina H.T. Lee and Zenobia C. Y. Chan

67 93

109

Chapter 7

Students’ Views on Health Promotion Zenobia C. Y. Chan

119

Chapter 8

A Call for Autobiographical Writings by Health Care Researchers Zenobia C. Y. Chan

123

Chapter 9

The Promotion of a Healthful Diet among Male Red Minibuse (RMBs) Drivers in Kwun Tong Mandy Y. M. Kwan and Zenobia C. Y. Chan

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127

vi

Contents

Chapter 10

Fall Prevention Community Program for the Elders in Hong Kong S. K. Cheng and Zenobia C. Y. Chan

139

Chapter 11

Fat and Fibre Dietary Assessment Tool for Adults in Hong Kong Queenie P. S. Law and Zenobia C. Y. Chan

149

Chapter 12

What Is a Three-Hour Workshop on Stress Management? Zenobia C. Y. Chan

159

Chapter 13

Teaching Crisis Management in Health Care Zenobia C. Y. Chan

167

Chapter 14

Hearing the Voice of a Married Working Mother’s Fear of Losing Her Housemaid S. F. Chan and Zenobia C. Y. Chan

173

Invisible Instability of Hong Kong City and Human Relationship: Representation of Virus in Hong Kong Films Chan Ka Lok Sobel

187

A Workshop Program Supporting a Change in the “Heart and Art” of the Bereavement Service within a Workplace Miranda M. M. Leung and Zenobia C. Y. Chan

191

Chapter 15

Chapter 16

Chapter 17

Two-Day Workshop on Developing Critical Thinking in Nurses May M. Y. Li and Zenobia C. Y. Chan

Chapter 18

Primary Health Care Program: Occupational Safety and Health for People with Intellectual Disabilities Gary Wong and Zenobia C. Y. Chan

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Index

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205

219 231

ABOUT THE EDITOR*

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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 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 Nova Science Publishers, Inc.) and two Chinese books. She has published papers related to nursing, family studies, counseling, 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] Health Issues in Chinese Contexts, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook Central,

Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved. Health Issues in Chinese Contexts, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook Central,

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PREFACE Health Issues in Chinese Contexts, Volume 1 is a collection of the health care professions’ research studies and writings in Chinese contexts, such as Hong Kong. This book has four major purposes: to describe some qualitative health research studies; to introduce some creative primary health care programs; to discuss the importance and roles of health care leadership training workshops; and to share some teaching observations and experiences in health promotion, autobiographical writings, stress management and crisis management from the postgraduate teaching level. This book demonstrates the wisdom and work experiences of many contributors who are front-line multidisciplinary health care providers who should be noted at the international level because of the uniqueness and creativity of the topics and contents mentioned. The purpose of this book is to provide evidence-based research data that can enhance health knowledge understanding and practice; to offer some practical health care programs and workshops that can shed some light for other health contextual services and training; to demonstrate some classroom teaching techniques; and to relate some observations of health care courses that can help other educators to enhance their own concepts and skills in teaching and learning. Chapter 1 is an exploratory study of the strain on co-resident female spouses of male patients suffering from cerebrovascular accidents. The number of stroke patient care givers has been increasing in correspondence with that of stroke victims. Under the early discharge policy of Hong Kong, the population of family carers is expanding. Elderly females in a family are commonly assigned the informal role of family carer. In modern Hong Kong, traditional Chinese culture is facing a challenge from Western culture wherein family structure has changed from extended family to nuclear family. Elderly females in a family are inevitably become female spousal carers. In this chapter, female spousal carers of stroke victims were studied. They were long-term carers of physically-dependent husbands. Their experience in caring was investigated by a qualitative approach in feminist phenomenology design. Individual interviews were used for data collection and five themes were extracted from their content by content analysis. Five themes were extracted: ‘The caring’, ‘Carers’ difficulties and support’, ‘Carers’ needs and stress’, ‘Obligation’ and ‘The ultimate worry— old age home’. The themes portrayed the picture of caring and introduced carers’ challenges and available support. Carers’ needs and stresses were also identified. Although facing challenges, they were committed to caring and their perception of old age home care arrangement was given. The interaction of traditional Chinese culture and modernization of Hong Kong has brought both positive and negative influences on the process of caring. The

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Zenobia C. Y. Chan

caring experience of Hong Kong Chinese spousal carers participating in this study reflected that they were passively influenced by many factors, including family context. In order to initiate change to assist carers, recommendations for health care professionals, policy makers and future research trends were suggested. Implications and limitations of this study were also provided. Chapter 2 reports the influential factors and the attitudes of adolescents in Hong Kong towards healthful and unhealthful beverages by a focus group study. All participants, a total of 68 secondary school students between 14 and 17 years of age, were interviewed in their own secondary school located in different districts all over Hong Kong. Unhealthful beverage consumption habits formed in youth can considerably affect the health of young people. Little is known about adolescents’ attitudes toward healthful and unhealthful beverages in Asia, and the major factors influencing their beverage choices. Research results are as follows: fruitflavored tea beverages, water, and fizzy drinks were found to be the most favorite beverages among the adolescents. In addition, Hong Kong adolescents also prefer Chinese soup among the beverages. Peer pressure and price were the major influential factors that affect the adolescents’ choice of beverages. Gender differences were also found in the consumption patterns. The study calls for promoting adolescent healthful beverage consumption habits by organizing, for example, a school-based health behavior program including parents and health providers. Chapter 3 describes an exploratory study on working overtime in a private company and practising a healthful diet. Understanding the importance of a balanced diet can undoubtedly help us to maintain a good health. An imbalanced diet due to working beyond normal office hours is commonly seen in workplaces in a competitive society. An exploratory, qualitative study with 30 white-collar employees in a private company was elaborated here. However, little evidence from existing literature was found in relating the impact of working overtime with an imbalanced diet, especially because the resources and supporting documents from Hong Kong are rather limited. In order to evaluate the eating pattern and food consumption during overtime work, the concept of a healthful diet and the point of views on the working patterns were analysed. The determinants of health relating to irregular eating habits and working overtime were explored by qualitative research, which can provide a more in-depth insight for a better approach. Data from 30 participants was collected using multiple case studies with a personal essay as an exploratory tool. The data was interpreted using content analysis by coding all text. The results showed a similar understanding of the definition of overtime working and balanced diet among the participants, and most of them expressed their strong opinions and agreed with the concept of the relationship between overtime working and a healthful diet. However, the participants showed little response regarding the existing healthful eating programme, which may reflect insufficient promotion to the working group by the government. Data saturation, insufficient supporting documents and the response to the personal essay were seen to imply certain limitations in the chapter. This chapter is expected to empower individuals with the concept of practising a healthful diet with enhanced knowledge and information regarding the negative impact of an unhealthful diet while working late hours at the office. Chapter 4 reveals the stressors among female patients undergoing thoracic surgery and methods of pre-operative education to reduce their stressors with the 10 case studies from Hong Kong. This study aimed at exploring patients’ stressors, identified pre-operative education need and stress level management. The study adopted a case study approach. Ten

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Preface

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female pre-operative lung cancer participants were invited. Data collected through in-depth interviews and content analysis was used for data analysis. The results showed stressors associated with anxiety, operative complication, and social, hospital and economic impact. Religious and social support and information seeking were adopted as stress-relieving measures. Participants preferred small group instruction, written or audiovisual information to enhance memory. This study had limitations, such as limited time and funding, and the results might not be generalized. Chapter 5 discusses crisis management in the event of fire and fire safety in the operating room. Patient safety is a global challenge today. It is nurses’ chief responsibility. A hospital environment is a potential place for a patient safety crisis, particularly in the operating theatre. There are many hidden risks that can harm both patients and health care professionals, causing many medical incidents. With careful crisis management, potential risks can be handled properly. Though fire is an innate risk in the operating room, few studies focus on nursing crisis management related to the operating theatre’s fire safety. Chapter 6 demonstrates the implementation of reforming health care design, offering an opportunity to evaluate the effectiveness of leaders in the nursing and medical fields. It examines how leaders are directing changes in health care organisations. Organisational cultures are affected by the values and beliefs of individuals or the organisation. People in working groups are willing to adapt to behavioural changes under the influence of their leaders. This chapter raises this issue and makes people rethink leadership styles and roles within an organisation. The focus is on the evaluation of the Community Medical Geriatric Consultant in the workplace. Discussions on his or her leadership styles and roles illustrate how he or she can influence team members in behavioural changes and sustain the subsequent. Chapter 7 explores students’ views on health promotion. Two goals of this chapter are to encourage students to question the dominant discourses of health promotion and to revisit responses to students’ views on health promotion. Chapter 8 calls for autobiographical writings by health care researchers. Autobiography tells a reader how the author perceives the world and understands certain facts. The aim of this chapter is to illuminate and explore how autobiographical writing may be useful in the work of qualitative researchers in the field of nursing. Chapter 9 introduces the Promotion of Healthy Diet among Male Red Minibuses (RMBs) Drivers in Kwun Tong. Eating as important human activity. Nowadays, people eat less healthfully than in the past due to an abundance of unhealthful, yet tasty, food, which is readily available throughout the city. In order to promote a healthful diet, a program targeting 20 RMBs drivers in Kwun Tong to increase their knowledge and awareness of a healthful diet will be implemented. A registered nurse, a dietitian and the public light bus association will collaborate together on this program. Talks and consultations will be conducted at a health centre in Kwun Tong. Free health assessments, snack packages and pamphlets are included to further encourage and reinforce the message. Follow-up programs to maintain the ongoing effect of healthful eating will be suggested. Various parties, such as the government and the Department of Health, can be invited, or they can collaborate with each other to maintain the drivers’ health. Chapter 10 presents a fall prevention program for community-dwelling elderly. As ageing populations are a global concern, a health promotion program for fall prevention is important. However, this has not yet been fully developed in the primary health care service in Hong

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Zenobia C. Y. Chan

Kong. The program described in this chapter advocates positive evolutionary cognitive behavior changes of the elderly on the issue of fall prevention. Approximately 100 elderly people living in the Kowloon Central district are encouraged to participate in a one-year program. The elderly should be assessed multi-dimensionally to identify the determinants of fall by a voluntarily fall prevention team in order to implement various strategies to address motivation and the development of individualized fall prevention measures. Qualitative evaluation should be performed from multiple perspectives. Although the cause-effect relationships of the variables of the elderly cannot be determined in this program, fall prevention strategies corresponding to the feelings and views of the elderly can be emphasized. Chapter 11 presents a self-constructed Fat and Fiber Dietary Assessment Tool for Adults in Hong Kong. Colorectal cancer is becoming a global epidemic. In the last decade, colorectal cancer was the second most common form of cancer in Hong Kong. It accounted for 16% of all new cancer cases in 2004 and is on the rise. In the face of this rising, there is a pressing need to control further outbreaks. Although there are many types of dietary assessment tools focusing on measuring food intake habits, this assessment tool is suitable for the Chinese population because it is localized to reflect foods common in an Asian diet, specifically listing common foods in Hong Kong. Chapter 12 raises a question: What is a Three-Hour Workshop on Stress Management? Based on the author’s own teaching experience and contact with more than 800 teachers in the past five years, the majority find that their work consumes half or more of their waking hours. Many said they regard their teaching work as their first or second priority (some identified their family or their personal interests as the first priority). In this chapter, the author discusses the possibility of bringing such a workshop to a secondary school setting, and offers a detailed description of the workshop content, process and possible outcomes in a Chinese society such as Hong Kong. Chapter 13 discusses the contents of a course titled Crisis Management in Health Care. There is a dearth of literature regarding the content and skills needed for teaching a crisis management course in health care settings. With a view to raise attention in medical education about the need to teach crisis management, and the importance to address students’ learning experience, this chapter aims to describe four three-hour evening sessions on crisis management delivered in February to March 2006 for 18 master students who are either a nurse or a teacher and study health education and health promotion provided by the School of Public Health in Hong Kong. More importantly, it highlights the teaching skills and then explores the opportunities for applying crisis management in health care settings in order to respond to natural and man-made crises effectively and promptly. Chapter 14 advocates the need to hear the voices of married working mothers with babies who have lost their housemaid. Many Hong Kong married women are involved in the labor force. The employment of a full-time housemaid from overseas is therefore very prevalent in some of these families, especially where there are children and/or elderly relatives. Without their assistance in doing the housework, taking care of the children and the elderly, the wife may not be able to work outside the home. This chapter reports an interview with a Hong Kong married working woman with babies living with her husband’s family who felt worried that her Indonesian housemaid would either refuse to renew the contract or would become pregnant after her renewal of the contract. This interview consisted of a preparation stage, a process stage and an outcome stage. By applying an integration of counseling skills, including

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Preface

xiii

Rogers’ person-centered model, Krumboltz’s “soft” behaviorism and Gestalt therapy, along with some communication techniques, her worries were explored and clarified. Both shortterm goals and long-term goals were established as the outcome of the interview. More attention should be paid to the difficulties of most married working women in balancing their roles in their family with their career. Chapter 15 explores the discovery and widespread use of antibiotics, which coincided with the appearance and spread of the “talking pictures”. The incidence of and problems associated with antibiotic resistance increased in parallel with the threat to cinema presented by television; the HIV epidemic coincided with the “VCR epidemic” in the early 1980s; and the beginning of the 21st century saw a bright future ahead both for science, in the form of molecular genetics, and for art, in the form of the digital revolution. It seems that there is an invisible and microbiologic relationship between cinema and disease and viruses. This relationship can be called “bioterrorism in films”, to use Pappas’s term. Chapter 16 is about bereavement service. In order to promote the team spirit of “Heart and Art” of the Bereavement Service within every Pediatric and Adolescent Medicine Department (P and AM Department) in Hong Kong, a slogan competition is launched prior to the commencement of a series of bereavement workshops. Six half-day workshops are proposed to be held every Tuesday morning in the United Christian Hospital (UCH) in 2008. Each workshop has a different main theme related to bereavement services inside the P and AM Department. The normal grieving process and grief responses of different genders with theoretical supports are discussed by reflective learning and experience sharing. Ways to break the bad news to the patient and to the family members are discussed, as well as how to talk with children about anticipated and sudden death. Care and major issues before and after death are explained in detail. Funeral arrangements of different cultures are illustrated by experts or video shows. Helping ourselves or our colleagues to overcome the frustration of the loss of the clients we cared for (“Care for the Carer”) is also explored. Appropriate attitudes and counseling skills towards bereavement within the P and AM Department are expected to be cultivated through team spirit building from the series of workshops and the slogan competition. Chapter 17 demonstrates the importance of providing training in critical thinking in nurses. The complex nursing problems confronting today’s nurses demand a need for critical thinking (CT) skills. CT is essential to leadership, since it is underpinned by responsible thinking, which facilitates the development of problem-solving skills. Supporting staff in thinking critically is necessary to improve patient care and decrease sentinel events. In Hong Kong, limited training exists for nurses to understand and utilize CT concepts and skills. CT training for nurses is therefore timely and relevant for nursing professional development. The contexts of this workshop, including the rationale, content, teaching modes and evaluation methods, are outlined. This workshop aims to promote understanding by nurses of the importance of leadership and CT in health care settings, helping nurses to cultivate critical thinking and enabling them to apply CT skills in clinical practice. Emphasis on innovative, interactive, experiential and participatory approaches underpinned by a supportive learning environment will help nurses develop CT skills. Participants will comprise 30 registered nurses with more than five years’ working experience in hospitals belonging to the Hospital Authority. Chapter 18 presents the Primary Health Care Program: Occupational Safety and Health for People with Intellectual Disabilities. A two-year primary health care program, called

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“Work Safety Begins with Your Participation”, has been planned. The program aims at empowering participants with occupational safety and health (OSH) knowledge and skills, and in helping their employers, colleagues, and families by providing them with a supportive environment. To meet the needs of the individuals, peers, family members, and the community, various intervention strategies can be implemented. This program includes an OSH educational group, a peer support group, individual job-site visits and home visits, a daily log of the participants, and building a network of community resources for the participants. The program is also believed to help the communities manage issues of OSH for people with intellectual disabilities at work.

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In: Health Issues in Chinese Contexts, Volume 1 Editor: Zenobia C. Y. Chan

ISBN: 978-1-61209-385-7 © 2009 Nova Science Publishers, Inc.

Chapter 1

EXPLORATORY STUDY OF THE STRAIN ON CO-RESIDENT FEMALE SPOUSES OF MALE PATIENTS SUFFERING FROM CEREBROVASCULAR ACCIDENT Mavis Tong* and Zenobia C. Y. Chan ABSTRACT

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The number of stroke patient care givers has been increasing in correspondence with that of stroke victims. Under the early discharge policy of Hong Kong, the population of family carers is expanding. Elderly females in a family are commonly assigned the informal role of family carer. In modern Hong Kong, traditional Chinese culture is facing a challenge from Western culture wherein family structure has changed from extended family to nuclear family. Elderly females in a family are inevitably become female spousal carers. In this chapter, female spousal carers of stroke victims were studied. They were long-term carers of physically-dependent husbands. Their experience in caring was investigated by a qualitative approach in feminist phenomenology design. Individual interviews were used for data collection and five themes were extracted from their content by content analysis. Five themes were extracted: ‘The caring’, ‘Carers’ difficulties and support’, ‘Carers’ needs and stress’, ‘Obligation’ and ‘The ultimate worry—old age home’. The themes portrayed the picture of caring and introduced carers’ challenges and available support. Carers’ needs and stresses were also identified. Although facing challenges, they were committed to caring and their perception of old age home care arrangement was given. The interaction of traditional Chinese culture and modernization of Hong Kong has brought both positive and negative influences on the process of caring. The caring experience of Hong Kong Chinese spousal carers participating in this study reflected that they were passively influenced by many factors, including family context. In order to initiate change to assist carers, recommendations for health care professionals, policy makers and future research trends were suggested. Implications and limitations of this study were also provided.

*

e-mail: [email protected]

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Mavis Tong and Zenobia C. Y. Chan

INTRODUCTION

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An increasing incidence of stroke is expected due to the rapid growth of the elderly population in the coming years (Hong Kong Government, 1995). Many studies have been conducted on carer stress, but there is still room to be explored regarding the meaning of caring (Chipchase and Lincoln, 2001). A thorough understanding of the meaning of caring for spousal caregivers can be beneficial in the continuity of caring. Early detection of potential problems for carers and patients is a golden chance to facilitate caring and to reduce the frequency of hospitalization, which would result in reduced cost to the health care system. In spite of the identified research gap, a better understanding of carer stress can strengthen the partnership between carer and patients. As a result, the planning of care and support for patients and their carers can be more effective and efficient in the long run (Cheung and Hocking, 2004). It is found that carers in Hong Kong need more help from the health care sectors and from central authorities regarding health issues (Mackenzie and Holroyd, 1996). In Chinese culture, women are perceived as the native carers. Their perception of caring is, to a certain extent, influenced by traditional Chinese culture. Their perception will be explored by individual in-depth interviews. Information collected will be analyzed to explain their living experience of caring. For any identified difficulties of the carers, results can be obtained to facilitate the development of long-term patient rehabilitation services. As an important element in patients’ rehabilitation, carers should no longer be neglected. The restricted geographical and socio-economic status of participants may contribute to certain limitations of the results. Further areas for study may include a broader participant area and expected support for the carers. In order to have a better understanding of carers’ perception of caring, they will be studied using a qualitative approach. By having a deeper understanding, a framework of support can be proposed in order to assist them in the long process of rehabilitation.

CVA in Hong Kong Stroke is one of the common causes of death worldwide (Murray and Lopez, 1997). Chinese individuals have a higher incidence of stroke and related mortality than Caucasians (Wu et al., 2001). As the third leading cause of death in Hong Kong (Department of Health, 1996; Hong Kong Government, 1995; Hospital Authority, 2001c, 2001d), it affected more than 20,000 people in the year 2001 (Hospital Authority, 2001a) and contributed to more than 3,000 deaths (Hospital Authority, 2001b). As medical technology advances, stroke mortality declines (Hospital Authority, 2001b; Yu, Tse, Wong and Tong, 2000). Around 30% of stroke patients have a good recovery within three months, whereas nearly 40% must live with severe disability for the rest of their lives (Kay, 1993). Stroke mainly affects people over the age of 60 (Woo, Yuen, Kay and Nicholls, 1992). Caring for stroke patients can be a stressful task, as evidenced by caregivers reporting a considerable burden for several years after the initial event (Bugge, Alexander and Hagen, 1999; Greveson, Gray, French and James, 1991). Many of them have encountered a variety of problems, such as financial difficulties, social isolation, knowledge deficit and, eventually, poor physical and mental health (Bugge et al., 1999; Dennis, O’Rourke, Slattery, Staniforth

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Exploratory Study about the Strain on Co-Resident Female Spouses of Male Patients… 3 and Warlow, 1997; Forster et al., 2005; Greveson et al., 1991; Han and Haley, 1999; Kotila, Numminen, Waltimo and Kaste, 1998; Low, Payne and Roderick, 1999; Hanger and Mulley, 1993; Van Veenedaal, Grinspun and Adriaanse, 1996). Teaching family caregivers to cope with these problems and to relieve their own stress are tasks worth doing. There is evidence that their well-being affects the health and recovery of stroke patients (Kotila et al., 1998; Scholte op Reimer, de Haan, Rjinders, Limburg and van de Bos, 1998). Studies have shown that cognitive functioning, the presence of post-stroke depression, and behavioral abnormalities of stroke patients affect the well-being of family caregivers (Anderson, Linto and Stewart-Waynne, 1995; Kinney and Stephens, 1995). Depression is commonly found among patients following stroke, and it can ultimately impede stroke survivors’ functional recovery and be detrimental to their quality of life (Gaynes, Burn, Tweed and Erickson, 2002). Stroke is a common disabling disease requiring the involvement of family caregivers for patients’ successful rehabilitation (Low et al., 1999). It is shown that spousal carers of stroke patients who are advanced in age with health problems of their own are demonstrating an increased number in the Hong Kong population (Hong Kong Government, 1995). Aged family caregivers occupy large proportion of the carer population, and investigating the caring experience of spousal female carers can help to grasp the meaning that caring holds for them.

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Activities of Daily Living (ADL) Activities of daily living (ADLs) is a measurement of one’s ability to perform tasks of self care. Basic ADLs usually refer to activities ranging from mobility, bowel and bladder management, eating and drinking to dressing and grooming. The Berthal Index (BI) is a quantified measurement of physical ability in self care. It is found that carers of high physical dependence stroke victims have more stress (Carod-Artal, Egido-Navarro, GonzalezGutierrez and Seijas, 1999; Kotila et al., 1998; Thompson, Bundek and Sobolew-Shubin, 1990). Carers of physically dependent relatives share with them the same confinement.

Caring and Carer In the process of caring, carers need to take on many roles. Patients count on their carers for self-care tasks, and carers assist the patients in adapting to change, such as change in working life, sex life, social mobility and interpersonal relationships (Holbrook, 1982). Caring is a fundamental and important element in human existence (Roach, 1987). It promotes self actualization and it is an expression of respect and engagement in the process of caring (Benner and Wrubel, 1989; Cheung, 1998; Frank, 2002; Mayeroff, 1990; Roach, 1987). Although the process of caring can be stressful, carers usually perceive the caring role as their own responsibility (Cheung and Hocking, 2004; Van Manen, 2000). Among CVA victims, carers are mostly relatives (Twigg, 1992). Among the relatives, the spouses are expected to be the key person who provides 24-hour care each day (Cheung and Hocking, 2004; Woods, 1996). It is well known that being a carer is stressful (Robinson, 1983). Being a CVA victim’s carer who must tackle a patient’s physical and psychological needs is even more stressful (Blake and Lincoln, 2000; Blake, Lincoln and Clarke, 2003). Psychologically,

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Mavis Tong and Zenobia C. Y. Chan

a patient may demonstrate a depressed mood or even depression (Jones, Charlesworth and Hendra, 2000). Spousal caregivers of CVA patients have long been identified as a high risk group for strain (Cantor, 1983). The condition worsens with a higher level of patient ADL dependence (Cheung and Hocking, 2004). It was found that strain and the impact of stroke patients on their caregivers are long lasting and persistently high (Blake et al., 2003; Dennis, O’Rourke, Lewis, Sharpe and Warlow, 1998; Langton, 1990). Home care for physically dependent relatives is burdensome (Mackenzie and Holroyd, 1996). Traditional Chinese females tend to be submissive. In the process of caring, their attitude and tendency to seek support were among the researcher’s interests.

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Stroke Victim Stress Stresses of CVA patient carers are multi-dimensional. Physical stress is commonly seen in the carers (Knight, Devereux and Godfrey, 1997; O’Brien, 1993). The greater the partners’ disability, the greater the caregivers’ strain (Carod-Artal et al., 1999; Kotila et al., 1998; Thompson et al., 1990). Inadequate sleep is commonly identified (Anderson et al., 1995; Schulz, Tomkins and Rau, 1988). Under a stressful environment with inadequate rest, a general deterioration in physical health will undoubtedly result (Elmstahl, Malmberg and Annerstedt, 1996; Grant, 1996). The irreversible injury and long rehabilitation induces chronic sorrow or even depression (Hainsworth, 1996). Similar to physical stress, the partner’s inabilities are positively correlated with the prevalence of caregiver depression (Blake and Lincoln, 2000; Hosking, Marsh and Friedman, 1996; Jones et al, 2000; Kotila et al., 1998; O’Brien, Wineman and Nealon, 1995; Thompson, Sobolew-Shubin, Graham and Janigian, 1989). Stroke victims’ slow recovery contributes to low mood or depression (Robinson, 1983) and the depressed mood, in turn, hinders patients’ progress (Parikh et al., 1990). The psychological burdens include fear of recurrent stroke on partners, fear of stroke on carers themselves or even fear of partner’s death (Anderson, 1992; Holbrook, 1982; Schulz et al., 1988). The condition is even worse for carers with poor health (Elmstahl et al., 1996; Grant, 1996). Many researchers have suggested that anxiety is one of the psychological impacts on carers of stroke patients (Anderson et al., 1995; Hakim et al., 2000; Kotila et al., 1998; Schulz et al., 1988; Thompson et al., 1990). Besides physical and psychological impacts, secondary issues such as financial problems follow (Knight et al., 1997; O’Brien, 1993). The carers’ social life is undoubtedly sacrificed as a result of loss of time (DesRosier, Catanzaro and Piller, 1992; Robinson, 1990; Scholte op Reimer et al., 1998). Inadequate time turns into loss of lifestyle and leisure time (Anderson et al., 1995; DesRosier et al., 1992; Robinson, 1990; Schulz et al., 1998). Strain or conflict in families could ensue (Anderson et al., 1995; O’Brien, 1993; Schulz et al., 1988; Walley Hammell, 1992), and further develop to loss of relationships (DesRosier et al., 1992; Robinson, 1990; Scholte op Reimer et al., 1998). The nearly one-way sacrifices may cause low self-esteem in the stroke victim (DesRosier et al., 1992; Robinson, 1990; Scholte op Reimer et al., 1998). To conclude, there is a generally decreased quality of life for both parties (Aronson, 1997). Research results that reflect a positive correlation between caregivers and social confinement is good evidence for the need to fight for change and attention to the issue.

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Exploratory Study about the Strain on Co-Resident Female Spouses of Male Patients… 5

Carer Stress Caregivers’ subjective sense of well-being such as their perceptions of partner’s physical dependence is an essential factor affecting stress level (Blake and Lincoln, 2000; Blake et al., 2003; Draper, Poulos, Cole, Poulos and Ehrlich, 1992; Mitchley, Gray and Pentland, 1996; O’Brien et al., 1995; Scholte op Reimer et al., 1998; Thompson et al., 1989). Higher perceived dependence of partner corresponds to higher stress level of the carers (Blake et al., 2003; Spranger and Aaronson, 1992). It is related to self-reported stress and less effective coping strategies (Gunthert, Cohen and Armeli, 1999). Negative mood is presented as upset, anger, worry, guilty feelings, fear or feelings of disgust (Blake and Lincoln, 2000). The informal carers will experience tremendous change of stress after relatives are discharged home (Anderson et al., 1995; Draper et al., 1992). Carer strains not only affect the carers physically and psychologically (Warburton, 1994), quality of patient care is also influenced (Glass, Matchar, Belyea and Feussner, 1993). Social support such as good family support and effective stress coping resources and strategies are proved to be beneficial to caregivers (Cheung and Hocking, 2004; Knight et al., 1997; Schumacher, Stewart and Archbold, 1998). Jones et al (2000) mentioned that strategies to address patient mood and carer stress should be present in community service. Certain researches on stroke informal caregivers have been carried out but very seldom of them were confined to home care of Chinese female spousal stroke carers.

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Hong Kong Society and Chinese Culture Confucianism, an overwhelming philosophical view in China, emphasizes the importance of family. Cope-Kasten (2001) specified it concerns with harmonious order both in individual and society. Family is the most fundamental unit in Chinese culture; it is referred to as nuclear family which is composed of parents and children (Pickle, 2001). The father-and-son relationship is one of the central human relationships in the Chinese tradition (Pickle, 2001). Cope-Kasten remarked husband-and-wife is considered as the most basic relationship (2001). Gallagher (2001) commented that husbands and wives have complementary responsibilities in which women were regulation and harmony of families whereas men were that of government. Traditional China was a patriarchal society in which women were subordinate and belonged to men. However, lives of women are different nowadays (Cope-Kasten, 2001). Although concepts of traditional Chinese have been becoming less important in modern Hong Kong, gender is still a hot topic to study. Gender is the organizing principle in feminist research, and investigators seek to understand how gender and a gendered social order have shaped women’s lives and their consciousness. Feminist research aims to ameliorate the distortion of female experience so as to relieve women’s unequal social position (Lather, 1991). The issue has been debated in many different aspects of social life such as the sexual division of labor within family and different roles that men and women play (Burman, 1994; Rogers and Pilgrim, 2005).

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Feminism and Feminist Research Feminism desires to bring about social change, as it recognizes environmental factors such as structural and interpersonal conditions that oppress women (Fonow and Cook, 1991; Hall and Stevens, 1991; King, 1994). Feminist research is derived from feminism (Sigsworth, 1995). Traditional research methods seem to be male-centered and ignoring women’s experience (Bunting and Campbell, 1990). Feminist questioned the conception of ‘science’ which is observed as a reflection of male bias (McKay, 1989). Feminist research seeks to understand gender and gendered social order that shapes women’s lives and their consciousness through qualitative approaches (Pateman, 2000; Polit and Beck, 2004). It is a research to be done on women for women by the same gendered researchers who are also women (Hammersley, 1992; McCormack, 1981; Porter, 1991; Reinharz and Davidman, 1992; Stevens and Hall, 1992; Webb, 1993). Hinds, Chaves and Cypress (1992) stated that gender, culture and family are factors that inter-related to behavior and, thus, need to be considered when studying the whole human experience in a humanistic approach and the multi-factorial nature of the human existence is important to feminist researchers. Oakley(1981) said that a major intension of feminist research is to advocate for women’s issues and the everyday experiences of womanhood. Feminist research is sometimes equated with qualitative approaches (Lather, 1988; Sigsworth, 1995) and the researcher gender is still a matter of discussion (White and Johnson, 1998).

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Aims and Objectives Ikels (1993) highlighted that most of the elderly in Hong Kong grew up in Mainland China . However, little is known on the level of influence by filial piety regarding caring perception (Holroyd and Mackenzie, 1995). Extensive western studies have demonstrated caring associated difficulties in carers (Mackenzie and Holroyd, 1996). Finch (1993) stated that in western society, not only kinship, demographic, financial and social factors were also influential in caring. However, not much was known about caring and its impact on carers in Chinese families in Hong Kong. The aim of this research is to investigate women’s experience of caring in traditional Chinese context by a feminist research perspective. In Hong Kong, formal service for family carer is undeveloped and not expected in health care professionals (Chan, 1998). As feminist research is to provide betterment of women (Stanley, 1990), it is hoped that evidence can help female carers to express their concerns.

Study Design Qualitative research was selected as it enables the collection of data that captures unique experience of the spousal carers (Diers, 1979; Patton, 1990; Yin, 2003). Also, Russell (2004) mentioned that phenomenology enables interpretation of the world. So, a qualitative feminist phenomenology approach study is selected to explore the women’s world of caring.

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Exploratory Study about the Strain on Co-Resident Female Spouses of Male Patients… 7

Samples Selection of Participants Sampling method of participants was purposive sampling which allows participants with sufficient knowledge and experience in the area of interest (Morse, 1991). Participants were recruited from out-patient clinic of a public hospital upon their husbands’ follow up. Husbands of the potential participants have a history of cerebral vascular accident as recorded by stroke registry in public hospital. Eligible participants were further selected according to certain pre-set criteria. The stroked victims were male in gender and aged forty to eighty, being Hong Kong residents, having lived in the family household and having at least one child. For the caregivers who were the wives, inclusion criteria were, undoubtedly, having female gender and aged from forty to eighty, legally a wife of the victim and also a Hong Kong resident, having a Chinese ethnicity, literate, Cantonese speaking and living together with the victim. She also should be ADL independent and having no history of mental illness. On set of stroke was expected to be at least six month before interview. It is suggested that three months after a stroke is still the acute stage (Blake et al., 2003). Six months post-stroke is long enough in time for carers to be aware of problems, and one year after stroke is an optimal level of functional capacity expected in patients.

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Data Collection Feminist research methods typically include in-depth, interactive and collaborative individual interviews or group interviews (Polit and Becks, 2004; Webb, 1993). Semistructured in-depth interviews are commonly used for data collection as it allows in-depth exploration (Bunting and Campbell, 1991). This research was conducted by individual faceto-face interviews in Chinese with each participant in their own accommodation. The interviews were audio-taped, field notes were taken and transcribed verbatim to English by the interviewer.

Data Analysis Content Analysis (Recurrent Themes) Analysis of qualitative data includes data collection, data analysis and writing up findings (Creswell, 1994; Strauss and Corbin, 1990). When data was collected, the researcher has transcribed verbatim and all transcripts have been read repeatedly so as to gain an overall understanding about the spousal carers and their situation. Different themes were identified and five themes were categorized: i) Tasks in caring, ii) Difficulties and support of carers, iii) Carer needs and stress, iv) Obligation and v) Ultimate worry – old age home.

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Trustworthiness Credibility ensures the research reflects complexity of reality, rejecting standardization, prediction and control in favor of concern for conceptuality and exceptions (Sigsworth, 1995). Rigor of feminist research is best evaluated by adequacy of the process of inquiry relative to the purpose of study, its credibility and how worthwhile it is (Hall and Stevens, 1991; Koch and Harrington, 1998; Webb, 1993). In this research, trustworthiness was further ensured by: (a) keeping field notes to record the researcher’s personal view and responses while collecting data that might influence findings; (b) transcribing all verbatim; (c) analyzing data through a number of cycles and stages; (d) having peer check for reviewing the analysis. Researcher and participants worked as partners in feminist research.

Ethical Considerations Ethical approvals were obtained from Survey and Behavioral Research Ethics Committee (SBREC), joint-CUHK Clinical Research Ethics Committee (joint CUHK-CREC), hospital Chief of Service (COS) and Specialized Out-patient Clinics (SOPD) Department Operation Manager (DOM). Written consents in Chinese were obtained from each participant and reassurance of freedom to withdraw was given before initiation of interview. It is ensured that their contributions would remain anonymous and confidential. Consent forms were signed by participants after full explanation of the research purpose.

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Review Profile of Participants Eight eligible spousal carers have participated in this research. Their husbands have had a stroke for not less than six months and table 1 demonstrates the length of time from the onset of a stroke to time of interview. Demographic data such as educational level, age of participants, year of marriage, and number of co-resident children were obtained before interview. They were full-time housewives who aged between 53 and 72 at the time of interview and their educational level was generally low. Age and educational level of carers are listed in table 2. Number of co-resident children was from zero to two and year of marriage was from 23 to 54 and the above details are illustrated in table 3. Mean Barthel Index (BI) of the stroke partners ranged from 31 to 65, mean BI was 52 with standard deviation 4.48 which implies a moderate level of ADL dependence. Details of BI are shown in table 1. Table 1. Information of stroke victims Husband of participant BI Length of years since onset of stroke

1 55 3

2 45 1

3 65 3/4

4 65 4

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5 41 2

6 61 1

7 31 2

8 55 6

Exploratory Study about the Strain on Co-Resident Female Spouses of Male Patients… 9 Table 2. Age and educational level of participants Participant Age Educational level

1 63 P

2 53 S

3 62 N

4 58 P

5 58 P

6 68 N

7 62 P

8 72 N

7 0 41

8 0 54

Key of educational level: P – primary; S – Secondary; N - no formal education.

Table 3. Family characteristics Participants No. of co-resident children Length of marriage

1 0 45

2 2 23

3 0 44

4 1 37

5 1 32

6 0 43

I. TASKS IN CARING

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Caring Demand After stroke, physical functioning of patients is affected. The participants in this chapter were wives of stroke patients who are ADL dependent. The most commonly mentioned caring task were bathing, assisted toileting, napkin changing, feeding, mobility assistance, turning, handling husband’s emotion, fall prevention, cooking, cleansing, shopping, following doctor’s and nurse’s instructions, giving medications, transportation arrangement and handling economic expenses. On top of the exhausting caring, the wives were also taking care of the family. Time arrangement was tight and busy because the caring tasks were timeless and laborious. Incontinence care, turning, fall prevention and handling husband’s emotion were tasks that required round the clock. In night time, in order to accomplish the timeless demand, carers’ sleep was disrupted. Furthermore, the caring tasks were physically demanding. Many of the tasks such as transfer and lifting required manual handling that exerted physical strain on carers. Degenerative joint change and sprain muscle were common examples. “I’m on duty 24 hours a day….I’m probably up every hour during the night….I sleep next to him…in the living room with an extra bed…so that I will wake up whenever he moves…he moves at night and he falls!...

Carers voluntarily scarified their sleeping and resting time for better caring but they did moan the hardship of it. They found it difficult to go back to sleep in between routine rounds as intervals in between were short. Long term inadequate sleep was a common problem of coresident spousal carers. Poor sleeping quality lowered their concentration in daytime but they perceived they were able to live with the inadequate rest. Some of the carers verbalized difficulty in ignoring their husbands because the husbands might then lose temper and develop emotional changes. In this research, all of the participants verbalized exhaustion and fatigue upon the long term timeless and laborious caring.

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Mavis Tong and Zenobia C. Y. Chan “I always tell myself that I can manage. I always get a headache as I cannot sleep well. But I can still change his napkin with the headache. I am sometimes sleepless although I’m always tired, maybe my body has adapted to little sleep.”

Spousal family carers are usually referred to a 24 hours caring providers (Cheung and Hocking, 2004). Many Chinese families recognize caring as burdensome because of the timeless caring (Chan and Chang, 1999). Consistent with many previous studies, the caring task was a significant part of caregiving (Mackenzie and Holroyd, 1996; Ngan and Cheng, 1992; Twigg, 1992). As time goes by, the physical condition of diseased relatives degenerates and the increasing demand of caring creates ascending stress and restrictions on carers (Cheung and Hocking, 2004). Mackenzie and Holroyd (1996) highlighted emotional, social and physical strains greatly affected carers of chronically ill relatives.

II. DIFFICULTIES AND SUPPORT OF CARER Support from Family

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Spouse and relatives were recognized as the most available in providing emotional support and keeping company. It was observed that other relatives, mostly referred to coresident children, in the family hardly took part in caring while the spousal carers demonstrated reluctance in inviting them to help. None of the participants were able to identify another potential carer in the family who would be ready to take up the caring role. “My daughter takes little part in caring…because she has no time…she is a teacher…whenever she finishes dinner it is almost eight o’clock in the night…and she needs to continues working on her unfinished task…after that…she sleeps. She sometimes stays with me and takes care of Mr. Tam on holidays”

Generally, source of emotional and social supports were referred to family whereas that of tangible and informational support were referred to health care professionals (Sit, Wong, Clinton, Li and Fong, 2004). This situation-specific support is consistent with other studies. It is carers’ reflex to seek tangible support form co-resident relatives. However, in nuclear families, support from co-resident child is inadequate and the situation is silently tolerated by the spousal carers.

Support from Health Care Professionals Consistent with other studies, availability of emotional support and social companionship were comparatively better than that of tangible support and information support to the carers (Sit et al., 2004). Health care professionals provided informational support such as teaching of technical skills but knowledge for caring was sometimes reported to be inadequate. For example, it was hard for carers to differentiate the urgency of husband’s complaints. Sit et al. (2004) suggested a presence of positive correlation between educational level and informational support that carer with lower level of education has less informational support.

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Exploratory Study about the Strain on Co-Resident Female Spouses of Male Patients… 11 Due to the 24 hours continuous caring, the carers basically had no time seeking and receiving services for help or assistance. However, carers regarded their knowledge as adequate enough to fulfill caring tasks. Nevertheless, advices from health professionals were always welcomed. “Soon after his discharge, he was referred to an out-reach team for home exercise. The staff terminated the service to my husband when they found that he was also receiving community rehabilitation service. We need to pay for the community service and we want him to have exercise as much as possible, but the staff just refused us because he thought my husband got more than adequate.”

Possession of rehabilitation equipment that facilitate home care was one of the unmet needs identified. It was noted that caregivers’ need for help or temporary assistance was not addressed. Hesitance was noted when talking about negotiating support from health care or social welfare system. Similar to other studies, frustration was resulted in the process of social support application (Cheung and Hocking, 2004). Frustration originated from long waiting time and heavy paper work. It is observed that the carers tend not to rely on community resources in order to save limited resources for others, guilty feeling would result if they occupy part of the limited service.

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III. CARER NEEDS AND STRESS Similar with other researched carers, meaning of caring motivated carers to carry on but its pragmatic issues such as loss of time, social isolation, physical and psychological stress were highlighted (DesRosier et al., 1992; Hunt, 2003; Robinson, 1990; Scholte op Reimer et al., 1998). O’Brien (1993) suggested confinement at home, physical and financial strain were commonly strain whereas Aronson (1997) suggested there was decreased quality of life in carers.

Physical Stress “I’m exhausted because of joint pain; basically it is painful 24 hours a day…related to transfer and lifting. And I’m tired because of inadequate rest…napkin change at nighttime…I am obviously more short-tempered and my joint pain is becoming more serious.”

Physical and psychological stress induced somatic complaints (Sit et al., 2004). All of the carers reported physical symptoms such as reduced physical strength, musculoskeletal pain, fatigue, reduced concentration, sleeplessness, headache and declined general health. Some of the participants have contracted chronic illness as tennis elbow. Sit et al. (2004) have also found that most of the carers expressed a sense of fatigue and stress during the caregiving experience. The deteriorating health has driven them faster to their ultimate worry, which is old age home care for their husbands.

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Mavis Tong and Zenobia C. Y. Chan

Psychological Stress Many of the spousal carers verbalized concerns about their own health because deterioration of their physical condition would hinder their caring to their much loved husbands. “I am always anxious. I can be scared by even a ring tone. I’m afraid that is a call telling me my husband has had his patella broken because of a fall.”

Carers reported increased stress and anxiety levels after the husband’s incident. Psychological stress was expressed by burden of living, husband’s physical condition and financial stress. Participants in this study neither were financially capable to employ assistance nor could pay for institutional care. Having no solution, relieving method or time for relieve, carers were suffering from a persistently stressful environment. In previous studies done in Hong Kong, it is found that psychological stress is more overwhelming than physical stress (Chan and Chang, 1999). Anxiety, depression and chronic sorrow were observed (Hainsworth, 1996; Hakim et al., 2000).

Social Isolation

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“I don’t even have time to read the newspaper. I have given all of my time and money to him. I have nothing now.”

Sit et al. (2004) mentioned a feeling of confinement that was commonly reported among carers. Feeling of confinement and social isolation were frequently reported as the carers were as homebound as the husbands. The carers have had no time for their own social life such as gathering with friends or relatives. The wives have given up their career and their hobbies so that a sense of emptiness was highlighted. Breaks or leisure time cannot be expected in the near future. Some of the participants reported the need of respite relief so as to pursue other activities.

Financial Burden “Besides stress, inadequate rest, joint pain and no social life, the economic factor is also a stressor to me because this flat is still in loan. Fortunately I have my daughter. Expenses of this family are large and nowadays everything is expensive, miscellaneous items are a great expense.”

Consistent with other studies (Knight et al., 1997), financial hardship was reported by all families. Expenses were spent on food, consumable items such as napkins, medications or transportation. Carers reported a great share of family income was put on their husband’s expenses and not much was left for other activities. Although all of them were receiving disability allowances from the government, planning of the monthly expenditure were required in order to control expenses. Almost all participants have talked about the experience

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Exploratory Study about the Strain on Co-Resident Female Spouses of Male Patients… 13 of seeking assistance or support from health and social welfare system. Their reported satisfaction was generally poor regarding allowances amount and troublesome application procedures.

IV. OBLIGATION Commitment “He is in the highest priority. I do feel harsh, I feel exhausted. But I will recover soon. I always tell myself that I need to be strong. It is not because I’m his wife, it’s human instinct. He is already in a difficult situation and you cannot just sit here and see how he suffers. You need to help him. If that happens to my parents, I will also take very good care of them.”

Their dedicated caring was based on love, a sense of responsibility, commitment, sense of humanity and close relationship. After marriage, women are obligated to serve husband in Chinese culture. The wives were delighted by her husband’s improvement such as improved mobility and it was regarded as a merit of carers’ contribution. The caregivers highlighted their occasional depressed mood and query about their endurance of withstanding the caring. They worried that they may pass away earlier than their husbands and no one would take care of him. It is described that stroke was a “difficult situation” that nothing can be done to change. Stroke of their beloved husbands was a cruel blow and it was a must to relieve the hardship and shoulder the pain.

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V. THE ULTIMATE WORRY: OLD AGE HOME Participants had fears that their husbands would eventually require old age home care. They strived toward the goal of delivering excellent care but they came across uncountable stress and difficulties. They worried about their own health condition and their beloved relatives, institutional care and lack of support (Cheung and Hocking, 2004). When their husbands’ health condition declined to a level that home care became unmanageable, old age home would be the only solution. They mentioned service in old age home was poor because client and staff ratio was too high that elderly were overlooked and the staff were indifferent. Some carers reported their wishes to let their partner live well in the last days so old age home was not preferred.

DISCUSSION I. The Caring Caring is about love and labour (Graham, 1983). Confucianism has significant impact on Chinese behavior and social interaction (Whall and Fawcett, 1993). Majority of Hong Kong people are ethnic Chinese that are greatly influenced by this philosophy (Koo, 1989; Luk

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Mavis Tong and Zenobia C. Y. Chan

2002). In Confucianism, filial piety is one important believe that family is a basic unit of prestige importance (Mackinnon, Gien and Durst, 1996). Family is expected to take care of the diseased relative (Shih, 1996). However, nowadays the value of Confucian has been changed (Davis, Martinson and Gan, 1995). Politically, many structurally fragmented families have been left in Hong Kong after waves of overseas emigration before handover of Hong Kong in 1997 (Luk, 2002). Socioeconomically, living environment in Hong Kong is limited. About 30% of Hong Kong population lives in public housing with small household size. Before year 2000, average number of members per family is about 3.3 (Luk, 2002). In Britain, most dependent relatives were cared by their spouses. International and local researches illustrated that most of the carers were female spouses (Davis et al., 1995; MacKenzie and Holroyd, 1996; Twigg, 1992). The increasing longevity and decreasing birth rate resulted in increasing proportion of elderly spousal carer in future. Together with transition of family structure, reduced kinship ties and social support contribute even harder stress to family carers.

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II. Carer Difficulties and Support The early discharge policy of Hong Kong public hospital and community based care resulted in great responsibility and caring stress to carers (Hong Kong Government, 1991). Strong family support is important to carer (Knight et al., 1997; Schumacher et al., 1998). Carer living only with patient has weaker family support (Ngan, 1990; Sit et al., 2004). Level of involvement in caring is greatly affected by co-residence (Twigg, 1992). However, with the decreasing birth rate, mortality and morbidity rate in Hong Kong, the predicted problem of aging is facing challenges brought by reduced number of family support network (Ngan, 1990). Carers’ reluctance to seek support from relatives or neighbors because a sense of dependence is expected in Chinese culture (Mok, Chan, Chan and Yeung, 2003).With the transformation from extended family to nuclear family, carers are more isolated and, as a result, corresponding health care service provision is of increasing urgency.

III. Carer Needs and Stress In the process of caring, carers are required to adjust their lifestyle to the new role. Social support is beneficial to psychosocial health of the carer (Ethgen et al., 2001; Sit et al., 2004). With the majority of people living in accommodation not more than 40 square meters (Wong and Cheng, 1990), use of this equipment is restricted because of limited living space. Educational level is corresponding to information seeking behavior (Sit et al., 2004). Uncertainty induced by caring job is stressful (Chan and Chang, 1999). Besides commitment, caring also calls for knowledge and skills (Benner and Wrubel, 1989; Cheung, 1998; Roach, 1987). For many of the cares, information for caring is not adequate and it is stressful when it comes to decision making (Bowers, 1987). Moreover, as carers are as homebound as their partners, the services for information may not be accessible to them. Due to the tremendous stress, provision of respite support is highlighted in many studies and it provides deeper insight to the family and empowers the relationship between them (Cheung and Hocking, 2004).

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Exploratory Study about the Strain on Co-Resident Female Spouses of Male Patients… 15

IV. Obligation Previous studies suggested that caring is fundamental to human survival (Benner and Wrubel, 1989; Cheung, 1998; Leininger, 1988; Roach, 1987; Watson, 1999). Caring implies a way of commitment, knowledge and skills (Benner and Wrubel, 1989; Cheung, 1998; Roach, 1987). The commitment of the carers in caring actualized that caring is a way of being, believing and acting (Benner and Wrubel, 1989; Cheung, 1998; Mayeroff, 1971; Roach, 1987). It is an expression of respect and response to human values that gives meaning to life (Benner and Wrubel, 1989; Roach, 1987). Responsibility is commonly reported and Van Manen (2000) mentioned responsibility itself keeps driving carers to keep in touch with the one they care about. Their dedicated caring reflected their strong bonding which is evidence of good interpersonal relationship and it correlates to good coping in caregiving (Pakenham, 2002).

V. Carer’s Worry: Old Age Home

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The idea of handing over the responsibility is rare among the carers (Sit et al., 2004). They ignored their negative feelings upon the caring but this kind of suppression may make carers burn out (Luk, 2002). Moving to an old age home has been described as difficult for elderly people (Burnett, 1986; Zarit and Whitlatch, 1992). In Chinese society, old age home admission means loss of respect and loss of everything to the elderly (Lee, 1997; Nay, 1995). Elderly themselves have mixed feelings towards institutional care (Lee, 1997). They perceive the old age home as the only alternative when nobody could take care of them but it is also correlated with a sense of powerlessness (Lee, 1999). Moving to an old age home is a life event, slightly less stressful than the death of spouse or divorce (Gordon, 1985).

Limitations The small size of this study may mean that it is not representative of the whole population. As there are pre-set inclusion criteria for stroke victims and participants, the sample may be biased in the direction of a healthy population. Criteria as being literate, Cantonese speaking, Hong Kong resident, ADL independent and mentally healthy may exclude carers from some backgrounds. Samples were drawn from one hospital that implied they were living in a similar geographical region with similar socioeconomic backgrounds and results obtained may not be generalized to all districts of Hong Kong. The study was done on co-resident spouses and conclusions obtained may not be applicable to spousal carers with different living arrangements. This women only study is unable to investigate difference between male and female carers in performing the caring task. Some studies found that the male carer is less involved in performing intimate personal care tasks than female (Twigg, 1992). Participants recruited were homogenous in nature and sample selected may contribute to selection bias. When interviews are used for data collection, capturing and interpretation of participants’ data may not be adequate and participants may have answered the researchers question with an expected answer. Relationship between researcher and the researched affects the results (Emden and Sandelowski, 1998; Heron, 1996; Lincoln and Reason, 1996; Richardson, 2000; Whittemore, Chase and Mandle, 2001). The researcher in this study was trying to investigate

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Mavis Tong and Zenobia C. Y. Chan

if carers have stress in caring so as to provide a basis for change. The direction of researcher may contribute to bias of data interpretation and make the result skewed to the expected side. Also the women only researcher may introduce bias when interpreting data.

Implications for Practice, Development and Further Study

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Social Support Group Elderly people in Hong Kong were found to have a limited social support network (Chi, Lee, Hu, Ye and Wang, 1993). Family carers are not prepared to take up the demanding and long-term burdensome caring (Man, 2002). Health care providers are important in assisting carers to manage their stress (Payne, Smith and Dean, 1999). A patient support group is regarded as good support (Luk, 2002). In Hong Kong, activities for caregivers help prevent them from social isolation. Number of self-help and support groups has increased recently (Wong and Chan, 1994). Potential caregivers can be identified and referred to patient support group for early interventions. Home Visit Caregivers need to take care of their beloved relatives at home and the caring task may interfere with their normal lives. Home visit discover clients who are alienated from society, provide tailor-made service and maintain continuity of care (Kim and Keshian, 1994). So that it allows health care professionals to go to the patient for service provision continuously. Moreover, it is critical in programs serving families so that rapport is built between clients and health care professionals and this less hierarchical strategy allows women to gain a voice (Kim and Keshian, 1994). Home visits are a service that health care professionals visit the client. Intimacy between client and health care professionals allow rooms for accurate assessment. Nurses who are in the excellent position to extract information should make use of the advantage to prescribe the most suitable care. Mackenzie, Holroyd and Lui (1998) highlighted the importance of individual assessment of different families before providing optimal care. In Hong Kong, a formal service for family carer is undeveloped and not expected in health care professionals (Chan, 1998). Informational Support Possible explanations for inadequate informational support to carers were irrelevant information provided by the health care professional, or the information was too complicated to understand or too difficult to memorize (Ho, 2002; Rodgers et al., 1999). The incorrectlydesigned educational content could be one of the explanations of the carer having inadequate knowledge. Conventional informational support relying on a written format is less accessible to those with a low educational level. It is recommended that the health care professional should provide tailor-made information according to client’s need regarding mode of message transmission. Informational support from health care professionals has potential. Tangible and informational support is a key implication in future nursing practice (Sit et al., 2004). Nurses are frontline staff who have close contact with patients and have clear ideas of health care policy; they can flexibly advise or mobilize services to assist relatives in the process of caring.

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Exploratory Study about the Strain on Co-Resident Female Spouses of Male Patients… 17

Policy Makers The focus of health care professionals on the patient’s cure and care while overlooking the needs of family carers is an international phenomenon (Chan and Chang, 2000). With the transition of Hong Kong culture, the trend away from the nuclear family as the most common family structure (Chan and Lee, 1995) has resulted in weakened social support for the elderly spousal family carer. Ikels suggested that most of the elderly in Hong Kong grew up in mainland China, and many Chinese still behave and interact under the influence of traditional Chinese culture (as cited in Davis and Harrel, 1993). Their problems in caring were, to some extent, related to a cultural issue. The identified carer needs and problems in this study could be a blueprint for future service provision. There were fewer than 900,000 people, around 14% of the total population of Hong Kong, who were aged 60 or above by mid-1996. By the year 2025, the predicted aged population will be increased to 24% (Bartlett and Phillips, 1995). There were about 40,000 elderly, or 5% of the elderly population, receiving institutional care in more than 600 old age homes in Hong Kong in 1997 (Social Welfare Department, 1997). The population of old age home residents will increase accordingly as the government aims to provide more old age homes to meet the aging population (Hong Kong Government, 1997).

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CONCLUSION It can be concluded that carers’ needs have already exceeded the services provided by hospitals. Under current hospital policy, population change and disease prevalence, caregivers of patients must be prepared well before they are faced with the challenge. Community-based care is inevitably the future trend. Support of carers is highly appreciated. Planning for support should be noticed by health care professionals to enhance better community-based care. In this chapter, the living experience of caring of participants was explored. Their needs and areas of inadequate support were identified. It is known that their caring experience is stressful and burdensome; the results were similar to other Western studies. Carers of ADLdependent patients were under stress because of physical, psychological, social and financial strain. By exploring their perception, it was found that Chinese culture did influence people’s views of caring. Obligation was commonly reported; people were willing to care, and they tended to silently tolerate and withstand the stress brought on by caring without asking for support from society or relatives. The increasing care needs of their husbands and progressively degenerating health conditions exaggerated their stress and limitations. They struggled with difficulties and gained strength in tackling the cruel situation. The presence of their own limitations, in turn, elicited further worry ,such as the need for old age home care in the future in the even that they could not take care of their husbands alone.

ACKNOWLEDGEMENTS I gratefully acknowledge the carers who participated in this research. I would also like to thank hospital Chief of Service (COS), Dr. Alex Yu; Department Operation Manager (DOM) of Specialized Out-Patient Clinic Miss Yip; and the staff of the specialized out-patient clinic

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Mavis Tong and Zenobia C. Y. Chan

for their help. I would also like to offer special thanks to registered midwife Miss Ho for her help in doing peer check for data analysis, and Vincent O’Brian, a news reporter, who kindly edited this chapter. Last but not least, I would like to deliver my whole-hearted thanks to my direct research supervisor, Professor Zenobia Chan, who gave me her greatest support throughout the process of this research.

AUTHOR’S BACKGROUND Mavis Tong is a registered nurse (general) currently working in a hospital under the Hospital Authority. She received a Bachelor of Nursing degree at The Chinese University of Hong Kong (CUHK), and has earned a Master of Health Science (Primary Health Care) degree at the School of Public Health under CUHK. This chapter originated from her master’s dissertation, completed in 2008.

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Exploratory Study about the Strain on Co-Resident Female Spouses of Male Patients… 25 Warburton, R. W. (1994). Implementing caring for people: Home and away. London: Department of Health. Watson, J. (1999). Postmodern Nursing and Beyond. Churchill Livingstone, Edinburgh. Webb, C. (1993). Feminist research: Definition, methodology, methods and evaluation. Journal of Advanced Nursing, 18, 416-423. Whall, J., and Fawcett, J. (Eds.). (1993). Health and Culture: Exploring the relationships. Akville, Ontario: Mosaic Press. White, A., and Johnson, M. (1998). The complexities of nursing research with men. International Journal of Nursing Studies, 35, 14-48. Whittemore, R., Chase, S. K., and Mandle, C. L. (2001). Validity in qualitative research. Qualitative Health Research, 11, 522-537. Wong, D., and Chan, C. (1994). Advocacy and self-help for patients with chronic illness: the case of Hong Kong. Prevention in Human Services, 11(1), 117-139. Wong, R. Y. C., and Cheng, J. Y. S. (1990). The Other Hong Kong report. Hong Kong: The Chinese University of Hong Kong Press. Woo, J., Yuen, R., Kay, R., and Nicholls, M. G. (1992). Survival, disability and residence 20 months after acute stroke in a Chinese population: Implications for community care. Disability and Rehabilitation, 14(1), 36-40. Woods, R. T. (Eds.). (1996). Handbook of the clinical psychology of ageing. New York: Chichester Publisher. Wu, Z., Yau, C., Zhao, D., Wu, G., Wang, W., Liu, J. et al. (2001). Sino-MONICA project: A collaborative study on trends and determinants in cardiovascular diseases in China, Part I: Morbidity and mortality monitoring. Circulation, 103(1), 462-468. Yin, R. K. (2003). Case study research: Design and methods. (3rd ed.). California: Sage Publications. Yu, T. S. I., Tse, L. A., Wong, T. W., and Tong, S. I. (2000). Recent trends of stroke mortality in Hong Kong: Age, period, cohort analyses and the implications. Neuroepidemiology, 19, 265-274. Zarit, S. H., and Whitlatch, C. J. (1992). Institutional placement – phases of the transition. Journal of the Gerontological Society of America, 32, 665-672.

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Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved. Health Issues in Chinese Contexts, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook Central,

In: Health Issues in Chinese Contexts, Volume 1 Editor: Zenobia C. Y. Chan

ISBN: 978-1-61209-385-7 © 2009 Nova Science Publishers, Inc.

Chapter 2

INFLUENTIAL FACTORS AND ATTITUDES TOWARDS HEALTHFUL AND UNHEALTHFUL BEVERAGES FOR ADOLESCENTS IN HONG KONG: A FOCUS GROUP STUDY Ivy Chan and Zenobia C. Y. Chan

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ABSTRACT Objectives: To explore the influential factors and the attitudes towards healthful and unhealthful beverages for adolescents in Hong Kong. Design: Qualitative research with a focus group approach Setting: All participants were interviewed in their own secondary schools located in different districts all over Hong Kong. Participants: 68 secondary school students between the ages of 14 and 17 Phenomenon of Interest: Unhealthful beverage consumption habits formed in youth could considerably affect the health of young people. Little is known about adolescents’ attitudes toward healthful and unhealthful beverages in Asia, and the major factors influencing their beverage choices. Analysis: Content analysis was adopted. Results: Fruit-flavored tea beverages, water, and fizzy drinks were found to be the most favorite beverages among the adolescents. In addition, Hong Kong adolescents also prefer Chinese soup among the beverages. Peer pressure and price were the major influential factors that affect the adolescents’ choice of beverage. Gender differences were also found in the consumption patterns. The study calls for promoting adolescent healthful beverage consumption habits by organizing, for example, a school-based health behavior program including parents and health providers.

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INTRODUCTION Adolescents’ beverage consumption habits bear a strong relationship with their general health status [1]. Water is simply an essential nutrient for life. This is true because, excluding fat or adipose tissue, about 70% of body weight is made up of water. Water is the fluid in the body in which all life processes occur [2]. It occupies three main locations known as fluid compartments. The largest volume of water lies inside the cells and is called intracellular fluid. Water molecules of intracellular fluid nestle around the cell’s molecules, helping to maintain their structures as well as participating in many chemical reactions. Water serves as a solvent for minerals, vitamins, amino acids, glucose and many other nutrients. It also has a core functional role in digestion, absorption, transportation and the use of nutrients. Although water is essential to humans and it is widely known that fluid intake is the most important way to restore the body’s hydration level, few studies have focused on water intake and beverage consumption habits, especially among Asian adolescents. This study adopted a qualitative inquiry to explore the influential factors and the attitudes of Hong Kong adolescents towards healthful and unhealthful. This chapter is organized in sections including a literature review, phenomenon of interest, research method, research results, discussions and conclusion.

LITERATURE REVIEW

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The three perspectives of healthy beverage will be reviewed including biological effect, psychological effect and socio-behavioral effect.

BIOLOGICAL EFFECT AND BEVERAGES Beverage consumption habits exert a strong influence on overall nutritional status and are relevant to several contemporary nutrition policy debates [3]. According to a study from the United States years ago, beverage choice has a significant effect on the nutrient adequacy of children’s and adolescents’ diets. The study found that milk and citrus juice consumption decreased among the adolescents, while the consumption of carbonated soda was increased. The replacement of milk and juice with carbonated soda or soft drinks in children’s diets has a negative effect on their nutritional quality [4]. Milk consumption was found to be positively correlated with the likelihood of achieving sufficient intake of vitamin A, folate, vitamin B12, calcium and magnesium [3,4]. Juice consumption also positively correlated with achieving sufficient intake of vitamin C and folate. In contrast, carbonated soda consumption was negatively correlated with achieving vitamin A intake [4]. As such, reduced intake of milk and juice would influence the adequacy of nutrients for the body. Second, the increased consumption of sweetened drinks is associated with obesity. This is likely because overconsumption of sweetened drinks is especially problematic when energy is acquired from liquids and these drinks represent energy added to but not displacing other dietary intake [5]. In addition, excessive consumption of sweetened drinks is associated with low intake of nutrients among children aged 6 to 13. This is associated with the displacement of milk or

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The Influential Factors and the Attitudes towards Healthy and Unhealthy Beverages… 29 fresh fruit juice from children’s diets [5]. Several articles have reported reduced intake of calcium, phosphorus, magnesium, vitamin A, folate and riboflavin in children who have a high daily intake of sweetened drinks [5,6,7], although the consumption of sweetened drinks could lead to higher daily energy intake and greater weight gain [6]. Do our adolescents understand clearly the nutritional status of drinks or do they just value the pleasure of taste? We examined the underlying factors affecting their choice of beverages.

Psychological Effect and Beverages

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Adolescents’ choice of beverages might be influenced by the special effects attained after consuming certain beverages. Those drinks are called energy drinks which could significantly improve aerobic endurance and anaerobic performance [8]. They might also bring about significant improvements in mental performance, including choice reaction time, concentration and memory (immediate recall), which reflect increased subjective alertness [8]. These psychological effects could influence adolescents’ choices of beverages, especially for athletes or those who are studying for examinations [8]. This study, therefore, also investigated the psychological responses of adolescents when they chose among beverages. Moreover, obesity is becoming more prevalent among adolescents, and this has been a public health concern [9]. As such, there are many beverages on the market that advocate their body-slimming effects. A survey showed that as many as 63% of the female adolescent subjects aged 15 to 16 were dissatisfied with their weight and wanted to lose weight, despite the fact that only 15% were overweight. This inaccurate body perception is characteristic of adolescents nowadays, especially among girls [9]. Because of this perception, many adolescents prefer choosing a beverage that would make them more fit or slim.

Social-Behavioral Effects and Beverages Studies of adolescents’ health behavior in Denmark [10] have shown that friends and classmates exert a stronger influence in some aspects of health behavior than parents do [1113]. These results indicate that the contemporary relations of children and adolescents can potentially reduce social differences. Adolescents’ social networks, such as their school class and their peer group, could be important factors in combating the negative health effects of adverse socioeconomic family background and in preventing subsequent poor health and health behavior among young people. A study from the University in Hong Kong has pointed out that negative peer influences were significantly stronger in boys than in girls, whereas positive peer influences were significantly stronger in girls than in boys [14]. Peer influence on adolescent behavior has been found to be quite significant [14]. Despite the antisocial behaviors of adolescents, their choice of living style and diet patterns could be strongly influenced by peers. Since adolescents tend to cluster together, their choice of beverages could be easily influenced by peer pressure. Sometimes, they would like to be in the “same circle” by behaving similarly, such as choosing the same kinds of drinks. They might also like to pretend to be mature, free, and independent enough to choose certain kinds of beverages. However, alcoholic drinks and

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I. Chan and Zenobia C. Y. Chan

beverages are excluded from this research. We are only looking more closely at the decision point of choosing different kinds of beverages by adolescents in Hong Kong.

PHENOMENON OF INTEREST Adolescents’ beverage consumption habits can exert a strong influence on their overall nutritional status, and are relevant to several contemporary nutrition policy debates. Beverage and fluid consumption is influenced by many factors as mentioned above, but we know very little about the specifics. It is therefore important to identify the adolescents’ beverage consumption patterns and the factors influencing their beverage choices. On the other hand, soup is a widespread and well-known dietotherapy in Chinese society. Some Chinese soups make use of traditional Chinese medicine (TCM) and herbal products, which have a long history of use based on religious and cultural traditions, and plants are viewed as sources for health remedies [15]. Apart from the medication effects, soup also represents the cohesion of the Chinese family; preparing homemade soup is a sign of concern, love and care in the family. This study therefore also examined Hong Kong adolescents’ attitudes toward Chinese soup.

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RESEARCH METHOD The study adopted a focus group approach of conducting interviews. This method is different from the broader category of group interviews. It explicitly uses group interaction to generate data. Instead of asking questions to each person in turn, focus group interview encourages participants to talk to one another: asking questions, exchanging anecdotes and commenting on each others’ experiences and points of view. Research participants thus create an audience for one another. Since research that attempts to uncover the nature of a person’s experiences naturally lends itself to qualitative analysis [16]. Therefore, focus groups were employed as a strategy for data collection in this study. And the collected qualitative data from focus group discussions could identify the most salient motivators and barriers influencing the consumption of different beverages among young people, as well as to identify their attitudes toward beverages.

Participants and Setting We interviewed 68 adolescents with ages ranging between 14 and 17 (mean age: 14.5 years old) in eight focus groups. The subjects included 34 girls and 34 boys, 60 of them studying in Form 3 and 8 of them studying in Form 4 in different local secondary schools at different districts in Hong Kong. Altogether, eight focus groups were interviewed and each group represented an individual secondary school. These schools were recruited by the convenience sampling method [17], but the students from each school were randomly selected by a teacher according to age. The aim was to establish whether there is any

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The Influential Factors and the Attitudes towards Healthy and Unhealthy Beverages… 31 systematic variation in the way different groups discuss a matter [17]. In fact, for the sake of accuracy and equity of sampling, eight schools were chosen from Hong Kong Island, then the Kowloon side, and the New Territories, respectively. In Hong Kong Island, one school came from the Eastern district; in the Kowloon side, schools were from the Yau Tsim Mong, Kowloon City, Sham Shui Po and Kwun Tong districts; as for the New Territories, schools were from the Yuen Long, Tai Po and Shatin districts. These eight schools varied in their academic level according to the number of admitted students with different academic background. In Hong Kong, schools are ranked based on measures of student discipline and academic performance. Band I schools are rank the highest, followed by Band II schools, and finally, Band III schools. Schools at different academic levels were selected by convenience sampling.

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Data Collection All group interviews were conducted after school hours on weekdays in classrooms, so the adolescents would feel more comfortable in a familiar setting and would not have to travel to another location. The duration of each group interview was approximately 90 minutes and was videotaped. All group interviews were conducted by the same moderator (researcher), who is experienced in interacting with the adolescents. For each group interview, the moderator arrived early to prepare the room and the recording equipment. The topic guidelines for group discussions were distributed to each participant before starting the group interview. It allowed the participants to prepare before the discussion. The group interview began with the moderator introducing herself and the general aim of the group discussion. The interviewees were informed that confidentiality and anonymity would be respected. The university ethics approval was obtained in 2005 before starting the data collection. Issues regarding consent, confidentiality, the right to withdraw from the interview, and the right not to respond to any questions were also explained according to recommended guidelines [18-20]. The interviewees were informed that all points of view were welcomed and there were no right or wrong answers. Following that, the interviewer asked a prescribed flow of questions while remaining neutral both verbally and nonverbally. Each participant completed a consent form at the beginning of the group interview. The same interview rundown was used for each focus group, although this operated as a flexible guide rather than as a structured protocol. The interviews began with a set of open-ended questions, which were directed to all the groups in order to examine the interviewees’ attitudes and behavior toward beverage intake. Depending on the responses obtained from each focus group, the moderator then probed for additional information from the participants.

Data Analysis Content analysis was adopted. It is one of the most important research techniques in the social sciences, seeking to understand data not as a collection of physical events but as symbolic phenomena and to approach their analysis unobtrusively [21]. Content analysis is therefore defined as a research technique for making replicable and valid inferences from data to their context [21]. As a research technique, content analysis involves specialized pro-

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I. Chan and Zenobia C. Y. Chan

cedures for processing scientific data. Like all research techniques, its purpose is to provide knowledge, new insights, a representation of “facts” and a practical guide to actions [21]. After data collection, the video and audio-tapes were fully transcribed [21-22], and a coding scheme developed with the co-investigator who is the author’s supervisor of this study. Text units were collated according to the theme of the questions using the simple and constant comparison method. We compared themes across ethnic and gender groups and prioritized issues generating the most discussion, either as views expressed by a majority of participants or as minority views that generated much discussion [23]. Data were analyzed according to the relevant themes under the following: type of beverages chosen by the adolescents, beverage consumption environment, the importance of taking healthy beverages, characteristics of beverages and benefits, reasons that affect their choices, and attitudes toward Chinese soup.

RESULTS

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Table 1. Typical profiles of the sampled schools Group No.

Schools

Location / District

Banding

Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8

XX Secondary School XX Secondary School XX Secondary School XXX College XX Secondary School XX Secondary School XX Secondary School XX Secondary School

Yau Tsim Mong Yuen Long District Eastern District Kowloon City District Sham Shui Po District Kwun Tong District Tai Po District Shatin District

3 1 2 1 3 2 1 3

Total No. of students 766 1,149 1,180 1,062 837 1,017 1,143 900

All group interviews were conducted within two months, between October and December 2005. Each focus group consisted of 8 to 10 participants. Sixty of them were Form 3 secondary students and eight of them were Form 4 students. Most students in Hong Kong spend six years in a primary school and five years in a secondary school. Following this, there are two years of matriculation (Form 6 and Form 7), and then university education for students with higher academic achievements. Table 2. Gender distribution and the total number of participants in each focus group Group No. Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8

Date of interview 21-10-2005 (Fri) 31-10-2005 (Mon) 4-11-2005 (Fri) 11-11-2005 (Fri) 14-11-2005 (Mon) 24-11-2005 (Wed) 29-11-2005 (Tue) 12-12-2005 (Mon) Total

Girls 3 4 4 8 0 5 4 6 34

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Boys 5 4 5 0 9 3 4 4 34

Total 8 8 9 8 9 8 8 10 68

The Influential Factors and the Attitudes towards Healthy and Unhealthy Beverages… 33 Table 3. Demographic information of the interviewees Sex

No.

Grade

No.

Girls

34

Form 3

60

Boys

34

Form 4

8

Total Ratio

68 1:1

Total Ratio

68 1:7.5

Age 14 years 15 years 16 years 17 years Total Mean Age

No. 39 23 4 2 68 14.5

With regard to two overarching themes that emerged from our data: adolescents’ beverage consumption behavior and adolescents attitudes toward beverages. Under adolescents’ beverage consumption behavior, four sub-themes emerged: type of beverages, situations, consumption behavior, and factors and barriers. With regard to adolescents’ attitudes toward beverages, there are five sub-themes: the importance of drinking healthful beverages, characteristics of beverages and benefits, reasons affecting their choices, attitudes toward Chinese soup, and others. We describe the findings according to these themes and sub-themes as follows.

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Factors and Barriers in Beverage Choices An individual’s social and physical environment, such as her family, workplace, neighborhood and school can directly or indirectly affect health beliefs and behaviors [24]. We therefore were interested in identifying the major factors affecting adolescents’ choice of beverages. Result indicated that peer influence is one of the factors most commonly affecting an adolescent’s choice of beverages [24]. Twenty percent of our participants expressed that peer influence would affect their choice of beverages, some of them even connected that they would be isolated from others if they drink differently. G1F2

:

G3F3

:

G7M2

:

Sometimes I just buy the same stuff like my schoolmates. I’ll try the drinks they recommend. Yes, sometimes I would, when people said that tastes good, I would buy and try one, after trying it, if I also think that tastes good I would keep on buying it. If others drink it I would also drink it, otherwise I would be ostracized.

Peer influence may be direct or indirect. Direct peer pressure may occur in the form of encouragement or dares [25]. Indirect peer influence can also occur when adolescents mingle with peers who drink; adolescents may have the perception that in order to increase social acceptance and make friends with peers, they would need to drink the same beverages [25]. Studies of adolescents’ health behaviors in Denmark have shown that friends and classmates seem to influence some aspects of health behavior more than parents do [11-13]. The results above indicated that the contemporary relations of children and adolescents could potentially reduce social differences. Adolescents’ social networks such as their school classmates and their peer group might be important factors in combating the negative health effects of adverse socioeconomic family background and in preventing subsequent poor health and health behaviors among young people [26-27].

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I. Chan and Zenobia C. Y. Chan

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Apart from peer influence, price is another major factor affecting adolescents’ choices of beverages. Under financial constraints, the responses of adolescents indicate that the attractiveness of their favorite beverage affects them. Since most of the adolescents are financially dependent at the age of 14 to 17, their pocket money is limited, although there were some exceptional cases of borrowing money or asking parents for more pocket money to buy their desired beverages. However, healthful food and drinks can be more costly—for example, a 250 ml bottle of fresh orange juice costs about HK $12 (US $1.6), but a whole box of sweetened drink such as lemon tea costs only HK $3 to $4 (US $0.4 to $0.5). Therefore, price is one of the important issues in determining an adolescent’s choice of beverage. G1M4

:

G1M1 G1M2 G5M3 G6M3

: : : :

G1F3 G1M3 G1M5

: : :

Say if there’s a comparatively expensive drink but you didn’t have enough money with you, then you would probably choose a cheaper one or even think better of buying one. I may choose the cheaper one instead of the expensive one. Price is definitely an important factor affecting my choice… Price would also be a factor, if it costs more than ten dollars, I definitely won’t buy it. For some drinks, it would be cheaper when one buys two bottles at the same time. Well yes, it’s still the issue of money. Price is also an important factor. I would get back the money from daddy after purchase. If I have more money left, I would buy it. If I can’t afford it, I can borrow some money from others.

Packaging, taste and quality were also mentioned by adolescents in the interview. It was more common for girls than boys to make comments about the packaging or the special shape of the beverage. Some even made emphatic negative comments about beverages “made in China”. In fact, the quality control of food in China is still needs much improvement. According to a survey by the research and development centre of the State Council of China, fake products occupied at least 5% of the retail market in China, and it was estimated that there are about two billion fake products flowing into the market. For example, an underground workshop in the Shan Tung province was found to extract artificial protein by using trashed shoes to produce milk with added scent, water and additives. Also, a batch of fake bird nest imported from China was recently discovered by the Hong Kong Customs Department. G1F3 G4F3 G8M3

: : :

G4F7 G4F4 G4F8 G4F2

: : : :

Interviewer G1F3

: :

G3M2

:

G5M2

:

G1M4 G5M9

: :

Yes. Some bottles have interesting shapes. I’ll buy them if they are interesting. Would also look at the external appearance and packaging Would look at the appearance, that would add more joy to drinking it, like the Double Star's drinks, they also got some cartoon characters on them. I would not choose those from Mainland China, feel like they're not too safe Would worry that there'd be problem with their quality Wouldn't drink them even when I am in China If the appearance looks like it's manufactured in China, or if it's not a well-known brand, I also would not buy it Have you ever changed to drinks of other brands under such circumstances? The production line of the brand I like has moved to the mainland. I know nothing about its quality and the additives used. So I’m ill-disposed to the brand. I once bought “Red Bull” to drink, but stopped buying it having learnt from the newspaper that there was something wrong with it. If there’s problem with its quality, for instance, problem with its hygiene, then I won’t buy it again. The external packaging and the taste of the drinks would attract me to buy them Would also consider the taste, if it doesn’t taste good to me I won’t buy it.

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The Influential Factors and the Attitudes towards Healthy and Unhealthy Beverages… 35 Negative comments were heard from some interviewees who showed distrust toward the quality of beverages made in China. Some of them even refused buying drinks in China. Apart from the origin of beverages, quality is also a concern if the beverage was found to have problems, or if the taste gets poor. Some of interviewees, especially the boys, would refer to the media announcements, and if they found something wrong with the beverages they consume regularly, they would then stop buying them. Apart from peer pressure, price, packaging, taste and quality of beverages which affected the adolescent’s choices of beverages, our results also indicate that very few participants (n=4) would think of the healthfulness of a beverage before purchasing it. This suggested that health consciousness toward beverages is not well established among Hong Kong adolescents.

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Attitudes towards Healthful Beverages Beverage consumption attitudes, taken as a set of beliefs about beverage consumption and the effects of beverage consumption, determine the beverage consumption behavior of adolescents [28]. It appears that the amount of consumption and the types of beverages are strongly correlated with beverage consumption attitudes [29-30]. Generally, adolescents have different opinions on the definition of healthful beverages. In fact, the definition of healthful beverages given by the interviewees helped us understand their perception of healthful drinks. Some of them expressed that healthful beverages have therapeutic effects; for example, they cure some sicknesses or diseases and the adolescents could benefit from drinking healthfully. Specific benefits mentioned include healthy growth and energy for the rest of the day. Some interviewees thought that the beverage should be good for health, and should not consist of any artificial or chemical components. A female student commented that homemade drinks are healthful drinks from her point of view, especially drinks made by her mother. A male student remarked that most healthful drinks are less attractive and taste bad, like “Red Bull”, which is a brand of canned tomato juice. Another male student pointed out that healthful beverages are comparatively more expensive among all beverages. From their point of view, healthful beverages include tea, water, soup, fresh fruit juice, homemade chrysanthemum tea, soya bean milk and Canton love-pes vine. These results showed that adolescents’ knowledge and their perception regarding healthful beverages were appropriate in general. However, healthful beverages were not only described in terms of the ingredients, but also in terms of intake frequency. It would be unhealthful if the beverage consumption exceeded a certain level and affected the intake of other food and nutrients. Adolescents themselves have also reported in interviews that media advertisements have a great influence on their perception of healthful beverages [31]. For instance, student G2M2 said that the advertisements don’t lie. In addition, professionals and parents also exert a certain level of influence on adolescents in their perception of healthful and unhealthful beverages. Everybody has his or her own thoughts, including our adolescents. The above comments and opinions on the definition of healthful beverages that came from the adolescents’ point of view were obtained from the focus group interviews. Interestingly, results also suggested that adolescents gained information about healthful or unhealthful beverages from their parents, peers, media and their own experiences. For example, student G6M1 learned from

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36

I. Chan and Zenobia C. Y. Chan

advertisements that there is a brand of sports drink that can replenish physical strength. Also, an advertisement introduced the idea that “calcium added to a beverage is healthful” to the general public, including teenagers.

Importance of Healthful Beverages to Adolescents

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We asked our teenage informants whether it is important to drink healthful beverages. Most of our interviewees gave no comments, or they expressed that they would freely chose any drinks they like. The healthfulness of beverages did not seem to be an important factor to them. Student G3F1 said: “I don’t care much whether the drinks are healthy or unhealthy.” Student G4F6 from another group said, “Mummy always said if we wanna drink something we better drink healthfully; that’s why she bought us so much fresh orange juice. But I think this is not such a big issue because if a drink is allowed to be sold in the market, its quality could not be too bad.” In contrast, there were still a few students who gave more attention to this health issue: G1F3

:

G1M4

:

G4F4 G4F5

: :

G5M5

:

G6M3

:

It’s important; sometimes there’s a lot of sugar in the drinks, and sometimes certain ingredients (e.g., aloe) are not authentic. Of course it’s important, because we always take in drinks during the day; if they are not good for health or even hazardous for health, they would have a great impact on our body. Would also think that taking in ‘unhealthful’ drinks would have an impact on our body The soft drinks would decay all the teeth; it’s no big difference from having chronic sickness. I think it’s important; for example, drinking milk can help increase one’s height. I always drink milk; it’s good to be taller… if you drink a lot of Coke, you would (easily) get diabetes in the future. The chance will increase. They are not good for health—even the face color would get worse after drinking them. Yes it would, although it won’t show up now, it will show up when you get old, it will accumulate, (I) would try to reduce having drinks with high sugar level; for example, would choose skim milk with low sugar. “Fill-it-yourself” (type of drink in convenience stores) has high sugar level. I drink it quite frequently at present but would try to reduce it.

Most of the comments above focused on the negative consequence of drinking unhealthful beverages, such as the comment that consuming unhealthful drinks with extra sugar added would affect health in the long term. In addition, excessive intake of sweetened drinks has also been associated with childhood obesity [33]. It is also well recognized that frequent consumption of sugar in beverages, particularly between meals, can be a significant factor in the initiation and progression of dental caries [33]. Actually, the interviewees pointed out the adverse effects to the body of drinking unhealthful beverages, rather than pointing out the importance of healthful beverages to them.

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The Influential Factors and the Attitudes towards Healthy and Unhealthy Beverages… 37

Reasons for Choosing Unhealthful Beverages Several interviewees mentioned that they would choose the unhealthful drinks that they like because they don’t often drink them. Therefore, they thought it would not be a problem for them. Interviewer G1M1

: :

Interviewer

:

G1M1

:

Why drinking unhealthful beverages? I don’t often drink them. I don’t often have the drinks I’m fond of. I drink some unhealthful beverages, though. But what do you mean by often? Will you change your habit and drink only healthful beverages? Seldom. Sometimes I choose the less healthful ones. Sometimes I choose those I’m fond of.

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A male student (G2M1) expressed that the first impression is important to him, so he would try those drinks with a better taste instead of the healthful ones. Some of them might think that they have no choice but other than choosing among the beverages that are available in the market. Usually, most of the drinks are unhealthful. Other reasons suggested by the rest of the interviewees included: happiness, texture, satisfaction of desires, and assumed harmlessness to the body. G2M1 G2M2 G2F1 G2M3 G4F6 G5M3 G7F1 G7F4 G7M4

: : : : : : : : :

G8F3

:

They taste better! Life is short. First impression is the most important. That’s the case with most beverages available in the market. So there’s no choice. Have had too much. I’ll choose those I like. It’s not a matter of healthfulness. I drink both. They hardly affect me. If it can be sold in the market, it would not be too bad. No influence; liquid is relatively easier to absorb and assimilate into the body. I feel happy after drinking it. Satisfy the need at that point. Although drinking Coke would put on more weight, the taste is more important, so I drink it. Would not drink too much, would not exceed three to four bottles a day.

Another student (G2M4) from secondary Form 3 even expressed the idea that drinking unhealthful beverages still serves the body’s needs. In summary, Ajzen proposed that “individuals will intend to perform a behavior when they evaluate it positively and perceive it to be under their own control” [34]. Being free to choose what to drink allows the adolescents to have the feeling of being adults who have the freedom to choose. G2M4 Interviewer G2M4

: : :

Couldn’t care less. I just drink what I like. Would you feel unwell after drinking them? Just drink other nutritious stuff after that.

Attitudes towards “Chinese Soup” Soup has always been perceived as a healthful supplement in the Chinese diet. For centuries, soup has played a distinctive role in meals. The best Chinese soup is prepared hours in advance, allowing all of the nutrients and flavor to permeate the liquid. Soup can be consumed any time of the year, using different ingredients to cater to different seasons of the

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I. Chan and Zenobia C. Y. Chan

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year. Actually, soup making is an art in itself. The finest and freshest ingredients should only be used in the preparation process. The secret to good Chinese soup does not only lie in the selection of the right ingredients but also in the method of preparation. Usually, in traditional Chinese families, women are responsible for cooking and preparing soup for the whole family. The current study found that many families of our interviewees do make soup at home. Most of their mothers were responsible for making soup, while some families had Chinese soup made by other family members such as grandparents, fathers, or even the teenagers themselves. On average, the interviewees had Chinese soup two to three times a week. Since all members in most Hong Kong families might work outside of the home, most family members could not afford the long preparation time because Chinese soup usually takes three to four hours or even longer on average to prepare. Despite this, we found that about 70% (n=48) of our adolescent interviewees would like to choose Chinese soup over other soup and the beverage they are fond of. In addition, it was found that Chinese soup has a special meaning to 56% (n=23) of the participants. Interviewer G1M1

: :

G4F6

:

G6M3

:

G7M2

:

What does “Chinese soup” mean to you? Well, if it’s soup made by my mother, it shouldn’t be wasted. After all, it’s my mother’s concern for me. Soup has a special meaning…it represents family cohesion because all members have dinner together. The warmth of family. Mother takes time to make it and strengthen the family bonding. Soup is a traditional beverage for Chinese and it has a long history.

Although Hong Kong is an “East-meets-West” city and it is an important international financial centre, Hong Kong is still part of China. The concept of traditional Chinese culture does exist in everybody, especially in the Chinese who live in Hong Kong. These responses indicate that Chinese soup serves an important role in the daily life of many Hong Kong Chinese adolescents. Most Chinese like drinking Chinese soup and also sharing with others soup that has been prepared for hours. Soup can also be highly healthful, natural and of great variety. To many people, it is considered therapeutic and its presence can be a sign of family love and care.

DISCUSSIONS Gender Differences Traditionally, patriarchal values do not only put women in an inferior position relative to that of men, but also differentiate among the women of the household. The equality of women has been an important political issue. Old patriarchal values are intertwined with values of equality in current rural China throughout the twentieth century [35-36]. Traditional Confucian beliefs consider that women’s work is in the private sphere and that it is inferior [35,37]. However, in more recent decades, liberation of women from traditional barriers has become more important in Chinese society [36]. This study has certainly seen many significant changes in women’s roles and expectations. They have the right to choose what

Health Issues in Chinese Contexts, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook Central,

The Influential Factors and the Attitudes towards Healthy and Unhealthy Beverages… 39 they like or don’t like. In the twenty-first century, there is a significant indication of gender differences regarding health consciousness in choosing beverages. Our results also indicated that the female interviewees were more aware of the healthfulness of the beverages they drink relative to the male interviewees. Two-thirds of the female interviewees expressed that healthful beverages are important to their health status. They realized that soft drinks are high-sugar drinks that could pose high risks for developing chronic illness in the long run if they consume them frequently.

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Revisiting the Meaning and Function of Soup in the Chinese Culture Fifty-six percent (n=23) of the interviewees thought that Chinese soup carries a special meaning to them. In the presence of all students, we found that 14 out of these 23 interviewees were boys, and only 9 were girls. Traditionally, in Chinese families, women are responsible for meeting others’ emotional needs and making efforts to improve the well-being and harmony in the family [38]. Females act as a source of emotional support and care at home. Though there is limited evidence, typically mother or daughters show more warmth and appreciation to family members at home [38]. In contrast, males are less sensitive and expressive in their emotional feelings. As such, it is perhaps surprising to note that there were more boys than girls in this study who appreciated homemade Chinese soup. Perhaps boys are sensitive to emotional expression but are less likely to or don’t want to express it in front of people. As a boy grows from babyhood, no one specifically tells him how he is supposed to be as a male. Rather, he comes to learn quickly what he is not supposed to do, such as playing with dolls, crying too much, and spending too much time holding on to his mother, and so forth. Such myriad inappropriate behaviors are eliminated one by one through a process of disapproval, reactions of dismay and withdrawal of affection. To summarize, the healthfulness of beverages did not seem to be an important factor to our adolescent interviewees, and this would not have much of an influence in their daily lives. Being free to choose what to drink might give the adolescents the appeal of acting just like adults. If this speculation is true, this implies that adults should act as good role models to the next generation. With regard to attitudes toward Chinese soup, our adolescent interviewees would like to choose Chinese soup over other soup and the beverage they are fond of. Also, Chinese soup has a special meaning to our teenage interviewees, especially the males. On the other hand, our female interviewees were more aware of the healthfulness of beverages they consume relative to the male interviewees.

Suggestions for Future Research Due to limitations in resources and time, only 68 adolescents were recruited in this study. Future research could increase the sample size. Family members’ perspectives were not covered. Future research could identify possible correlations between family perspective and adolescents’ beverage choices. The above results and opinions can act only act as a reference that reflects the behavior and attitudes towards beverages in the sample of adolescents in Hong Kong.

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40

I. Chan and Zenobia C. Y. Chan

CONCLUSION The voices of youths regarding their choices of healthful beverages are forthright and clear. This study identified the major factors affecting Hong Kong adolescents’ choice of beverages. These factors include peer influence, price, packaging, taste, and quality. Therefore, this study also acts as a need assessment in the areas of healthful drinking of adolescents. By understanding their drinking behavior and attitude, programs to establish new role models of healthful drinking, skills to select drinks, and reinforcement for participation can be introduced after the research. The results also allow parents, teachers and health professionals to consider areas for improvement in their health education. The next challenge is also to apply and incorporate the principles in daily life practices.

BACKGROUND OF AUTHOR Ivy Chan attained her bachelor’s degree in biomedical science in 2003 and a master’s degree in health education and health promotion in CUHK. She previously worked as a project coordinator in the field of health education and promotion. She has focused on planning and implementing health education programs for school children, and evaluating the effectiveness of health education programs. Meanwhile, she has worked as a medical administrator in a private physiotherapy centre.

REFERENCES

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C.Ballew, S.Kuester, C.Gillespi. Beverage choices affect adequacy of children's nutrient intakes. Arch. Pediatr. Adolesc. Med. 2000;154:1148-52. S.M.Kleiner. Water: an essential but overlooked nutrient. Journal of American Diet Association. 1999; 99: 200-6 R.A.Forshee, M.L.Storey. Total beverage consumption and beverage choices among children and adolescents. International Journal of Food Sciences and Nutrition. 2003;54(4):297-307. C.Ballew, S.Kuester, C.Gillespie. Beverage Choices Affect Adequacy of Children’s Nutrient Intakes [Nutrition]. Archieve Pediatric Adolescence Medicine. 2000;154(11):1148-1152. Committee on School Health. Soft Drinks in School. Pediatrics. 2005;113:152-154 G.Mrdjenovic, D.A.Levitsky. Nutritional And Energetic Consequences of Sweetened Drink Consumption in 6 to 13 year old Children. Journal of Pediatric. 2003;142:604610 C.Ballew, S.Kuester, C.Gillespie. Beverage Choices Affect Adequacy of Children’s Nutrient Intakes [Nutrition]. Archieve Pediatric Adolescence Medicine. 154(11):11481152, 2000 Alford C., Cox H., Wescott R. The effects of Red Bull Energy Drink on human performance and mood. Amino Acid. 2001;21:139-150.

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The Influential Factors and the Attitudes towards Healthy and Unhealthy Beverages… 41 [9] [10]

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J.A.O’Dea. Self-concept, weight issues and body image in children and adolescents. Psychology of adolescents. 2003; chapter 5:88-119. A.Johansen, S.Rasmussen, M.Madsen. Health behavior among adolescents in Denmark: Influence of school class and individual risk factors. Scandinavian Journal of Public Health. 2006;34:32-40. R.A.Forshee, M.L.Storey. Total beverage consumption and beverage choices among children and adolescents. International Journal of Food Sciences and Nutrition. 2003;54(4):297-307. P.K.Johnson, C.Frary. Choose beverages and foods to moderate your intake of sugars: the 2000 Dietary Guidelines for Americans-what’s all the fuss about? Journal of Nutrition. 2001;131:2766S-2771S. D.S.Ludwig, K.E.Peterson, S.L.Gortmaker. Relation between consumption of sugarsweetened drinks and childhood obesity: a prospective, observational analysis. Lancet. 2001;357:505-8. H.K.Ma, T.L.Shek, P.C.Cheung. The relation of social influences and social relationships to prosocial and antisocial behavior in Hong Kong Chinese adolescents. Psychology of Adolescents. 2003;chapter 4:63-85. M.Li, P.Poon, J.Woo. A pilot study of phytoestrogen content of soy foods and traditional Chinese medicines for women’s health in Hong Kong. International Journal of Food Sciences and Nutrition. 2004;55(3):201-205. R.Malik, I.Oandasan, M.Yang. Health promotion, the family physician and youth. Improving the connection. Family Practice. 2002;19:523-528 A.Bryman. Social Research Methods. Oxford University Press, 2002. G. Hastings. Qualitative research in health education. Journal of the Institute of Health Education. 1990;28:118-127. C. Grbich. Qualitative Research in Health: An Introduction. Allen and Unwin, Sydney, 1999. D. Seal, F.Bloom, A. Somlai. Dilemmas in conducting qualitative sex research in applied field settings. Health Education and Behavior. 2000;27;10-23. K. Krippendorff. Content Analysis: An Introduction to Its Methodology. SAGE Publications Ltd, 1980. D.Gray, A.Amos, C.Currie. Decoding the image-consumption, young people, magazines and smoking. An exploration of theoretical and methodological issues. Health Education Research. 1997;12:505-517. P.Connell, C.McKevitt, N.Low. Investigating ethnic differences in sexual health: focus groups with young people. Sex Transm. Infect. 2004;80:300-305. K.W.Bauer, Y.W.Yang, S.B.Austin. “How can we stay healthy when you’re throwing all of this in front of us?” Findings from focus groups and interviews in Middle schools on environmental influences on nutrition and physical activity. Health Education and Behavior. 2004;31(1):34-36. B.S.Morton, D.L.Haynie, A.D.Crump, P.Eitel, K.E.Saylor. Peer and parent influences on smoking and drinking among early adolescents. Health Education and Behavior. 2001;28(1):95-107. L.Harnack J.Stang, M.Story. Sweetened drink consumption among US children and adolescents: nutritional consequences. J. Am. Diet Assoc. 1999;99:436-41.

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I. Chan and Zenobia C. Y. Chan

[27] P.M.Guenther. Beverages in the diets of American teenagers. J. Am. Diet Assoc. 1986;86:493-9. [28] A.M.Kwakman, F.A.J.M.Zuiker, G.M.Schippers, F.J.de Wuffel. Drinking behavior, drinking attitudes and attachment relationship of adolescents. Journal of Youth and Adolescence. 1988;17(3):247-253. [29] J.Davies, B.Stacey. Teenagers and alcohol. Her Majesty’s Stationery Office, London, 1972. [30] J.O’Connor. The Young Drinkers. Tavistock Publications, London, 1978. [31] Center on Alcohol Advertising (COAA) (1998, May 4). Outdoor advertising and youth. [On-line]. Available: www.traumafdn.org/alcohol/ads/outdoor.html [32] D.S.Ludwig, K.E.Peterson, S.L.Gormaker. Relation between consumption of sugarsweetened drinks and childhood obesity: a prospective, observational analysis. Lancet. 2001;357:505-508. [33] I.A.Ismail, B.A.Burt, S.A.Eklind. The cariogenicity of soft drinks in the United States. Journal of the American Dental Association. 1984;109:241-245. [34] K.S.Courneya, E.McAuley. Cognitive mediators of the social influence-exercise adherence relationship: a test of the Theory of Planned Behavior. Journal of Behavioral Medicine. 1995;18:400-515. [35] O.Kazuko. Chinese women in a century of revolution: 1850-1950. California, Stanford University Press, 1989. [36] O.Anson, F. W.Haanappel. “Remnants of Feudalism”? Women’s health and their utilization of health services in rural China. Women and Health. 1999;30(1):105-124. [37] R. Guisso. Thunder over the lake: the five classics and the perception of women inearly China, in: R. Guisso and S. Johannesen (Eds) Women in China (New York, Edwin Mellen Press), 1981. [38] L.Strazdins. Integrating emotions: Multiple role measurement of emotional work. Australian Journal of Psychology. 2000;52:41-50. [39] L.Strazdins, D.H.Broom. Acts of Love (and Work). Gender imbalance in emotional work and women’s psychological distress. Journal of Family Issues. 2004;24(3):356378.

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In: Health Issues in Chinese Contexts, Volume 1 Editor: Zenobia C. Y. Chan

ISBN: 978-1-61209-385-7 © 2009 Nova Science Publishers, Inc.

Chapter 3

AN EXPLORATORY STUDY ON WORKING OVERTIME IN A PRIVATE COMPANY AND PRACTICING A HEALTHFUL DIET Ida N. K. Lau and Zenobia C. Y. Chan

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ABSTRACT Understanding the importance of balanced diet can undoubtedly help us to maintain good health. An imbalanced diet due to working beyond office hours is commonly seen in workplaces in our competitive society. An exploratory, qualitative study with 30 white collar employees in a private company is elaborated here. However, little evidence from existing literature was found in relating the impact of working overtime on having an imbalanced diet, especially because the resources and supporting documents from Hong Kong are somewhat limited. In order to determine the eating pattern and food consumption during overtime work, the concept of healthful diet and the point of view regarding working patterns were analysed. The determinants of health relating to irregular eating habits and working overtime were explored by qualitative research, which can provide more in-depth insight for a better approach. Data from 30 participants was collected using multiple case studies with a personal essay as an exploratory tool. The data was interpreted using content analysis by coding all texts. The results showed similar understanding of the definition of overtime work and balanced diet among the participants, and most of them expressed strong opinions and agreed with the concept of the relationship between overtime work and a healthful diet. However, the participants showed little response on the existing healthful eating programme, which may reflect insufficient promotion by the government towards the working group. Data saturation, insufficient supporting documents and the response to the personal essay were seen to imply certain limitations in this study. This chapter is expected to empower individuals with the concept of practising a healthful diet based on enhanced knowledge and information on the negative impact of unhealthful diet while they are working late hours in the office.

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44

Ida N.K. Lau and Zenovia C.Y. Chan

INTRODUCTION

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It is beyond doubt that the world is moving faster with the improvement of sciences and technology, hectic lifestyles and demand for progress in every aspect. This phenomenon is even commonly seen in big cities such as London, New York, and Tokyo as well as Hong Kong. With this pace and the ever-changing working system in society, working overtime has become the norm in most workplaces during the past decade with the aim to increase efficiency. Prolonged working hours in every sector is no longer rare nowadays. The standard working pattern—the traditional eight-hour day or a nine-to-five job—is no longer guaranteed in the office. Most office workers expect to or are expected to work until late hours. However, most people can adapt well to this working style. This may be due to their innate sense of responsibility, which can give them the motivation to keep working until late hours. Some people may equate working overtime with earnestness in order to prove their dedication to their company. This may be a guideline in some companies by which an employee’s capability is evaluated (Caruso et al., 2006). Nevertheless, some workers may not realise how this working pattern can bring with it certain stressors on their health, including an altered eating pattern due to overload job (Eakin et al., 2001; Holmes, 2001; Poissonnet and Véron, 2000). To fill in the gap in the literature regarding the impacts of working overtime on the eating habits of full-time employees in a private company, this chapter aims to provide details on 1) the eating patterns and food consumption of this group of employees when they are required to work extra hours at the workplace; 2) their concepts of a healthful diet and working overtime; 3) the health problems caused by irregular eating habits and working overtime; and 4) their knowledge of the health promotion program. A qualitative research approach in the form of an essay-based questionnaire was used in the investigation.

PART I LITERATURE REVIEW Overview of Hong Kong Overtime Working Conditions A survey was previously conducted by the Hong Kong Census and Statistics Department (2004) to determine the pattern of employees’ working hours. The data showed that 24.7% of Hong Kong employees experienced overtime work in a seven-day period, and their average hours of work during these seven days were 47.5 in the nongovernment sector. Another survey was also conducted to investigate the work-life balance among the Hong Kong working population (Chung et al., 2006). The result showed that 52% of the respondents needed to work for 41 to 50 hours a week, and 36% had to work for more than 50 hours a week, which was more than the contractual working hours. The reasons for working overtime were also investigated. According to the respondents, the main reason was the heavy workload assigned to them. Other reasons included the following: 1) they have to remain at work to support their colleagues; 2) the request is made by a senior manager/boss; 3) they want to demonstrate their performance and industrial commitment; 4) they do not want to be the first person to leave the office or leave before their boss; and 5) working overtime is the

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An Exploratory Study on Working Overtime in a Private Company and Practicing… 45 only way to get a promotion. Although a minority indicated that they enjoyed working overtime, the reasons above reflect the psychological well-being gained by most Hong Kong employees in relation to working overtime; they have a strong sense of responsibility and obligation to their companies and colleagues, and working longer hours can reward them with the opportunity for promotion and advancement.

The Impacts of Working Overtime

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Studies have shown that working overtime is related to occupational injuries, cardiovascular disorders, poor general health, stress, musculoskeletal discomfort, preterm birth, work-family conflicts and risky health behaviours (Grosch et al., 2006; Dembe et al., 2005; Anderson, 2003). These injuries and serious illnesses caused by long working hours can result in an additional burden for employers, as they may be obligated to pay for the compensation and hire additional workers for replacement (Caruso, 2006). Moreover, with employees working longer hours, the amount of time devoted to sleep will be reduced (Gillan, 2005). This can affect the productivity of workers and the quality of their work. Employees cannot function properly with sleep deprivation, which results in errors and reduced productivity at work. Undoubtedly, low productivity is significantly related to an increase in overtime work. A study has shown that working overtime for two or more hours a day can negatively impact a workers’ lifestyle and increase job stress (Takashi et al., 2004). Poor working conditions can also lead to higher levels of absenteeism and staff turnover (Caruso, 2006). In addition to work performance, family relationships can suffer due to long working hours (Crouter, 2001). Less time devoted to family has a negative impact on husband-wife and parent-child relationships, especially when work spills over into weekends. These findings reflect the consequences of working overtime on physical, mental and social aspects of this group of workers.

Figure 1. Conceptual model of the relationship between demanding work schedules and occupational injuries and illness (modified from Schuster and Rhodes, 1985).

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Ida N.K. Lau and Zenovia C.Y. Chan

A theoretical model (figure 1) proposed by Michel Shuster and Susan Rhodes in 1985 was used to illustrate the relationship between working overtime and its impacts on occupational injuries and illness (Dembe et al., 2005). Various factors were involved, and the consequences of working overtime are indicated. This model was further modified to show the relationship between working overtime and having an imbalanced diet, which was also considered a health event. From the figure, we can see how organisational policy and a demanding work schedule can lead to possible health events. Imbalance diet is classified as one of the health issues observed in present-day society, and this can be the result of working overtime. This figure clearly demonstrates the relationship between poor working pattern and possible health events.

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The Significance of Healthful Diet on Work Performance Stress from working overtime can lead to poor diet, and this will eventually become harmful to general health (Holmes, 2001). Irregular eating habits can be adopted due to uncertainty regarding working hours. Some employees may skip their three meals due to heavy workload and fatigue. With lower consumption of sufficient nutrients for normal functioning, work performance can suffer and low productivity can be the result. Health promotion in the workplace is widely concerned nowadays, as more accidents and illnesses have been observed in the past decades. Poor health status due to overtime work is especially on the rise, as it is directly linked to work-related stress, which is the main cause of many diseases, such as cardiovascular disease, mental fatigue and physical problems (Eakin et al., 2001). Furthermore, various dietary guidelines have been established in many countries based on WHO recommendations over the past decades, but people may not comply with these guidelines due to hectic lifestyle (Truswell, 1998). Their awareness of a healthful diet may be lacking. Therefore, there is an urgent need for health care providers to encourage a healthful diet practices in the workplace.

PART II METHODOLOGY Research Paradigm This chapter uses qualitative research to explore one of the social phenomena in Hong Kong: the relationship between working overtime and a healthful diet. Qualitative research was used as the sample size is small (only 30 participants were included in this study), but the information about how working overtime can lead to a significant impact on a balanced diet can be explored in detail. Through a personal essay, the crucial information that truly reflects the opinions of the participants was gathered for further interpretation. Technically speaking, qualitative research focuses on the naturalistic and humanistic conceptions to understand various phenomena in the world. It reflects the true finding of the real world based on human experience and observations (Golafshani, 2003). It is said that both the researcher and the research participants should be involved in developing the

Health Issues in Chinese Contexts, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook Central,

An Exploratory Study on Working Overtime in a Private Company and Practicing… 47 research, as both need to contribute their knowledge and experience to the research (Silverstein et al., 2006). It is believed that the changes in everyday life should be recorded and observed by the researcher to enhance the credibility of the qualitative research (Golafshani, 2003). As a result, the research process is more important in qualitative research. Furthermore, Denzin and Lincoln (2003) stated that qualitative research is ‘many things to many people’. They believe that qualitative research shows multiple disciplines, not only in a naturalistic perspective, but also involves postpositivism in social and physical science.

Research Design

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A case study design is commonly used to conduct research in various aspects. According to Yin, a case study is applicable in exploring the contemporary phenomenon within its context in reality, especially when the boundaries between the phenomenon and the context are not clearly supported by evidence (Bergen and While, 2000; Cowley et al., 2000). Therefore, there are always assumptions for the use of a case study in the qualitative framework. In this chapter, a multiple case study was designed to explore the topic of interest. Unlike a single case study design, which focuses only on a single event or an individual, multiple case studies can be used to compare and analyse data from various scenarios. It is an useful exploratory tool to gather more in-depth information and supporting evidence, which can enhance the internal validity of the research study where causal relationships between variables are examined (Bergen and While, 2000). Furthermore, multiple case studies can generalise results to other circumstances and studies in different settings, which can fulfil the criterion of external validity (Koelen et al., 2001).

Informant and Site Selection The informants for this study were within the same private company, a commercial laboratory, but worked in different departments. Approximately 1,000 employees were recruited in this company and most employees are laboratory technicians who perform testing for product safety and verification. A snowball sampling was used to recruit informants in the chapter because the questionnaires can be distributed more effectively among people within the same social network and the collection of large sample in a population is available (Boys et al., 2001). Eventually, 50 informants with 25 female and 25 male colleagues were selected, and are holding administrative roles in the company. All informants are either degree holders, master’s degree holders or at doctoral levels, and have a good understanding of and writing skills in English.

Data Collection A personal essay-based questionnaire was used for data collection in this study. Fifty questionnaires were distributed among 25 female and 25 male colleagues, and 30 copies were completed and collected back. The response rate was 60%. Eleven open-ended questions were

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Ida N.K. Lau and Zenovia C.Y. Chan

established for informants to provide as much details as possible for exploring the relationship between working overtime and maintenance of a healthful diet. The use of a questionnaire in this case is more convenient for data collection compared to the use of an interview, as most informants are too occupied with their work and may not be able to spare the time to conduct an interview session. The questionnaire with a detailed background regarding the investigation was distributed by hand or through internal mailing. A period of one month was given to each informant to complete the questionnaire before returning it. A reminder was sent to the participants one week before the submission deadline, and an extension was granted if necessary. Although some questionnaires were received after the deadline, they were still accepted for data analysis.

Questionnaire Development The questionnaire was designed by the researcher based on the four guidelines and observations in the company. The questionnaire consisted of two sections; the first section aimed to collect personal information from the participants, while the second section was an essay-based questionnaire with eleven open-ended questions. Participants were asked to write their opinions on the essay questions. The questionnaire basically resembled an interview session, but in written form. It was designed especially for the participants to allow them to express their opinions freely without time and space constraints. The questions were established based on the four areas below: •

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• • •

How do employees working in a private company see their working pattern in the company? What are their attitudes towards healthful diet? Is there any relationship between working overtime in a private company and eating a healthful diet? How do they feel about their health conditions towards working overtime and having a balanced diet?

Data Analysis Content analysis was used to interpret the data. Qualitative content analysis can be described as ‘an approach of empirical, methodological controlled analysis of texts within their context of communication, following content analytic rules and step-by-step models, without rash quantification”. It can analyse verbal and textual data in a systematic way (Schilling, 2006). It is normally used to generate categories deriving from the interview sessions (Handron and Leggett-Frazier, 1994). Although an essay-based questionnaire was used in this chapter, it resembled the interview sessions in a written format.

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An Exploratory Study on Working Overtime in a Private Company and Practicing… 49

PART III DISCUSSION Participants’ Profiles A total of 50 copies of the questionnaire were distributed, and 30 copies were collected. Sixty percent of the participants responded. The order of each questionnaire for analysis was first randomly drawn, and the coding of P1 and P30 (table 1) was used to represent each participant as well as their questionnaire. Out of 30 participants, 60% were female and 40% were male; the majority of the participants ranged in age from 26 to 35. Forty-seven percent graduated with a bachelor’s degree, 33% were held a master’s degree and 20% had reached the doctoral level. In addition, 33% of the participants were already married, and among those who were single, only 10% lived alone. Furthermore, 30% were at the managerial level.

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Table 1. Profiles of 30 participants Participant

Gender Female

Age Range 26-35

Education Level Bachelor

Marital Status Single

Living Conditions With parents

Managerial Level No

P1 P2 P3

Female

26-35

Bachelor

Single

With parents

No

Female

26-35

Bachelor

Single

With spouse

No

P4

Male

20-25

Bachelor

Single

With parents

No

P5

Female

26-35

Master

Single

With parents

Yes

P6

Male

26-35

Doctor

Single

With parents

Yes

P7

Female

26-35

Master

Married

With spouse

Yes

P8

Female

26-35

Doctor

Married

With spouse

No

P9

Female

26-35

Bachelor

Single

With parents

No

P10

Male

26-35

Doctor

Married

With spouse

No

P11

Male

26-35

Doctor

Single

Alone

No

P12

Male

26-35

Doctor

Single

Alone

No

P13

Male

26-35

Master

Married

With spouse

Yes

P14

Female

26-35

Bachelor

Single

With parents

No Yes

P15

Male

26-35

Doctor

Married

With spouse

P16

Male

26-35

Master

Single

With parents

No

P17

Male

26-35

Master

Married

With spouse

Yes

P18

Female

26-35

Master

Married

With spouse

Yes

P19

Female

20-25

Bachelor

Single

With parents

No

P20

Male

20-25

Bachelor

Single

With parents

No

P21

Female

26-35

Master

Single

With parents

No

P22

Male

26-35

Bachelor

Married

With spouse

No

P23

Female

20-25

Bachelor

Single

With parents

No

P24

Male

26-35

Master

Single

With parents

Yes

P25

Female

26-35

Bachelor

Single

With parents

No

P26

Female

26-35

Bachelor

Single

With parents

No

P27

Female

36-45

Master

Married

With spouse

Yes

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50

Ida N.K. Lau and Zenovia C.Y. Chan Table 1. Continued Participant

Gender Female

Age Range 26-35

Education Level Bachelor

Marital Status Single

Living Conditions With parents

Managerial Level No

P28 P29

Female

26-35

Master

Married

With spouse

No

P30

Female

20-25

Bachelor

Single

With parents

No

Stages of the Data Analysis Process The translation process was not required, as all of the data collected were written in English. The data analysis was divided into three stages to explore in-depth information from the participants’ point of view toward the relationship between working overtime and healthful diet. Three sessions involved 1) participants’ views on working overtime and their working pattern; 2) participants’ understanding of a healthful diet; and 3) participants’ opinions on the relationship between overtime eating and healthful diet.

Session One: Participants’ Views on Working Overtime and Their Working Pattern

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Very often, overtime work refers to the work done beyond the official working hours, and it is very significant to learn whether the definition is synchronised among the participants in order to align the findings throughout the research. Not surprisingly, it was somehow standardised in most of the data; it refers to the work done beyond official working hours. P2: Working after working hours, whether at home or at the office, as well as working on a non-work day (e.g., Sunday, public holiday). P21: Feeling tired and wanting to leave the working environment, but it is prohibited or not the norm to leave or stop working.

In responding to the reasons why they have to work until late hours at the office, most of them reported that it was their responsibility to finish their daily work before leaving the office. However, due to the heavy workload, shortage of staff or engagement in meetings during official hours, they were unable to finish up their work on time. They would rather stay at the office for longer hours to get more tasks done rather than leaving the work for the next day, which would eventually add to their existing workload further. P9: …too many meetings during office hours, which means that the work that needs to be done must be accomplished after office hours. P23: It is an employee’s responsibility to complete daily work. P26: I normally stay at the office until 7 pm because of the workload and the ‘overtime atmosphere’ in the company.

Health Issues in Chinese Contexts, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook Central,

An Exploratory Study on Working Overtime in a Private Company and Practicing… 51 Apparently, all reasons reported were not positive. The participants showed uneasiness in handling their heavy workload, making it impossible to leave the office on time. Moreover, the reasons varied among the nature of the job and departments. For instance, some participants in the operation team, which is responsible for routine laboratory jobs, reported that they were unable to go home early because of the continuous experiments and machine handling. For those who deal with customer service and project development, their jobs are mainly focused on the customers’ inquiries and the urgent needs of certain technical support to local and overseas clients as well as their own colleagues and the progress of the existing programs designed for particular clients, such as the development of new techniques and methods to meet the market trend of safety products. These matters would require more handling time, especially with overseas clients or colleagues who are located in different time zones. P17: …emergency matters / handling clients’ enquiries as well as communication with overseas colleagues.

Interestingly, positive feedback was obtained when the participants were asked their opinions regarding the company working pattern. Some felt that an overtime working pattern is a culture in present-day society. Others mentioned that the working pattern was not healthful but not too serious. P10: The working pattern changes with time. Our workload is dependent on the season. Occasionally, changes in human resources increase the workload in training and adaptation. Overall, the working pattern is satisfactory. Family life can still be maintained.

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P11: Generally required to work overtime, but I do believe that it is the general trend nowadays. P17: Overtime working seems to be a ‘culture’.

Even though the data were collected within the same company, participants felt that the working pattern could be varied among departments and rankings. This may reflect peer pressure among colleagues and the pressure from the management levels, although people are more secure in their jobs due to better economy and lower unemployment rate at the moment. P28: …most staff work until 7 pm; some specific departments work until much later. The working pattern encourages overtime work, in line with what management has reflected.

When asked whether they would encounter the same working pattern they are facing now in a different company, most of the participants reported that the working pattern would be more or less the same if they were entering the same field (commercial laboratory in this case) or if they were working in a Hong Kong company. They believed that it is basically the culture within most Hong Kong firms. P2: More or less the same for a Hong Kong company. But if it is a US-based company, the working atmosphere would be much more relaxed.

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Ida N.K. Lau and Zenovia C.Y. Chan P10: If the different company is still in the same kind of business, the same working pattern will be encountered. If the company is in another business, a different working pattern may be encountered, perhaps better or even worse.

Some mentioned that the problem was mainly related to the culture of the company itself and the nature of their job. P18: It depends. If I were working in a company that did not provide service, I think I would have less OT than here. But here, because you are earning money from customers, you need to provide good service to them. P28: It depends on the workload and company’s working environment and culture. Management style greatly affects the employees. Of course the workload should also be taken into account.

Before ending this section, the participants were further asked about their opinions towards work-life balance. The meaning of work-life balance can vary depending on which side one is more favourable toward. If one saw his or her working life as more important and enjoyable, he or she would not mind working longer hours and spending less time in his or her social life. In that case, working overtime cannot be treated as a health determinant. Rather, it may be regarded as a form of achievement and self-satisfaction (Grosch et al., 2006). P11: … If you can gain success throughout your work, I am fine with working even during non-office hours…

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P12: (Work-life balance is) essential for a healthy life. But if you find yourself enjoying your work, you may not feel uncomfortable with working overtime.

In general, participants did show their understanding of work-life balance, such as spending time with family and friends after work; getting enough rest and exercise, staying emotionally healthy and having less stress over the weekend. According to Anderson (2003), work-related stress is mostly related to the constant changes in the organization, such as the working environment, the undefined roles for the employees and poor communication and relationship between employers and employees as well as among staffs. All of these factors have negative impacts of stress on one’s work-life balance; examples are behaviour problems such as depression, physical problems such as eating and sleeping disorders, emotional instability, problems of low productivity and quality of job performance. When one is no longer successfully bearing a work overload or overtime work, burnout will result, and it is the moment when the negative impacts of stress can be observed (Pratt, 1999). Furthermore, some have even mentioned that work life and social life are significantly linked, and a balanced work and social lifestyle can eventually benefit their performance in their work. A five-day work program was also mentioned, which was regarded as a further achievement in meeting the balance point between work and social life. This scheme (fiveday week) was introduced by the Hong Kong Government to civil workers starting on July 1, 2007. Its aims are to reduce work pressure and to improve the quality of family life, in which operational efficiency does not deteriorate. As a leading principle, the government believes

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An Exploratory Study on Working Overtime in a Private Company and Practicing… 53 that this can ultimately have a positive impact on both the private and public sectors in the community. Judging by the responses of the participants, there is no doubt that work-life balance is absolutely an important aspect in their life, as rich information was obtained, and some expressed strong feelings in responding to this question. P20: Without life, work is meaningless. Although we cannot escape from OT, we have to ‘activate’ our life in order to balance work with life. What I mean is, ‘activate’ is to do something that you really like to do. P26: (Work-life balance) is a must! All work has pressure. You can only release your pressure by having a leisure life, like hanging out with friends and playing sports. Also, work should not occupy all of your time. A successful person should have a warm family, a group of friends and good health.

In summary, the responses in this section were very much focused on whether overtime work could have significant impacts on one’s life, and how the participants could accept their current working pattern. It is not surprising to find out that most participants saw overtime work as a norm in present-day society, and it seemed to become a culture in which people were simply maitaining this ideology and normalizing it in their working pattern. This normalization may be the result of having no legislation regarding maximum working hours. Employees are vulnerable to the long-hour working pattern, as no law currently protects them. Working for up to 60 hours a week is not anything new to Hong Kong workers (IHLO Report, 2007). The five-day week scheme promoted by the Hong Kong Government to the community surely faces a challenge if no clear guideline or legislation is established for the public and private sectors to follow.

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Session Two: Participants’ Understanding of a Healthful Diet The understanding of a healthful diet is very crucial in this study, not only because it is a significant factor in this study, but also because the participants’ definition and points of view regarding a healthful diet can further illustrate how people conceptualize and manage a healthful diet in their daily life. It is no doubt that diet has been regarded as one of the important contributors of health, and eating healthfully is associated with good health in most cases (Falk et al., 2001). Certain studies have provided general dietary guidelines for people to maintain a healthful diet, such as reducing total fat intake, eating the right number of servings of a combination of vegetables, fruit and starch, as well as doing physical activities and consuming a balanced diet to maintain appropriate body weight (Truswell, 1998). Of course, the definition of a healthful diet can vary. Therefore, it is crucial to investigate each point of view toward a healthful diet. This stage revealed how well participants understood the concept of a healthful diet when they were asked to report the definition of a healthful diet. Their dietary intake was also investigated to countercheck their eating habits and whether a healthful diet could be achieved on a case-by-case basis. To further remind them and enhance their knowledge of healthful diet, they were asked to provide information on the kind of healthful diet

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programme they might have come across. This was an attempt to have them recall their memories of a healthful diet promotion and whether it was implemented in their daily life. It was good to see that the terms ‘low salt’, ‘less oil’, ‘more vegetables and fruit’ were found in most of the reports when the participants were asked about their point of view on a healthful diet. P29: A healthful diet should consider low salt, low fat, high fiber content, reasonable amount of carbohydrates and proteins, ideally from plants or plant products.

Some mentioned the proportion of each food category that should be consumed and ranked the importance of the normal three meals (breakfast / lunch / dinner) in a daily diet: P28: Healthful diet should consist mostly of vegetables / fruit, then protein (noodles / rice / bread), then milk or cheese or yogurt, then meat and very few snacks. Breakfast should be in the biggest portion, then lunch and the least dinner. P24: As my understanding, a healthful diet should consist of one portion of vegetables, one portion of meat and two portions of carbohydrates.

The amount of energy required was also treated as one of the factors related to a healthful diet. It was reported that daily energy expenditure should be directly proportional to the amount of food intake, and food consumption should depend on personal requirement:

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P4: A balanced diet is based on personal requirement. Energy intake should be sufficient and not exceed the energy consumption of that person. Different people require different consumption of different nutrients. P23: A healthful diet is what can provide your daily requirements. Nutrition can produce energy for your daily work, provided that you balance meat and vegetables; it is a good way to stay fit.

In addition, some participants pointed out that a healthful diet should be referring to a regular diet with regular time consumption. P13: . . . Having meals regularly (don’t eat too late) . . . P16: The time for meals should be fixed . . .

Rather than just asking for the definition of healthful diet, the participants’ daily eating habits were also investigated—whether they have three meals a day and what kind of food they consume in each meal. This can link their personal practice with their definition of a healthful diet to observe whether there is any contradiction between them. Out of 30 participants, only one reported that three meals a day is not required. The reason behind this comment is the overtime working pattern that leads to the practice of skipping breakfast and dinner; this will be further discussed in Session Three. When asked about what kind of food they consumed for the three meals, most of them could list what they normally ate, and it was good to see that some of them did have a

Health Issues in Chinese Contexts, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook Central,

An Exploratory Study on Working Overtime in a Private Company and Practicing… 55 healthful diet, such as eating plenty of vegetables and a balanced portion of carbohydrates and proteins. However, consumption of fruit was rarely seen in the reports. Some did mention that they had a habit of eating snacks during working hours in the late afternoon. P7: Breakfast: yogurt / yogurt drink / whole grain bread Lunch: soup and wheat toast / noodles Dinner: full meal with plenty of vegetables P28: . . . Breakfast is fruit / egg and ham. Lunch is lunchbox from home with vegetables, meat and rice. Dinner at home or dinner out is vegetables and meat with rice. Also, snacks during working hours in the late afternoon.

Interestingly, an unhealthful diet was also reported by two participants. They declared that eating at a fast food restaurant is where they settled with their three meals: P1: . . . Breakfast: usually coffee with bread, sometimes have McDonald’s. Lunch: dining out at fast-food restaurant . . .

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P2: . . . Junk food / fast food mainly.

To further investigate their understanding of a healthful diet, the researcher moved on to ask about their opinions of the healthful diet programmes they have come across so far. In recent years, the Hong Kong Government has been focusing on the promotion of healthful diet in the community, as extensive studies have shown that eating enough fruits and vegetables can help prevent many chronic diseases such as hypertension, diabetes, heart disease, stroke, cancer and obesity (Hesketh et al., 2005; Johnston et al., 2004). A health promotion program (‘2 plus 3 A Day’) was launched in June 2005 to empower the communities’ knowledge and raise their awareness of a healthful diet. This programme promotes the consumption of at least two servings of fruit and three servings of vegetables daily as part of a balanced diet in order to achieve optimal health. Another health promotion initiative has been launched in summer 2007 ([email protected]) to promote a healthful diet among those who normally dine out for their three meals. According to a baseline survey conducted by the Department of Health in 2007, 93% of people preferred to have a more healthful choice on the menu when eating out. This finding is not surprising, as a healthful diet is a particular concern nowadays and more people are paying attention to the types of foods that can produce fewer harmful effects to their health (Chamberlain, 2004). This campaign aims to provide more education and empowerment to the community so that they can have easier access to healthful dishes when eating out. On the other hand, the food premises operators are also encouraged to offer a wider choice of healthful dishes to their customers and to use more vegetables and fruits but less sugar, salt and oil in their recipes. Surprisingly, not many participants have knowledge of these healthful diet programmes, although these programmes are diversely and intensively promoted through community carnivals, television advertisements, banners along the streets and leaflets in health centres. This may be because the participants are too tied up in their work and may not be aware of the existence of health promotion programmes. Moreover, the government may at first mainly focus on the school level and children’s eating habits, and so the working group—particularly

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Ida N.K. Lau and Zenovia C.Y. Chan

those without children—may not have as much access to the information compared to parents and anyone working in the school setting. In particular, only one participant could elaborate more fully on the healthful diet programmes because she had previously conducted research on obesity. She and other participants also expressed their feelings on the difficulty of following the healthful diet programmes due to workload and the limited preferences when dining out. P18: One of my projects during study was to discuss obesity in HK. Actually, the HK government has provided plenty of pamphlets and programs to tell us about health, such as Healthy Eating Food Pyramid from 1999 to 2005, the Healthy Tuck Shop Movement during 1999–2001, Health Exercise for All campaign in 2005, and currently the 2 Plus 3 program. Now they are discussing the Exercise Prescription Program. I believe that work is the most important factor in changing our eating habits. P27: I always try to follow 3+2+1 diet programmes, but sometimes it is difficult to follow when I go out for lunch and dinner.

In general, participants did have basic knowledge of a healthful diet and what should be eaten to enhance good health, but the lack of knowledge regarding health-promotion programmes among participants may somehow reflect the insufficiency of promotion to the adult group by the government. Moreover, some participants may find difficulties in following some dietary guidelines when choosing food, especially when they have to dine out in traditional restaurants and the choices for healthful dishes are still quite limited up to this moment. Further responses referring to their irregular working hours are explored below.

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Session Three: Participants’ Opinions on the Relationship between Overtime Eating and Healthy Diet Exploring the relationship between overtime work and healthful diet is the main objective of this chapter. Both overtime work and irregular eating habits are the determinants of health, and it is very crucial to find out how these two aspects can be linked together, especially to fill the knowledge gap in the community. Certain studies have pointed out that the pattern people desire for food is based on social and cultural factors, and this can greatly affect the way people choose food and the eating pattern they routinely adopt (Caplan, 1996; Falk, et al., 2001). Through the understanding of how the participants defined the meaning of a healthful diet and overtime work in the previous two sections, the researcher now moves on to discuss the significance of overtime work in the practice of a healthful diet. Before proceeding to the investigation of the relationship between overtime work and healthful diet, the researcher first asked the participants whether they had encountered any health problems caused by overtime work. Many studies have pointed out that working overtime can lead to various health problems, both mentally and physically such as depression, headache, stomachache, tiredness and so on (Inoue and Matsumoto, 2000; Eakin et al., 2001). It is very crucial to explore whether the participants had experienced the same problems to further confirm that working overtime can be significantly related to our health conditions.

Health Issues in Chinese Contexts, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook Central,

An Exploratory Study on Working Overtime in a Private Company and Practicing… 57 Most of the participants encountered the same kinds of health problems by working overtime: physical problems such as headache, muscle pain, tiredness, skin allergy, menstrual disorders, and mental problems such as depression, anxiety and frustration. Some expressed their feelings about how overtime work can seriously disturb their mental health. P18: … And depression is always around me. I have a case of ‘talking during sleep’ (my spouse told me that I am saying office stuff during my sleep). I felt so depressed every time I have a complaint from another department for an unexplained reason… P19: … Some degree of depression, as I find myself facing a loss of my routine work, loss of my favourite schedules with friends or even TV programmes, and sometimes I can’t sleep well at night.

On the other hand, a minority of participants reported that they did not encounter any health problems related to overtime work. P24: No, as I have gotten used to overtime working. However, the resistance to diseases seems to be decreased if I work much later.

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P27: No health problems caused by overtime work; only not enough time to take a rest.

The important part of this chapter was to relate overtime work and the practice of maintaining a healthful diet. There was very clear evidence that overtime work greatly influenced the pattern of an individual’s eating pattern, and our findings reflect similar ideas to those that Newcombe (2007) mentioned: long work hours are related to ill health, which could be caused by unhealthful and increased consumption of food due to disrupted lifestyle as well as increased total intake by snacking and late evening meals. The majority pointed out that overtime work could change their eating habits, such as delaying their lunch and dinner time, consuming more snacks to comfort their mood, or ordering afternoon tea to relieve their hunger. Late dinner also resulted in late sleeping hour and insufficient rest time before sleep. Some even skipped meals, which allowed more time for finishing their heavy workload. All of these can be the considered factors in health deterioration. P6: Skip dinner and skip breakfast. Usually have one meal per day accompanied with snacks. P26: Eat late at night. Sometimes just eat instant noodles in the office. P27: . . . I need to have dinner very late and cannot choose the best fresh food to prepare dinner. After dinner, there is not much time to take a rest and go to sleep . . . P28: Under long-term stress, eating habits changed, including more snacks to cheer up the mood. Later dinner after 9pm and straight to bed afterwards, which affects health without proper digestion.

Some preferred eating at the restaurant or ordering food after work, as they did not have spare time to prepare their dinner at home or they were too reluctant to cook due to tiredness.

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Ida N.K. Lau and Zenovia C.Y. Chan P4: Eating meals outside or by delivery . . . P11: Normally I would have a late dinner, and most of the time, I would prefer to eat outside as it is too late after work. P18: . . . my supper time changes depending on my ‘off-work’ time. And sometimes it is too late and I am too tired to cook after work; as a result, I have ‘lunch box’ for both supper and the next day’s lunch!

Interestingly, three participants reported that overtime work did not have an effect on their eating habits or they simply were not concerned about it. However, no reasons were given for their perspectives. Lastly, the participants were asked to express their opinion on the adjustment of their eating pattern if an eight-hour workday were established as a company policy. We hoped to determine their wishes regarding healthful diet practices and the approach they would like to take in adopting the practice. This could also further reinforce and countercheck the relationship between overtime work and healthful diet by making this assumption. Most of the participants preferred consuming their meals on a regular and earlier basis with a more healthful diet such as fewer snacks, less fat and oils as well as eating more often at home. P1: That means I can come home and have dinner at an earlier time, so I can skip the tea or snack…

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P22: Will enjoy my lunch and dinner instead of fast food. Also, I will stay on time for having lunch and dinner as well. P24: I will have at least three mealss at a fixed time and reduce the chance of having a ‘fast’ food.

Some of them preferred cooking by themselves so that the type of food that they were consuming could be within their own choice in order to practice a healthful diet. P8: Cooking by myself. Add more vegetable and less oil, salt . . . P18: I’ll cook more during the week and I believe my own lunch box will be more healthful than the one from a restaurant—at least it will have more vegetables and less fat and ‘MSG’.

Other than reporting how their eating pattern could be adjusted by changing to a fixed work hours system, some concerns were also raised by the participants on this question, such as doing exercise if dinner time were arranged earlier and eating with their loved ones if they could leave work earlier. Although these are outside the scope of this chapter, it does, in a way, point out the consequences of the system of long working hours, lack of exercise and lack of family and social life. Certain studies have already shown that long working hours can deteriorate an individual’s physical health, social life and family relationship, which one should not neglect as they can pose a significant effect on our health condition as well (Crouter et al., 2001; Payne et al., 2002).

Health Issues in Chinese Contexts, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook Central,

An Exploratory Study on Working Overtime in a Private Company and Practicing… 59 P9: Will join some fitness course or study after work. P13: Having dinner earlier, having dinner with my wife, parents and friends. P28: The biggest one would be having dinner earlier, so that I could do exercise afterwards. . .

Overall, participants perceived the idea of the significance between overtime work and healthful diet, and overtime work has reported to have direct relationship on an individual’s eating habits. Participants are prone to increase their intake of unhealthful food such as snacks and fast food, which can gradually cause deterioration in their health. Some expressed strong feelings and desires to achieve a healthful diet pattern if their working hours could be shortened, especially among those who have experienced diet-related health problems such as stomachache and those who constantly have their dinner at a late hour. On the other hand, a minority reported that overtime work did not affect their eating pattern, as they have already gotten used to their eating and working pattern or they did not have much concern in this area.

PART IV IMPLICATIONS

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Research Implications The underlying aim of this chapter is to determine the possibility of working overtime, which can affect individuals’ eating patterns, and the way they could maintain a healthful diet. If working overtime is shown to be a feasible factor in food selection and consumption, how can this group of employees change to adapt a healthful diet? Even though working overtime is not significantly linked to a healthful eating pattern from the findings given by the participants, it is important to identify other determinants of health. It is believed that workplace health promotion is particularly challenging, as practice strategies and specific to the workplace setting are needed to implement the programme successfully (Eakin et al., 2001). In the case of Hong Kong, workplace health promotion may be more difficult to implement due to the hectic lifestyles and stress encountered by most of the employees. The concept of healthful lifestyle may become elusive. However, health promotion in the workplace is still very crucial because it can motivate learning and healthful activities and enhance healthful behaviour as well as advocate change (Benz Scott and Black, 1999). This can prevent illness and aid rehabilitation.

Implications for Employers Overtime work may not be an official company policy and some employers will discourage overtime work among their employees; however, the overtime working pattern may still be unavoidable and inevitable, especially when employees are too engaged with their heavy workload. Employers, on the other hand, can act as health promoters, as it is believed that the workplace is a convenient site for delivery of lifestyle health promotion

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messages among the adult population (Eakin et al., 2001). It is suggested that healthful eating can be promoted within a company, such as organizing a ‘healthy week’ or distributing fruits among employees regularly to enhance their awareness of healthful eating. In addition, from the research findings, participants showed their desire for a five-day work week. This can allow employers to put this concern under consideration as a strategy in promoting work-life balance in the company.

Implications for Employees It is necessary for employees to manage their own healthful diet even during difficult circumstances they are facing. With a heavy workload, there is no doubt that employees may unintentionally neglect the significance of a healthful diet and work-life balance. However, it should not be carried on as a habit. Employees should try to manage their own eating pattern during their working hours so that they will not suffer from irregular eating habits. Employees can also visit the Department of Health Web site so that their knowledge of maintaining a healthful diet can be further enhanced.

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Implications for Policy Makers The findings show that participants did not have much knowledge of existing health promotion programs such as 2 Plus 3 A Day and Eatsmart@restaurant campaign. This may be due to the fact that healthful diet programs are not promoted adequately among the working group. In order to enhance health promotion in the work place, it is suggested that leaflets and posters are delivered to private and public sectors. Health talks can also be organised for companies to bring out the message of healthful diet among employers and their employees. In addition, a five-day work week program is now implemented among government sectors, but it is still an option among private and public sectors. Policy makers should reinforce the significance of a five-day work week and encourage more companies to join this program. Furthermore, a policy for maximum working hours should be established to protect employees from long working hours.

Implications for Health Professionals In general, the health profession acts as a communicator in providing health information to individuals and communities. The purpose is to motivate learning and healthful activities among participants to enhance their health behaviour and advocate for social and policy changes (Benz Scott and Black, 1999). Knowing that the working group has little knowledge of a healthful diet, it is necessary to educate this group especially to enhance the impacts of overtime work on practicing a healthful diet. With knowledge and skills in health management, individuals can pass along the health messages to others and enhance consciousness of a healthful lifestyle. In addition, health professionals are experienced in health issues and they would provide relevant information regarding the social needs and existing health system for policy changes.

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An Exploratory Study on Working Overtime in a Private Company and Practicing… 61

LIMITATIONS One of the major limitations is that there is insufficient information in relating working overtime and its impact on a healthful diet in the existing literature. Most studies discuss these two aspects separately, or with little evidence showing their relationship. In order to fill this knowledge gap, many studies were reviewed, and a conclusion was drawn based on the existing evidence and research findings. The use of the personal essay is beneficial to a certain extent. However, the relatively poor response in completing the whole essay was observed in the first stage, as a long answer was required rather than a simple selection in multiple choice questions. Further explanation on the study objectives was required to provide a better scenario to participants to encourage them to complete the questionnaire. Moreover, the accuracy of the information may be suspected, as there was no reference standard in this case (Boissonnault and Badke, 2005). Data analysis with limited information was encountered, as simple yes/no results were received in some of the questionnaires. Furthermore, we were unable to find studies related to the investigation of the personal essay in the respective research areas. This could affect the validity of the study. Due to time constraints, this study was carried out only in a single company, which could not significantly reflect the whole scenario in the community. Only 30 informants responded with a completed personal essay due to limited resources, and this may not reach the saturation of data. As a result, transferability of these findings may be impossible due to the conditions under which the research was conducted, especially with relation to the selection of the study site and the target population.

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RECOMMENDATIONS FOR FUTURE STUDY Due to the various limitations encountered when exploring the relationship between overtime work and practising a healthful diet, it is suggested and recommended that interviews or focus groups be considered in further research to explore the hidden areas that could not be discovered by using the personal essay as a data collection tool. For example, the yes/no answer could be eliminated and more detailed information could be obtained if further guidance or prodding could be provided by the researcher during interviews or focus groups. Triangulation with the use of combined research methods such as both interview and personal essay for data collection is also suggested to obtain rich information from participants. Some participants showed that they did not have much concern regarding practising a healthful diet, as they had already gotten used to their current eating pattern. In order to target this group of people in changing their concept, it is suggested that behavioural modification be performed within this group of participants in order to enhance their knowledge of a healthful diet and advocate changes in their daily food consumption during the overtime work period. A case study can be applied to this group so that their eating habits can be followed up on a regular basis and advice can be given to empower them to overcome any difficulties encountered and to enhance their changes to a more healthful eating pattern regardless of their busy working lifestyle. A self-management program such as a food diary to record their daily consumption can be designed in guiding them to manage their own behaviour in a more

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healthful way and to enhance their independence upon the completion of the program (Verplanken and Faes, 1999; Crum, 2004). In addition, the research was conducted in one company due to time constraints. In order to obtain data diversification and to enhance the significance of the research findings, a target group can be selected from various companies within the same field, from different fields or from local and overseas companies. Comparisons can be made and conclusions can be drawn based on the research findings.

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CONCLUSION It has been observed that the two social phenomena discussed in this chapter—working overtime and practising a healthful diet—have raised concern in many nations. In Hong Kong, a demonstration took place on Labour Day 2007 to urge legislation on the maximum number of working hours per week. This may owe to the fact that the working hours are getting longer in certain sectors and occupational injuries were also seen to be related to working overtime. The workers are vulnerable to the risks and the harsh conditions that they are facing. On the other hand, the promotion of a healthful diet has been raised by the Hong Kong government in the recent years. Although the primary target group is students, this can indirectly enhance the awareness of a healthful diet, particularly among parents, as they prepare meals for their children. The message of practising a healthful diet is also passed along through television programmes and health talks. This can eventually provide more knowledge to the public and raise their concern on diet-related health problems. If individuals understood the importance of a healthful diet and the beneficial value behind it, and they were willing to make a change, it is believed that neglecting a healthful eating pattern in an adverse situation—such as facing an overtime work situation—should not be an excuse. The tiredness due to working long hours may somehow affect one’s appetite. However, one should not use this as an excuse to skip meals, and people should learn how to choose the right food to maintain a balanced diet. Moreover, one hopes that the message can be passed on not only within the research group in this chapter, but also to various sectors in the public. No matter what, one should not ignore the consequences of practising an unhealthful diet and the benefits obtained from a healthful diet. Overall, this chapter reflected the positive relationship between working overtime and practising a healthful diet. It is hoped that it fills the existing knowledge gap between these two health determinants. It is highly recommended that additional research concerning these two factors explored in the chapter can be conducted within similar target groups, both local and overseas as well as in different business sectors, in order to provide some insights into the relationship between working pattern and eating habits among various combinations. Moreover, this chapter can serve as a reminder to those people who must work overtime in their office to raise their awareness on their eating habits. This message is not only for the participants, but hopefully can be passed along to those who are within the social group of the participants. Furthermore, the participants showed little knowledge of existing health promotion programs. This could be a valuable topic for future researchers to explore and to evaluate the effectiveness and success of the existing health promotion programs organised by government as well as non-government organizations.

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AUTHOR’S BACKGROUND Ida N. K. Lau was completing her undergraduate study at the University of Liverpool in England with the bachelor degree in Biochemistry. She conducted her postgraduate study and earned her Master’s of Health Education and Health Promotion degree at the School of Public Health at The Chinese University of Hong Kong. This chapter originated from her master’s dissertation, completed in 2008.

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REFERENCES Anderson, R. (2003). Stress at work: the current perspective. The Journal of the Royal Society for the Promotion of Health, 123 (2), 81-87. Benz Scott, L. A. and Black, D. R. (1999). Health education and professional preparation: Health educator credibility, messaging learning, and behavior change. Health Education and Behavior, 26 (5), 609-620 Boissonnault, W. G. and Badke, M. B. (2005). Collecting health history information: The accuracy of a patient self-administered questionnaire in an Orthopedic outpatient setting. Physical Therapy, 85 (6), 531-543. Caplan, P. (1996). Why do people eat what they do? Approaches from food and diet from a social science perspective. Clinical Child Psychology and Psychiatry, 1 (2), 213-227. Caruso, C.C., Bushnell, T., Eggerth, D., Heitmann, A., Kojola, B., Newman, K., Rosa, R.R., Sauter, S.L. and Vila, B. (2006). Long working hours, safety, and health: Toward a national research agenda. American Journal of Industrial Medicine, 49 (11), 930-942. Chamberlain, K. (2004). Food and Health: Expanding the agenda for health psychology. Journal of Health Psychology, 9 (4), 467-481. Chung, R. T. Y., Pang, K. K. L. and Chan, K. S. L. (2006). Work life balance survey of the Hong Kong working population 2006. The University of Hong Kong: Public opinion programme. Cowley, S., Bergen, A., Young, K. and Kavanagh, A. (2000). A taxonomy of needs assessment, elicited from a multiple case study of community nursing education and practice. Journal of Advanced Nursing, 31 (1), 126-134. Crouter, A.C., Bumpus, M.F., Head, M.R. and McHale, S.M. (2001). Implication of overwork and overload for the quality of men’s family relationships. Journal of Marriage and Family, 63 (2), 404-416. Crum, C. F. (2004). Using a cognitive-behavioral modification strategy to increase on-task behavior of a student with a behavior disorder. Intervention in School and Clinic, 39(5), 305-309 Dembe, A.E., Erickson, J.B., Delbos, R.G. and Banks, S.M. (2005). The impact of overtime and long work hours on occupational injuries and illnesses: new evidence from the United States. Occupational and Environmental Medicine, 62 (9), 588-597. Denzin, N. and Lincoln, Y.S. (2003). Collecting and interpreting qualitative materials. (2nd ed.) Thousand Oaks: Sage Publication, pp. 9-13. Department of Health. Baseline survey for [email protected] campaign. Main

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report. Retrieved August 2007 from http://restaurant.eatsmart.gov.hk/files/pdf/ baseline_ survey_esr_campaign_en.pdf Department of Health. Central Health Education Unit. Two Plus Three Everyday. Retrieved 2005 from http://2plus3.cheu.gov.hk/html/eng/sec3_index.asp?fname=sec3_index.aspx Eakin, J.M., Cava, M., Smith, T.M. (2001). From theory to practice: A determinants approach to workplace health promotion in small business. Health promotion practice, 2 (2), 172181. Falk, L. W., Sobal, J., Bisogni, C. A., Connors, M. and Devine, C. M. (2001). Managing Healthy Eating: Definitions, Classifications, and Strategies. Health Education and Behavior, 28 (4), 425-439. Gillan A. Work until you drop: how the long hours culture is killing us. The Guardian Newspaper. Retrieved August 20, 2005 from http://money.guardian.co.uk/work/ story/0,1456,1552801,00.html Golafshani, N. (2003). Understanding reliability and validity in qualitative research. The Qualitative Report, 8 (4), 597-607. Government of The HKSAR (GovHK). Government moves to five-day week final phase. Retrieved 1st July, 2007 from http://www.info.gov.hk/info/5day/eng/index.htm Grosch, J.W., Caruso, C.C., Rosa, R.R. and Sauter, S.L. (2006). Long hours of work in the U.S.: Associations with demographic and organizational characteristics, psychosocial working conditions, and health. American Journal of Industrial Medicine, 49 (11), 943952. Hesketh, K., Waters, E., Green, J., Salmon, L. and Williams, J. (2005). Healthy eating, activity and obesity prevention: a qualitative study of parent and child perceptions in Australia. Health Promotion International, 20 (1), 19-26. Holmes, S. (2001). Work-related stress: a brief review. The Journal of The Royal Society for the Promotion of Health. 121 (4), 230-235. IHLO (International Trade Union Hong Kong Liaison Office) report. Hong Kong: Ten years on and no improvement in sight. Retrieved 30 June 2007 from http://www.ituccsi.org/IMG/pdf/Hong_Kong_report.pdf Inoue, K. and Matsumoto, M. (2000). Karo jisatsu (suicide from overwork): A spreading occupational threat. Occupational and Environmental Medicine, 57 (4), 284-288. Koelen, M.A. Vaandrager, L. and Colomér, C. (2001). Health promotion research: dilemmas and challenges. Journal of Epidemiology in Community Health, 55 (4), 257-262. Newcombe, R. G. (2007). Letter to Editor: Working hours and ill-health – A more serious relationship than it appears? International Journal of Cardiology, 114 (2), 284-285. Payne, N., Jones, F. and Harris, P. (2002). The impact of working life on health behavior: The effect of job strain on the cognitive predictors of exercise. Journal of Occupational Health Psychology, 7 (4), 342-353. Poissonnet, C.M. and Véron, M. (2000). Health effects of work schedules in healthcare professions. Journal of Clinical Nursing, 9 (1), 13-23. Pratt, J. R. (1999). Management News: Dealing with staff stress: Part 1. Home Help Care Management and Practice, 12 (1), 50-53. Schilling, J. (2006). On the pragmatics of qualitative assessment: Designing the process of content analysis. European Journal of Psychological Assessment, 22 (1), 28-37.

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Silverstein, L.B., Auerbach, C.F. and Levant, R. F. (2006). Using qualitative research to strengthen clinical practice. Professional Psychological: Research and Practice, 37 (4), 351-358. Special Topics Report No. 37: Pattern of hours of work of employees / Part-time employment. (2004). General Household Survey Section (1). Census and Statistics Department. Takashi, S., Seichi, H., Nagata, S. and Marui, E. (2004). Relationship between self- reported low productivity and overtime working. Occupational Medicine, 54 (1), 52-54. Truswell, A. S. (1998). Practical and realistic approaches to healthier diet modifications. American Journal of Clinical Nutrition, 67 (suppl), 583S-590S. Verplanken, B. and Faes, S. (1999). Good intentions, bad habits, and effects of forming implementation intentions on healthy eating. European Journal of Social Psychology, 29 (5-6), 591-604.

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In: Health Issues in Chinese Contexts, Volume 1 Editor: Zenobia C. Y. Chan

ISBN: 978-1-61209-385-7 © 2009 Nova Science Publishers, Inc.

Chapter 4

STRESSORS AMONG FEMALE PATIENTS UNDERGOING THORACIC SURGERY AND METHODS OF PRE-OPERATIVE EDUCATION TO REDUCE THEIR STRESSORS: TEN CASE STUDIES FROM HONG KONG S. H. Fok and Zenobia C. Y. Chan

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ABSTRACT This study aimed at exploring patients’ stressors, identifying pre-operative education need and stress level management. The study adopted a case study approach. Ten female pre-operative lung cancer participants were invited. Data was collected through in-depth interview, and content analysis was used for data analysis. The results showed stressors associated with anxiety, operative complications, and social, hospital and economic impacts. Religious and social support and information seeking were adopted for stress relief. Participants preferred small group instruction, written or audiovisual information to enhance memory. This study had limitations, such as time and funding constraints, and the results might not be generalized.

INTRODUCTION Usually, patients experience stress after admission into hospitals. Johnson et al. (1973), Hathaway (1986), and Gammon (1996) agreed that hospitalization is an extremely anxietyprovoking and worrying experience. However, Douglas et al. (1998) said that pre-operative education improved patient perceptions of vitality and mental health. Johnson et al. (1973), Byshee (1988), and Nelson (1996) argued that the provision of information helped to reduce stress. In recent years, Lookinland and Pool (1998) and Phelan et al. (2001) showed that ‘patient education’ had become one of the major activities among nursing interventions. In spite of the promotion of the quality of care, legal pressures of medical liability and financial

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pressures, patients and their significant others had increased desire for health care knowledge and played a more active role in their own care. Before the 1980s, nursing practice in Hong Kong focused on task-oriented care because it was highly effective in coping with the heavy workload. Later, the nursing professions developed awareness of holistic care. They were concerned with psychological well-being, physical and social support in caring for patients. However, the importance of pre-operative education was often neglected by the ward nurse. Many nurses did not recognize its effect on patients’ health outcome. Conversely, patients also did not understand the aim of preoperative education. They might not have paid attention to or simply refused to attend the program. Was the evidence on the effectiveness of pre-operative education strong enough to apply to the Chinese population? Could the method of pre-operative education meet the needs of the patients? These uncertainties reflected the necessity to explore the relationship between pre-operative education and health promotion in the Chinese context. This study aimed at exploring patients’ stressors prior to surgery, and whether preoperative education would meet their needs and reduce their stress level. This paper introduces the methodology of the study. It decides how to select the participants, collect and analyze data under ethical considerations. Then it describes the research results, analyzes the data and tries to draw a conclusion from the study. It also discusses the contribution and limitations and attempts to identify the implications of the study to current knowledge, practice, health promotion and health education.

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LITERATURE REVIEW A rigorous search was undertaken to identify relevant, reliable and valid reports through the electronic databases, including MEDLINE and CINAHL. The keywords were ‘preoperative education or information’, ‘stress’, ‘stress level’, and ‘anxiety’. The search aimed at reviewing the stress or anxiety of patients before surgery, the effect of pre-operative education, mode of pre-operative education, and the strengths and weaknesses of these studies.

Physiological Response of Stress Lundberg (2000) explained that the physiological response to stress was mediated by the Sympathetic Adrenal Medullary system (SAM), which influences catecholamine secretion, and the Hypothalamic Pituitary Adrenocortical (HPA) axis, which activates corticosteroid secretion. The SAM system reflects the intensity of stress and arousal and influences blood pressure and heart rate. The HPA axis responds to the affective aspects of stress, such as anxiety and distress. Lundberg (1995, 2000); Bjorntorp (1996); and Bjorntorp and Rosmond (2000) said that catecholamine, cortisol, cholesterol, blood pressure and heart rate were stress indicators and also a possible link between psychological stress and various physical health outcomes such as obesity, type II diabetes, hypertension, atherosclerosis, ischemic heart disease and coronary artery disease.

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Johnston and Wallace (1990), Mathews and Ridgeway (1981) argued that greater stress prior to surgery was associated with slower and more complicated post-operative recovery. Though McEwen (2002) explained that acute stress responses were necessary for survival, and that recurrent or prolonged stress responses led to wear and tear on bodily resources and increased the risk for future health problems.

Stress Management For stress management, Chan et al. (2006) presented various methods that were developed, such as physical exercise, progressive relaxation, tai chi, yoga, guided imagery and mindfulness meditation. Some of them are popular and have been widely adopted by the public nowadays. Within the health care system, researchers acknowledged the value of patient education. Devine and Cook (1986), Hathaway (1986), Breemhaar and van der Borne (1990), O’Connor et al. (1990), Mamon et al. (1992) and Lithner and Zilling (1998) stressed that there was a reduction of anxiety when information had been imparted during the preoperative period.

Effect of Pre-Operative Education

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Devine and Cook (1983) performed a meta-analysis which demonstrated benefits from receiving psycho-education interventions. The patients would have shortened length of stay, minimized medical complications, enhanced respiratory function tests and better resumption of activities. The experience from many professional staff members in Hong Kong also agreed that patients knew how to cooperate and comply after receiving pre-operative education.

Mode of Pre-Operative Education Style Among the studies, education programs were usually conducted by designated persons and adopted an interactive style between patients and staff. Chumbley et al. (2004) involved an anaesthetist or ward nurse to demonstrate the use of patient-controlled analgesia, and patients were allowed to ask questions. Ratanalert et al, (2002) invited an endoscopic nurse to conduct the education program and answered individuals’ questions. The involvement of designated persons to conduct the education program would ensure the uniqueness and comprehensiveness of the information. Content The content of pre-operative education usually includes different dimensions. Ayral et al. (2002) provided information involving the skills of surgery and anaesthesia, pre-operative preparation, pre-operative and post-operative nursing care and possible outcome of the surgery. Apart from the traditional type of leaflet and written information, Lewis et al. (2002)

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and Ayral et al. (2002) also provided information through advanced technology such as DVD multi-media and video, respectively.

Timing Chumbley et al. (2004) and Ayral et al. (2002) provided an education program on the day before surgery. Skelly (2003) conducted instruction on the day of preoperative assessment, and Quintrec (2002) delivered the information two to six weeks prior to the surgery. If the education program could be arranged days before the operation, then professional staff members are able to finish it systematically and patients are free from engaging in assessment or procedures performed by different disciplines.

Strengths and Weaknesses

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Strengths The studies showed the significant effect that pre-operative education had a positive implication on post-operative outcomes. Yen (2005) reported a shortened length of stay, Li (2005) showed that the patients experienced lower levels of post-operative pain and earlier ambulation, and Ratanalert et al. (2002) demonstrated adequate patient cooperation during the procedure. Therefore, it provided an evidence base for the nursing discipline to develop systematic patient education prior to surgery. Weaknesses Most of the studies—Yeh (2004), Lindberg and Willisch (2004), Lookinland et al. (1998), Chumbley et al. (2004), Lewis et al. (2002), Ayral et al. (2002), and Phelan et al. (2001)—were conducted with a quantitative approach, while only one study, conducted by Fitzpatrick and Abbey (2005), used a qualitative approach. It was difficult to search for more studies with a qualitative approach. Furthermore, most studies were performed in Western countries, especially the United States, by Phelan et al. (2001), Lookinland and Pool (1998), Raleigh et al. (1990) and in the UK by Chumbley et al. (2004), Hughes (2002), Beddows (1997), and Daphne (1996); while two studies were carried out in Taiwan by Yen (2005) and Li (2005). Since only two of these studies were conducted among Asian / Chinese cultures, it was uncertain whether the results could be generalized and applied to the Chinese population. According to the literature search, stress prior surgery might cause adverse effects to patients’ health. In fact, it was difficult to retrieve a study conducted in Hong Kong or in a Chinese context that focused on the exploration of stressors before various surgeries. Furthermore, although these studies showed the importance of an education program, they did not explore the teaching methods, mode of delivery, patients’ knowledge level, acceptance level or ability to deal with the new technology. In fact, patients were reported to refuse to attend the pre-operative education class because they did not understand the information. Watkins et al. (1986) and Davis et al. (1994) explained that giving more information might result in higher anxiety. Besides, Chinese, especially the older generation, having experienced the poorest and saddest period during the 1960s—i.e., the Great Leap Forward and the Cultural Revolution in mainland China—might

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be unable to read the written information or access the information through advanced technology owing to their lower education level or physical degeneration. As a result, it was in doubt regarding which method would mostly suit the Chinese population, especially the aged population, and alleviate their stressors or stress level.

SIGNIFICANCE OF THE STUDY This research would identify the stressors among patients before thoracic surgery. Then the health care professionals could design precise and concise interventions with a focus on patient stressors and tailor-made education program that would assist the patients to reduce their stress, cope with their critical life event and eventually promote health. Furthermore, it would stimulate followers to conduct further studies and seek results that could be generalized and applied to the whole population.

OBJECTIVES • • • •

Understand the stressors among the patients undergoing thoracic surgery Identify the patients’ needs regarding reducing their stress Identify the important role of pre-operative education in relieving stress Recognize the method of pre-operative education that would match with the patients’ needs

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METHODOLOGY Designs The project was conducted in a case study with a qualitative approach. Qualitative research had widely been adopted by various disciplines. Anthropology has used qualitative methods to understand cultural patterns and social relationships. Medical anthropology and medical sociology have relied on qualitative methods to explore the issues related to health and illness, from the micro-context of the clinical area to the broader socio-cultural context. Morse and Field (1985) explained that qualitative research was adopted when the research question pertained to understand or describe a particular phenomenon or event about which little was known; qualitative methods were particularly useful when describing a phenomenon from the emic perspective of the patient, caregiver or relatives. Bromley (1986) said that the case study usually deals with a relatively short, selfcontained episode or segment of a person’s life. It is a systematic inquiry into an event or a set of related events that aimed to describe and explain the phenomenon of interest. Various contemporary reports in different scopes, such as Bromley (1986) in psychology, Creswell (1997) and Yin (1994) in sociology, and Stake (1995) in education had used the case study method to develop rich and comprehensive understandings about people.

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In Chinese, there is an idiom: ‘heart, liver, spleen, lung, and kidney’ are the five vital organs. Therefore, lung surgery was regarded as a major surgery or a critical life-event and creates a substantial impact on one’s life. Different stressors would develop and affect health and post-operative outcome. Therefore, a case study and qualitative approach were chosen in exploring the stressors and education needs of people prior to thoracic surgery.

Research Questions There was a knowledge deficit in patients’ stressors before operation. Which kind of preoperative education would match the patients’ needs and alleviate the stressors? Therefore, the research questions were focused on ‘What were the stressors among patients undergoing thoracic surgery?’ and ‘In what way can pre-operative education alleviate the stressors?’

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Selection of Participants The selection of participants was based on intensity sampling. Denzin and Lincoln (1998) explained that intensity sampling was the selection of participants who were experiential about a particular experience. Within this study, the participants who were planning to have thoracic surgery were selected. The purposeful size of the participants was ten. The participant group was female. They were selected if their age ranged between 35 and 80, and planned elective lung resection surgery. The major lung disease group was lung carcinoma. They had no other history of surgery or psychiatric disease. Females were the only participant group because Gasperino and Rom (2004) and Pauk et al. (2005) said that woman appear to be at increased risk for most histologic types of lung cancer. In addition, many health care providers noted that women were more anxious and more likely to complain than men. Shaffer (1998) said that women easily underestimated the significant level of disease and stress level due to their social characteristics. In the Chinese context, especially the older generations, females are usually brought up and conceptualized as the major carer of the family. Family would be their first priority even when they were sick. It was noteworthy to focus on the stress issue and the related impact to the health of women, to place emphasis on women’s needs and explore deeply and seek suitable interventions for them.

DATA COLLECTION Individual in-Depth Interview The data was collected through an individual in-depth interview. Each interview lasted 1– 1½ hours. Darlington and Scott (2002) described the in-depth interview as a face-to-face interview, an active and meaning-making process. It would enhance the exploration of stress and suitable mode of pre-operative education for the participants.

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The semi-structure interview technique was used, and it involved a series of open-ended questions (Appendix I). The open-ended questions provided opportunities for both interviewer and interviewee to discuss some topics in more detail. Morse and Field (1985) stressed that semi-structure interview was useful because the interviewer could use cues or prompts to encourage the interviewee to elaborate the question. The data was collected by tape recording. This allowed the researcher to be free from taking notes, to observe more cautiously the interviewee’s response, and encouraged the interviewees to further express themselves as occasions arose. Moreover, the researcher was able to play back the information and guarantee that no useful information would be missed. However, it was necessary to notify the participant because the participant deserved the right to understand the process of the interview and consent to the recording.

Setting The study was conducted in a female cardiothoracic surgical ward within Queen Elizabeth Hospital. The ward was composed of eight female general beds and seven highdependency mixed beds. The individual interview was carried out in a single room. The participants could be transferred back to the clinical area whenever their condition suddenly deteriorated. It would also ensure the privacy, confidentiality and minimize interruption.

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DATA ANALYSIS The technique of content analysis was used for data analysis. Hancock (1998) explained that content can be analyzed at two levels. The basic level is solely transcription of data without any assumptions. The higher level is interpretation. The researcher examines the underlying meaning of the response. The process usually involves coding and classifying data. Therefore, a copy of the transcript was made after each of the interviews. All items would be recognized if they were in the right category before determining the linkage and relationship between them. Lastly, the original copy was reread to ensure that all useful information was analysed. A research assistant was employed for tape-recorded transcription and translating into English verbatim. The research assistant was fluent in both English and Cantonese. He had an honour’s diploma in biology from the former Baptist College, and a bachelor’s degree in law from Woverhampton University in the UK. Moreover, one of his job duties was acting as a secretary in various meetings. Apart from that, his job also included translation of the video interview into transcript. Therefore, he was acquainted in the use of Chinese and English, as well as the necessary techniques to prepare the transcript. Furthermore, the researcher monitored closely to ensure that the interpretation of the data would not be distorted throughout the translation process.

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TRUSTWORTHINESS Streubert and Carpenter (1995) argued that the goal of rigor in qualitative research was to accurately represent what those who had been studied experienced. Therefore, it was necessary to ensure the trustworthiness of the research. Tellis (1997) and Yin (1994) suggested that the development of a formal case study protocol enhanced the reliability of case study. Thus, several steps were implemented to ensure the trustworthiness. Firstly, the researcher developed research questions, formulated objectives and defined the major key terms before the study. These steps would guide the researcher to focus on and explore the main tasks and goals. Secondly, the semi-structure interview questions were set up to guarantee that the researcher would explore all of the proposed areas of the study. Thirdly, the in-depth interview could be continued until there was a saturation of data. According to Streubert and Carpenter (1995), saturation referred to the repetition of discovered information; no new themes or essences emerged from the participants.

ETHICAL CONSIDERATIONS Darlington and Scott (2002) explained that research ethics were based on core principles such as beneficence and duty of care. Therefore, mechanisms were developed to protect the interests of participants.

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Participants’ Consideration Before starting the interview, a comprehensive explanation on the aim and nature of the study was given and consent (Appendix II) to participate in the study was obtained. All participants were also informed that they might refuse to participate in the study. They could stop the interview at any time or refuse to answer any questions. In fact, the interviewer would also terminate the interview if the participants’ condition were to become unstable via facial expression under continuous observation. They were also assured of anonymity, although some of the information that they provided would be published, and all their information would be destroyed after the study.

Storage of Data All of the recorded and transcript data were locked and accessed by the researcher only. All raw data was destroyed by the researcher after the completion of the study. This served to protect the rights and ensure the confidentially of the participants.

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RESEARCH RESULTS Participants’ Profiles Ten female participants were successfully invited to join the study. Their age ranged from 35 to 78. Eight of them were married and two of them were single. Usually the participants were living with husband, children or siblings, while three participants were living alone. Most of the participants were housewife, and three of them were employed. The three participants over 70 years of age had a low education level. One of them could write her name only, and the other two participants could read limited words. All of the participants suffered from different levels of lung carcinoma and would undergo lung surgery. The details of the participants’ profiles are shown in the list (table 2). Within this paper, some codes are used to signify the participants to ensure anonymity. Thus, ‘I’ indicates the interviewer, whereas ‘P’ denotes the participants. The numeric code following ‘P’ suggests the sequence of the participants. Throughout the interview, the researcher encouraged the interviewees to express their feelings more deeply before the operation, and to talk about the nature of the stressors and their method for stress relief. The participants were also asked about their information needs, mode and time of delivery regarding the pre-operative education.

Stressors before Surgery Anxiety

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I: ‘What is your feeling now?’ P1: ‘I feel scared and worried … stress mainly comes from myself.’ P3: ‘I am worried about whether the tumour is benign or malignant. I am afraid to undergo radiotherapy or chemotherapy. My appearance will deteriorate; hair will be lost.’

As soon as the participants planned to undergo surgery, they would generate different degrees of stress owing to the uncertainty. One of the stressors was the possibility of followup treatment for the cancer after the operation. Apart from the side effects or the complication of altered physical appearance, there was a psychological impact. It might lower their selfesteem. They completely became a patient in front of the others. They perceived that they were unattractive due to their awful appearance. They might be unable to accept themselves. Johnston (1988) agreed that admission to hospital, anticipation of painful procedure, and worry about survival and recovery could all contribute to the stressful nature of the experience. As a result, the participants would link up all possible consequences with the operation and generate different degrees of anxiety when they were admitted for an operation.

Social Support P4: ‘I will go to my son’s home. The journey is so long. I will get car sick and vomit … I will also get car sick during travel to Japan, Thailand, and Korea.’ I: ‘So, you will be afraid that you cannot visit your son, grandchild, … take a trip after the operation?’

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Table 2. Personal and medical characteristics of the participants Code P1

Age 41

Martial status Married

P2

35

Married

P3

62

Married

P4

74

Married

P5

49

Single

P6

57

Married

P7

36

P8

Family member Husband, 1 daughter (age 17) Husband, 1 daughter (age 10) Husband, 2 sons (age 28 and 24)

Employment Employed Housewife

Diagnosis Right upper lobe nodule, left upper lobe nodule Left upper lobe mass

Housewife

Right middle zone nodule

3 sons (age >50, >40 and >30) brother and sister

Housewife

Carcinoma right upper lobe, D.M., H.T. Non-small cell carcinoma of left lower lobe

Housewife

Right lower lobe nodule, H.T.

Right thoracotomy and right lower lobectomy

Single

1 daughter, 1 son-in-law and 1 grandson Nil

Employed

Left lower lobe mass

76

Married

Nil

Housewife

Left upper lobe apical nodule

P9

78

Married

3 sons

Housewife

Carcinoma right upper lobe

P10

64

Married

Husband, 1 son and 1 daughter

Housewife

Left lower lobe mass

Left VAT + left lower lobectomy Left VAT + left upper lobectomy FOB + Right thoracotomy + right upper lobectomy Left VAT + left lower lobectomy

Employed

Type of surgery Right thoracotomy and right upper lobectomy Left thoracotomy and left upper lobectomy Right VAT and right thoracotomy and right middle lobectomy Right thoracotomy and right upper lobectomy Left VAT and left thoracotomy and left lower lobectomy

Others

Living alone Live with brother and sister

Living alone Living alone Living with third son

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P4: ‘Yes, I will.’

The participants might develop uncertainty if there were to be a change in their social life after the operation. They felt stress about being unable to maintain normal social interaction with others. P4: ‘No, I will never talk with them, they will tell me that nothing will happen and I should be fine…I also do not tell them (friends at the community centre). The aged people will speak badly… I also do not disclose to my close friends. I: ‘Will the bad words have a bad effect on you?’ P4: ‘Of course. I told them that I am taking a trip.’ P9: ‘My daughter-in-law is discontented with me…Death is best. Life is meaningless; I do not want to be a burden to my son.’

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In Chinese culture, it is taboo to speak bad words to others because they believe that these bad words become a curse. Conversely, they also do not like others to do the same to them, as they trust that it would badly affect their health. Consequently, they keep the condition of their health a secret and therefore do not receive the support of their social network. Furthermore, if their relationship with significant others is apathetic or bad, their stressor would be amplified or possibly develop into a sense of hopelessness. P3: ‘Today is the appointment and I must bring along the reports and go with him (husband), as well as tell the doctor…the first polyp was not too serious and the second polyp was confirmed to be benign…I worry about his health.’ I: ‘Is there any direct relationship between your operation and your husband’s health?’ P3: ‘I don’t know whether or not the cancer is inherited. I must take more caution when I have close contact with my relatives… My husband and I use common chopsticks when we eat. I am considered a patient by other people.’ P3: ‘We are over seventy; we rely on each other.’ P3: ‘It is very costly if they (two sons) come back (from UK and Taiwan). If they fail to come back, they will worry.’

The female participants had a strong bond with the family members. Though they were sick, they still maintained the caring role within the family. They would take every precaution to maintain the health of the family members. Caring for the family members would be the higher priority in contrast with their necessity to receive medical treatment. Conversely, they did not want to provoke any anxiety or worry for the family members. They chose to face the risk or stress by themselves despite their own need for support from the family. Baldree et al. (1982), Gurklis and Menke (1988) and Lok (1996) also reported that the physiological stressors were pain, discomfort, fluid and diet restriction, limitation of physical activities, fatigue and weakness. Therefore, the participants perceived their own inadequacy in maintaining a normal social life, inability to express their own needs and obtaining the support from the network, or demonstrating their caring role.

Hospital Systems P1: ‘This is a public hospital and we are not very familiar with the doctor.’

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P4: ‘I am afraid of trainees. The doctor and nurse are trainees.’

The reputation of the public hospital was lacking in their traditional view. They felt uneasy and were not able to build confidence in the professional medical and nursing staff when they were newly admitted to the hospital. Furthermore, in their concept, trainee means lack of experience and unskilled work. They might feel insecure if the trainees managed them because their chance of morbidity and mortality would greatly increase. Anderson (1975), Baldree et al. (1982), Eichel (1986) and Gurklis and Menke (1988) identified that the most frequent psychosocial stressors were anxiety, depression and feeling of inadequacy. When the participants experienced that they had no control over situation, they might generate stress.

Post-Operative Complications P1: ‘I am scared of any surgical failure, uncertainty following the operation and health deterioration.’ P1: ‘Mobility can deteriorate, or the body can be totally disabled or paralyzed.’ P4: ‘I am afraid of death…I have worked very hard for over half of my life. Now it has improved. Everything seems so good but I sudden require an operation. It is not worth it.’ P3: ‘It will be very painful in the operation. Will I be too tense that I cannot be able to relax? Will I fail to sleep and feel pain?’

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P7: Will I have difficulty breathing? How long will it take before I recover? Will my ribs be cut? These are my questions and worries.’ P8: ‘After discharge from hospital, I may not be able to cook. I have to go to the market to buy food, prepare and cut food with a knife and chopping board. I must use force. There will be a wound inside and I cannot recover so quickly.’

Usually, the participants felt stress when they encountered the uncertainly of surgery. The risk of an inoperable illness, death or disability affected their emotions. Pain was another common concern, especially among those who lived alone who worried about their ability to conducting activities of daily living by themselves. Their efforts to put plans in place before undergoing surgery created more stress. Johnston (1988) agreed that worry about survival and recovery could contribute to the stressful nature of the experience. Therefore, post-operative complications became one of the stressors about which they were concerned.

Economic impact P1: ‘I am scared about any possible adverse impact that will affect my family from an economic aspect,…working capability is lost right after the operation’ P5: My boss was not willing to release me but had no choice…he felt that I was irresponsible; the illness was not overriding. P5: ‘I am not young. I may not be able to get a job even I wish to…I am afraid that I cannot meet my expenses and I may lose my job.’

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P9: ‘I am afraid that a lot of problems require follow up (after surgery). The follow- up requires money. If I die, there would be no such problem at all. They (sons) are not wealthy.

The participants who were working were afraid of losing their job because of short notice prior to admission for surgery, and they might require a long recovery period. Their employers felt unhappy about suddenly losing manpower and might dismiss them later. Since some had reached middle-age, they thought that it was difficult to seek another job and would eventually lack financial support. Furthermore, the possibility of follow-up treatment for cancer might also induce additional financial burdens in the form of transport and treatment costs. They might not wealthy enough to cover these expenses on their own, and they did not want to become a financial burden to the family. Anderson (1975), Baldree et al. (1982), Eichel (1986) and Gurklis and Menke (1988) reported that stressors could come in any form, such as occupation. As a result, economic impact was also one of the stressors.

Method of Stress Relief Psychological / Spiritual Support I: ‘Why do you feel so clam?’ P2: ‘My support is coming from God, I think that it cannot be done by humans alone. Brothers and sisters of the church would pray for me, sing poetry to me.…My friends have shown their concern through telephone calls. They always tell me not to be so anxious, and that I will recover soon. My husband told me to relax, otherwise my anxiety may cause problems for the surgery or lead to a poor outcome.’

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P3: ‘I like to listen to Buddhism.’ P9: ‘If God asks me to go, I will follow Him. If God asks me to stay, I stay. Let God decide…I pray to Him….All rely on God.’

Usually, the participants who had religious support would be more relaxed and calm. They thought that their future was pre-determined or managed by their God. It was not under human control. Therefore, they believed that their God would prepare everything for them.

Clarification P5: ‘I hope that the doctors will tell me clearly where the problem is. If they could let me know more and explain it to me thoroughly, I would feel comfort psychologically’

The participants would feel relief from their stress if they were given more information. They would clarify any misunderstanding and queries with their doctors. Then they could feel psychologically well prepared. Devine and Cook (1986), Hathaway (1986), Breemhaar and van der Borne (1990), O’Connor et al. (1990), Mamon et al., (1992) and Lithner and Zilling (1998) stressed that there was a reduction of anxiety when information was imparted. Thus, provision of information would be considered an effective method in the management of stress.

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Social Support P1: ‘I have talked with them (husband and daughter), and whether or not the operation is successful, they will still comfort me.’ P1: ‘Having confidence in the doctor is very important…it would be better to have the same doctor for the medical assessment as well as the operation.’ P5: ‘I am very lucky because I have friends who say words to comfort me. They told me not to be too anxious, because my illness is not so serious….I listen to some optimistic views and I will become optimistic, and will not feel hopeless.’ P3: ‘The nurse will tell me encouraging words, such as don’t be afraid; such an operation is common; there will be only a little pain after the operation.’

It was shown that social support was an important element in relieving stress. Generally, the participants felt strong when they were accepted and given support by their family or friends. In fact, their family members and friends needed to do nothing other than voice some words of concern and care. Furthermore, the environment and every member of the professional medical and nursing staff were new to them. Therefore, they might have stress owing to the new experience. If the surgeons were to look after the participants throughout the whole period from medical assessment to the surgery, the surgeons would become their friends. They would have confidence in the surgeons and relief from their stress accordingly. Apart from that, they also regarded that they needed the support from nurses. Because the nurses express care verbally, they felt much better.

Mindfulness Meditation

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P3: ‘If you are afraid, just close your eyes.’ P6: ‘Comfort yourself. Being calm will be better. Being too nervous will affect the operation.’ P8: ‘Don’t think about that. I hope that the results will be good. If it is not satisfactory, it is predetermined.’

In fact, the participants would sometimes try not to think about the real situation in order to avoid creating any stress for themselves. For the management of stress, Chan et al. (2006) also agree that a variety of techniques are adopted in mindfulness meditation. Hence, the participants would assist in releasing some of their stress by keeping an open mind.

Preoperative Information Needs Nature of Disease P1: ‘I want to know more information regarding my disease, e.g., similar cases.’

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Nature of Operation P1: ‘Successful and failed cases, how the doctor operates, and how long for the anaesthesia.’

Post-Operative Care P2: ‘The information on recovery is useful for me…Apart from doing exercises to facilitate the recovery process, I thought more soup will also be useful…food might have a substantial effect.’ P6: ‘Tell me what should not be eaten after the operation…knowing more about the nursing care after the operation will be better.’ P3: ‘I have heard from my friends that I should not take analgesic medicine as long as I can tolerate the pain. Is that right? I do not have much knowledge on the drugs; I am afraid to become addict.’

Post-Operative Complication P1: ‘Regarding the possibility of having postoperative complications, it is better to know before the operation.’

Operative Surgeons

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P1: ‘The records of the doctor and whether the doctor usually conducts similar operations.…We are not familiar with the doctor, and this is different from the private hospital.’

According to participants’ descriptions, they need information regarding their disease and operation because they needed a smooth and speedy recovery. Therefore, they wanted more information on postoperative care and the complications that are associated with the operation. Then they could maximize their postoperative care and help to avoid complications. Henderson and Chien (2004) also suggested that the participants wished for all types of information about the proposed surgery. Therefore, the content of the information should include the nature of different diseases and operations, pre- and postoperative care, and possible postoperative complications.

Modes of Preoperative Education P5: ‘It will be time consuming if explained to us individually. The nurse might not have so much time. It may be in the form of a small group discussion. We may exchange our experiences.’ P6: ‘In the form of a group will be fine for me.…Sometimes you do not know; you may listen to others.’

Generally, the participants preferred to have the preoperative education talk in the form of a small group. They would be more relaxed and willing to raise questions, share experiences with others or learn from the others, and they regarded that it was impractical to conduct individual teaching by nurses in the busy environment. Among the studies, researchers usually adopted an interactive style. Chumbley et al. (2004) involved an

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anaesthetist or ward nurse to deliver the information, and patients were allowed to ask questions. Quintrec (2003) used a multi-disciplinary approach to brief the patients and their spouses, relatives or friends, and answered their questions. Therefore, the involvement of a small group of clients with their relatives or significant others in the program might minimize fear, promote relaxation and interaction between clients and professional staff. P2: ‘A pamphlet is good. We can read more details from the pamphlet.…But for the elders, there may have problems with their eyesight. If somebody reads to them it will be better.’ P1: ‘A leaflet could be read during leisure time.…A seminar is also good, but not to be held so frequently.…Holding a seminar before the operation is sufficient…perhaps in the form of a DVD or on the Internet.” P6: ‘A video or in paper form will suffice.…by mail, I would have more time.…I will forget if just listen to you. I could read it repeatedly.’ P5: ‘Although computer is popular nowadays, many people still don’t have one.…If you do not send the information to them by mail, they may not aware.’

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P4: ‘I do not know the words. I know neither Internet nor video. What is video?’

Usually, the participants thought that a booklet or pamphlet were useful because they might not absorb all of the information during the preoperative education talk. Then they could read the information carefully later for some information that they might have missed. However, low education level and deterioration of eyesight within the old age group might make them unable to read the written information or use the advanced technology. Ratanalert et al. (2002) prepared written information. Apart from the traditional type of leaflet and written information, Lewis et al. (2002) and Ayral et al. (2002) also provided information through advanced technology, such as DVD multi-media and video, respectively. Therefore, it was necessary to deliver the information in multi-dimension such as DVD, Internet or video, which might be considered instead of single mode of information delivery.

Timing of Preoperative Education I: ‘What is the right time to hold this seminar before your operation?’ P1: ‘A few days before the admission is sufficient…if too early, I will forget the information.’ P2: ‘One to two days before the operation is sufficient. If there is a substantial time lag between the seminar and operation, we may not be able to remember. One to two days in advance is appropriate for us to absorb the information and to ask any questions. If the seminar is held too early, anxiety may be created.’ P2: ‘The video will strengthen the knowledge…we may watch the video when we have time, have more understanding… the video should be given before admission.’ P3: ‘One week before is better….I need time to prepare psychologically.’

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P4: ‘One day before.’ P5: ‘It would be better when a patient has been confirmed to have a certain illness, the hospital should arrange a specific seminar to him.’

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P6: ‘One month to two weeks before.’

Most of the participants indicated that the preferred timing for preoperative education would be one to two days or less than one week before surgery. Therefore, memory would be fresh and minimal information would be lost. However, participants P5 and P6 would like to seek more information as soon as possible. This might reflect that the participants had an information need when they were told about their need for surgery. On the other hand, they were afraid that information would be lost if the preoperative education were conducted too early. Chumbley et al. (2004) and Ayral et al. (2002) provided an education program on the day before surgery, Skelly (2003) conducted instruction on the day of preoperative assessment, and Quintrec (2003) delivered the information two to six weeks prior to the surgery. Therefore, delivering the information to them at an early stage might be considered. Then the nurse could invite them to join the preoperative education talk within one week before the operation in order to recapture their memory and provide them with the chance to clarify any queries. Research results showed that stressors were associated with anxiety that was generated from uncertainty regarding the social support from family members, relatives and friends; the hospital systems which were related to unfamiliarity with the public hospital and lack of confidence in the trainees; potential postoperative complications; and economic impact that might be engendered from the effects of surgery. Usually, the participants would adopt different methods to relieve their stress, such as psychological or religious support, clarifying the information with the professional staff, gaining the support from family members or friends, or mindfulness meditation. For the preoperative information needs of the participants, they regarded all information relevant to their disease and operation as useful, especially the information on food and soup, which they believed was helpful in health promotion. The preferred mode of preoperative education program was small group teaching supplemented with written material, while the favorite timing of the program was one to two days prior to the operation or when they were informed about the need for surgery. This was because they thought that their memory would be fresh and information loss would be minimized, and the patients would be afforded better psychological preparation, respectively.

CONTRIBUTIONS Supporting Previous Literature Reviews From the results of the study, most of it supported the studies in the literature review. Within this study, the participants experienced anxiety when they were planning to have an operation because they linked up all of the possible consequences of the operation. Johnston (1988) said that admission to hospital, anticipation of a painful procedure, and worry about

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survival and recovery could all contribute to the stressful nature of the experience. Furthermore, the stressors of the participants included unfamiliarity with the environment and professional medical staff; complications such as pain, disability, deficits in self-care or social interaction; economic impact; or even death. Ellard et al. (2006) agreed that even when the operation was considered a minor surgery, strong emotional reactions could be provoked. Stressors could be in any form, such as sudden change in life event, disease, occupation, and so on. In the exploration of preoperative education needs, the participants indicated that they would have better psychological preparation if they could access the information as soon as they were told that they needed surgery. They might feel better if they were able to clarify their questions with the medical staff. Devine and Cook (1986), Hathaway (1986), Breemhaar and van der Borne (1990), O’Connor et al. (1990), Mamon et al. (1992) and Lithner and Zilling (1998) also stressed that there was a reduction in anxiety when information was imparted during the preoperative period. Furthermore, the participants considered that all of the information relevant to their disease and operation was useful. Henderson and Chien (2004) also suggested that the participants wished for all types of information about the proposed surgery. Moreover, the participants suggested that the preoperative education talk should be conducted one to two days or less than one month before the operation because they might forget the information if the education talk was held too soon before the day of surgery. Chumbley et al. (2004) and Ayral et al. (2002) provided an education program on the day before surgery, Skelly (2003) conducted instruction on the day of preoperative assessment, and Quintre (2002) delivered the information two to six weeks prior to the surgery. Hence, even though the culture might be different, their psychological response and need might not have a significant difference.

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Strength and Importance of the Study This study successfully identified the stressors of the participants. One of the significant and specific discoveries was the caring role of the females. Traditionally, the female is responsible for caring for the family members, parents, husband, children, grandchildren and so on. If the female caregiver were sick, her own illness would take a lower priority whenever there was a family member who needed care. Their stress would increase when they were unable to achieve the role of caregiver. McEwen (2002) explained that recurrent stress responses and prolonged activation of the bodily systems leads to wear and tear on bodily resources, which in turn increased the risk for future health problems. Therefore, the study alerted the nursing professions that caring, the particular social role for females, should also be taken into consideration as much as provision of preoperative care to clients. The study also identified a characteristic that is specific to the Chinese culture. This is the concern regarding diet after surgery, because the participants believed that the consumption of proper diet would speed up the recovery process. Therefore, it was necessary to provide more guidelines on diet instruction.

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LIMITATIONS Restriction of Time Throughout the study, the researcher experienced several limitations. Firstly, limited time was a crucial factor. There was only half a year available from the recruiting of participants to the process of data analyzing.

Restriction on Selection of Participants Although there was an increasing trend in females with lung cancer, the number of potential participants was much lower. Besides, many of the females, especially the older generation, were brought up to follow the belief of ‘three follow and four moral’ Sam Chung See Tak—they would follow their father at home, their husband after marriage and their son when they were old. Therefore, some of them indicated that they would like to decide in consultation with their children whether they should join the study; some of their children refused solely because they did not want their mother to know about their diagnosis or were afraid that the study would exacerbate their mother’s anxiety.

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Generalizability of the Research Furthermore, all participants were drawn from one thoracic surgical center, and the background of these participants was similar. Moreover, male patients were not included in the study, so a comparison and exploration between both genders and among different social classes was unavailable. This made the portrayal of the real needs of the entire surgical population impossible.

IMPLICATIONS FOR KNOWLEDGE, CLINICAL PRACTICE, HEALTH EDUCATION AND HEALTH PROMOTION Filing Knowledge-Practice Gaps In the past, the nurses were not aware of the significance of preoperative education, as they might have thought that previous literature might not be applicable to the Chinese population. Nevertheless, the research findings supported the previous literature review. Therefore, it reflected that the clients would be benefit from a tailor-made pre-education program for the Chinese population. In fact, the nurses had already implemented the preoperative education program. They might only need to revise the current practice and devise a tailor-made program with available resources to satisfy the clients’ needs. As a result, this study minimized the theory-practice gap in the clinical environment.

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Clinical Practice At present, the preoperative education program is conducted by the nurse specialist at regular intervals. However, only a limited number of clients would be invited to join the program. Therefore, the nurse specialist encouraged the ward nurse to conduct individual teaching for those who had not attended the structured preoperative education program. However, individual teaching might have disadvantages. Firstly, it would induce cost implications, as there was shortage of manpower. Secondly, the content of the program might vary if time and manpower were severely tightened. As a result, the effectiveness of the program might vary. According to the results of the study on the needs of the mode and timing of a preoperative education program, the necessity of revising the program was shown. For example, it might provide information via audio-visual aids such as video and written information during the preoperative assessment phase. This would ensure access to the information as soon as possible. These modes of delivery of preoperative education would satisfy clients with different needs, i.e., different levels of knowledge. Then the nurses of the clinical ward area could hold a small group education class for those clients who were scheduled to have surgery one to two days later. This would provide a chance for clients to clarify and ask questions, and share and learn from each other. In addition, it would also serve to reinforce and refresh their memory. Furthermore, their relatives or friends could be invited to participate in the program in order to promote a sense of support.

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Health Education and Health Promotion Devine and Cook (1983) demonstrated a meta-analysis that showed that the patients who received preoperative education would have a shortened length of stay, fewer medical complications, and better compliance with medical and nursing interventions. This implied that the patients had learned a strategy for coming and improved their postoperative health status through the participation in a preoperative program, achieving health promotion goals. Furthermore, a positive postoperative outcome enhances the patients’ belief that preoperative education is a method that boosts their coping skills in these vital events, i.e., surgery. Therefore, the patients could adopt it as one of their coping strategies in facing similar events later in their life. The patients would also become a live role model to the other patients, significant others or friends, because the bonding and trusting relationships among them were much stronger than the nurse-patient relationship. As a result, it would be easy to gain the support and cooperation from subsequent patients in participating in the preoperative education program. Thus, more patients would gain benefits for health promotion from the health education program. It also provided evidence that patients would benefit from the preoperative education. Then the nurse would be positively reinforced that his or her effort had enhanced the health promotion of patients. Moreover, the nurses would benefit from a reduced workload and stress level due to the quick recovery of patients.

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Further Direction for Clinical Practice and Research The result was consistent with the traditional belief among Chinese about the food treatment, Sik Liu. The Chinese believe that ginseng enhances respiratory function, bird’s nest promotes the immunological system, and Chinese soup supports health. Therefore, one might consider exploring more deeply the Sik Liu food treatment. This would assist in establishing a proper attitude towards diet among the Chinese instead of following the lay belief blindly. Under the current Hospital Authority policy, clients were cared for without a designated medical staff. This was an attempt to prevent too heavy or too light a workload for individual medical staff members. However, it would inevitably create stress for clients. For that reason, it might be worth reviewing the present policy, and to perform further studies to explore the implementation of family medicine, and cooperation among medical staff of various specialties and family medicine.

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CONCLUSION This study was conducted within the Cardiothoracic Surgical Unit of Queen Elizabeth Hospital. Ten female participants with lung cancer prior to surgery were invited. They all underwent an individual in-depth interview with recording. Content analysis was used for data analysis. The participants had to consent, and ethical consideration was ensured prior to the interview. The results of the study indicated that the participants’ stressors were associated with anxiety, postoperative complications, social interaction, hospital and economic impact. The participants relieved their stress through religious and social support and seeking more information. Usually, they preferred the preoperative education program in small groups and included all information that was relevant to the disease, surgery, postoperative care and complications. In addition, they suggested that the program should include hard copy such as leaflets, and DVDs or videos to enhance their memory. However, this study had some limitations. It included only female participants from one center because of limited time, resources and funding. The results might not be generalized and applied to both sexes and other surgical contexts. However, this study bridged the theorypractice gap, supported the previous literature findings and provided inspiration for further studies.

AUTHOR’S BACKGROUND FOK Sui-ha is a registered nurse. She is the ward manager of Department of Cardiothoracic Surgery, Queen Elizabeth Hospital where she has worked for over 15 years. She had completed the specialty training in cardiac and cardiothoracic intensive care nursing in Cardiac Intensive Care Unit of Queen Elizabeth Hospital and Adult Intensive Care Unit of Brompton Hospital in Unite Kingdom respectively. Besides, she had also been awarded Bachelor of Science in Nursing by The University of Hong Kong and Master of Science in Health Education and Health Promotion by The Chinese University of Hong Kong.

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Douglas, T. S., Mann, N. H. and Hodge, A. L. (1998). Evaluation of Preoperative patient Education and Computer-Assisted Patient Instruction. Journal of Spinal Disorders, 11 (1), 29-35. Eichel, C.J. (1986). Stress and coping in patients on CAPD compared to haemodialysis patients. American Nephrology Nurses Association Journal, 13(1), 9-13. Ellard, D. R., Barlow, J. H., Mian, R. and Patel, R. (2006). Perceived Stress, Psychological Well-being and the Activity of Neutrophils in Patients Undergoing Cardiopulmonary Bypass Surgery. Stress and Health, 22,143-152. Fitzpatrick, E. and Abbey, H. (2005). What characterizes the ‘usual’ pre-operative education in clinical contexts? AORN, 7(4), 251-258. Gammon, J. and Mulholland, C. W. (1996). Effect of preparatory information prior to elective total hip replacement on psychological coping outcomes. Journal of Advanced Nursing, 24, 303-330. Gasperino, J. and Rom, W.N. (2004). Gender and lung cancer. Clinical Lung Cancer, 5(6), 353-359. Gurklis, J.A. and Menke, E.M. (1988). Identification of stressors and use of coping methods in haemodialysis patients. Nursing Research, 37(4), 236-239. Hancock, B. (1998). Trent focus for research and development in primary health care: An introduction to qualitative research. U.K.: University of Nottingham. Hathaway, D. (1986). Effects of pre-operative instruction on post-operative outcomes: a meta-analysis. Nursing Research, 35, 269-274.. Henderson, A. and Chien, W. T. (2004). Information Needs of Hong Kong Chinese Patients Undergoing Surgery. Journal of Clinical Nursing, 13, 960-966. Hughes, S. (2002). The effects of giving patients pre-operative information. Nursing Standard, 16(28), 33-37. Johnson, J.E., Morrissey, J.F. and Leventhal, H. (1973). Psychological preparation for an endoscopic examination. Gastrointestinal Endoscopy, 19(4), 180-182. Johnston, M. (1988). Impending surgery. In S. Fisher and J. Reason (Eds), Handbook of life stress, cognition and health (pp. 79-100). Chichester: Wiley. Johnston, M. and Wallace, L. (Eds) (1990). Stress and medical procedures. Oxford: Oxford University Press. Lewis, C., Gunta, K. and Wong, D. (2002). Patient knowledge, behavior and satisfaction with the use of a preoperative DVD. Orthopaedic Nursing, 21(6), 41-49. Li, Y. L. and Wang, R. H. (2005). Abdominal surgery, pain and anxiety: preoperative nursing intervention. Journal of Advanced Nursing, 51(3), 252-260. Lindberg, N. M. and Wellisch, D. K. (2004). Identification of Traumatic Stress Reactions in Women at Increased Risk for Breast Cancer. Psychosomatics, 45,(1), 7-16. Lithner, M. and Zilling, T. (1998). Does pre-operative information increase the well-being after surgery? Nursing Science and Research in the Nordic Countries, 18, 31-33. Lok, P. (1996). Stressors, coping mechanism and quality of life among dialysis patients in Australia. Journal of Advanced Nursing, 23(5), 873-881. Lookinland, S. and Pool, M. (1998). Study on effect of methods of preoperative education in women. AORN, 67(1), 203-213. Lundberg, U. (1995). Methods and applications of stress research. Technology and Health Care, 3, 3 - 9.

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Lundberg, U. (2000). Catecholamines. In G. Fink (Ed.). Encyclopedia of stress, vol. 1 (408412). San Diego, CA: Academia Press. Mamon, J., Steinwachs, D.M., Fahey, M., Bone, L.R., Oktay, J. and Klein, L. (1992). Impact of hospital discharge planning on meeting patient needs on returning home. Health Services Research, 27,155-175. Mathews, A. and Ridgeway, V. (1981). Personality and surgical recovery: A review. British Journal of Clinical Psychology, 20(4), 243-260. McEwen, B.S. (2002). The end of stress as we know it. Washington, D.C.: J. Henry Press. Morse, J. M. and Field, P. A. (1985). Nursing research: the application of qualitative approaches, 2nd edition. London: Chapman and Hall. Nelson, S. (1996). Pre-admission Education for Patients Undergoing Cardiac Surgery. British Journal of Nursing, 5(6), 335 -340. O’Connor, F.W., Devine, E.C., Cook, T.D., Wenk, V.A. and Curtin, T.R. (1990). Enhancing surgical nurses’ patient education: development and evaluation of an intervention. Patient Education and Counseling, 16, 7-20. Pauk, N., Kubik, A., Zatloukal, P. and Krepela, F. (2005). Lung cancer in women. Lung Cancer, 48(1), 1-9. Phelan, E. A., Deyo, R. A., Cherkin, D. C., Weinstein, J. N., Ciol, M. A., Kreuter, W. and Howe, J. F. (2001). Helping patients decide about back surgery: a randomized trial of an interactive video program. Spine, 26(2), 206-212. Ratanalert, S., Soontrapornchai, P. and Ovartlarnporn, B. (2002). Preoperative education improves quality of patient care for endoscopic retrograde cholangiopancreatography. Gastroenterology Nursing, 26(1), 21-25. Shaffer, R. B. (1998). Cardiac surgery and women. The Journal of Cardiovascular Nursing, 12(4), 14-31. Stake, R.E. (1995). The art of case study research. Thousand Oaks, California: Sage Publications. Streubert, H. J. and Carpenter, D. R. (1995). Qualitative research in nursing: Advancing the humanistic imperative. Philadelphia: J.B. Lippincott Company. Tellis, W. (1997). Application of a case study methodology. The Qualitative Report, 3(3), 116. (http://www.nova.edu/ssss/QR/QR3-3/tellis2.html) Watkins, I.O., Weaver, I. and Odegaard, V. (1986). Preparation for cardiac catheterization: tailoring the content of instruction to coping style. Heart and Lung, 15, 382-389. Yeh, M. L., Chen, H. H. and Liu, P. H. (2005). Effects of multimedia with printed nursing guide in education on self-efficacy and functional activity and hospitalization in patients with hip replacement. Patient Education and Counseling, 57, 217-224. Yin, R.K. (1994). Case study research; design and methods (2nd edition). Newbury Park, California: Sage Publications.

APPENDIX I. SEMI-STRUCTURE INTERVIEW QUESTIONS Step I 1. Self-introduction. 2. Explain the reason and introduce the process of the interview.

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3. Remind the participant that the interview will be recorded, and the interview will be stopped whenever the participant refuses to continue or her condition does not allow. 4. Obtain informed consent. Step II 1. What do you feel before the surgery? 2. Do you feel stress? 3. What are the causes of stressors, e.g., family, the outcome of operation, occupation, etc.? 4. How do you deal with the stress that you have mentioned? 5. How do you relieve your stress level? 6. Can preoperation education help you to relieve your stress? 7. Which type of method of preoperative education will meet your needs?

APPENDIX II. CONSENT ‘Stressors among patients undergo thoracic surgery and methods of pre-operative education to reduce their stressors: ten case studies from Hong Kong.’

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Dear Participant: I am FOK Sui-ha, a master degree student of The Chinese University of Hong Kong. I am conducting a study called ‘Stressors among patients undergoing thoracic surgery and methods of pre-operative education to reduce their stressors: ten case studies from Hong Kong.’ I would like to invite you to join the program so I have a chance to work out a more systematic method to assist preoperative patients in relieving their stressors and yield a better postoperative outcome. Participation in the program is voluntary. Your refusal to join the study will not affect care received at the Department of Cardiothoracic Surgery. I will stop the interview whenever you want to discontinue participation, or your condition is not suitable to carry on. All of your information will be kept confidential and will not be shared with the ward staff. The final report will contain anonymous quotations only, and all information will be destroyed after the program. Thank you for your participation.

Name: (Participant) Sign: Date:

____________ ____________ ____________

Name: (Researcher) Sign: Date:

____________ ____________ ____________

Name: (Witness) Sign: Date:

I, FOK Sui-ha will send you the result of the study if you desire. *Yes___ No___ (√ if appropriate)

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In: Health Issues in Chinese Contexts, Volume 1 Editor: Zenobia C. Y. Chan

ISBN: 978-1-61209-385-7 © 2009 Nova Science Publishers, Inc.

Chapter 5

NURSING CRISIS MANAGEMENT: FIRE SAFETY IN OPERATING THEATRES Yvonne Y. Wong and Zenobia C. Y. Chan

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ABSTRACT Patient safety is a global challenge today. It is the nurses’ chief responsibility. The hospital environment is a potential place for patient safety crises to occur, particularly in operating theatres. There are many hidden risks that can harm both patients and health care professionals, causing many medical incidents. When careful crisis management is in place, the potential risks can be handled properly. Though fire is an inborn risk in the operating theatre, few studies have focused on nursing crisis management related to the operating theatre’s fire safety. This chapter attempts to address the importance of fire safety nursing crisis management in the operating theatre and perioperative nurses’ capability in this field. The close relationship between crisis management and health care professionals, traps existng in the operating theatre and an actual fire incident that took place in a Hong Kong operating theatre are introduced. Through a local case scenario, it is hoped that a wellstructured fire safety crisis management plan in operating theatres is developed to prepare for any future fire crises. Hospitals’ administrative and frontline staff can learn from this small but significant episode. Operating theatre nursing staff members should also equip themselves well in managing crisis by means of regular training.

INTRODUCTION Crises cause huge human and financial losses. They also have an unpredictable impact on society (Lalonde, 2007). As the world advances, the frequency and dimensions of crises are also expanding (Coleman, 2006). Crises happen in the natural environment, health care settings, airlines and petroleum companies (Harvard Business School, 2004). Events like the 9/11 terror attack, severe acute respiratory syndrome, and ozone layer depletion are just the tip of the iceberg (Daniell, 2004).

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Good crisis management in the hospital setting is vital to patient safety, which is an important topic in the health care field nowadays. Comprehensive management also helps to maintain the quality of health care services provided (Spillan, 2003). Nevertheless, few studies have focused on crisis management in health care organizations (Alfredsdottir and Bjornsdottir, 2008; Spillan, 2003). Operating theatres contain many unseen environmental risks that can endanger patient safety (Tzeng, 2006). The occurring frequency and severity in operating theatres are greater than in any other clinical areas (Stokowski, 2007). The operating room nurse is the main person who delivers patient care perioperatively. There is little literature and research on nursing crisis management. Crisis management is mainly focused on reducing physicians’ medical errors (Shcoenbaum and Segel, 2006). Fire is an innate risk. It occurs when a source of ignition makes contact with a combustible object. Many sectors, like the petroleum industry, government buildings and transportation network, have noted the importance of fire safety by installing fire alarm systems and doing regular fire risk assessments and drills (Fire Services Department, 2008). Fire is also a potential risk in operating theatres. In the United States, the Association of periOperative Registered Nurses has prepared a fire safety tool kit and some relevant guidelines. This is to raise theatre nurses’ awareness on this subject and to better prepare perioperative nurses in fire prevention (AORN, 2008). However, operating theatre fire safety information in Hong Kong is insufficient compared with other countries. As a result, fire safety in the operating theatre is a crucial issue that must be addressed and explored (Association of periOperative Registered Nurses 2005). A well-planned and effective fire crisis management system in the operating theatres of Hong Kong is necessary. This chapter consists of four parts: 1) a brief literature review on crisis management and its relation with health care settings; 2) a presentation of the possible crises in operating theatres followed by a case scenario of a fire crisis in an operating theatre; 3) a fire safety crisis management plan for operating theatres; and 4) some discussions based on fire safety in operating theatres. It contains three objectives: 1) to present the topic of fire safety in Hong Kong operating theatres; 2) to introduce a crisis management plan that is locally constructed; and 3) to suggest some implications for future crisis management.

LITERATURE REVIEW Overview of Crisis and Crisis Management A crisis is a sudden and serious situation that requires prompt action (Harvard Business School, 2004). It represents both opportunity and danger (Hoff, 2001) and makes people learn and grow (Wiger and Harowski, 2003). Individuals and groups at all levels can be affected (Borodzicz and Haperen, 2002). Crisis management is the process of working throughout a crisis until it is resolved (Hoff, 2001) with the use of suitable crisis interventions (Spillan, 2003). This concept has arisen since ancient times. Hansell (1976) mentioned that our antecedents could predict natural disasters by warnings. They planned and manipulated effective methods to save their lives (as cited in Hoff, 2001). The theory and practice of crisis management is founded on inherent human characteristics such as helping the needy and the culture of caring. Knowledge from

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health and social sciences like Freud’s psychoanalytic theory and ego psychology further consolidate the field of crisis management.

Crisis Management in the Health Care Sector The general public perceives that the present health care sector is dangerous and ineffective (Hoyle 2005). Studies have shown that around 44,000 to 98,000 patients die due to medical errors annually in the United States. Nearly 800 health care errors occurred in the United Kingdom. Moreover, at least 10% of hospitalized patients experienced injuries caused by the medical management that originally helped them (Edozien, 2005; Hoyle, 2005). Due to the huge medical expenditure, the current health care environment centres on cost control. As a result, there is inadequate financial support for preparing health care crises (Tzeng 2006); the existing crisis management system and the guidelines are therefore not complete enough.

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Health Care Professionals, Crisis and Crisis Management Health care professionals like nurses are generally viewed as crisis counsellors, who often carry out crisis interventions in health care setting for their clients with life-threatening diseases and disasters (Hoff, 2001). On the other hand, health care providers themselves may also face crises due to the high-risk hospital environment (Abu Zead, 2006). Many patient safety crises are taking place every day (Tzeng 2006). Maintaining patient safety is a crucial global responsibility of all health personnel (Flanagan et al., 2004), especially nurses (Nursing Council of Hong Kong, 2002; Kozier et al., 2004). This principle is particularly applicable to operating theatre nursing. Operating theatre nursing is the first recognized nursing specialty (McGarvey et al., 2000). This group of nurses utilize proficient surgical techniques to offer good patient care services (Bull and FitzGerald, 2006). Continued maintenance of patient safety has been identified as the heart of operating theatre nursing (Alfredsdottir and Bjornsdottir, 2008). A great number of surgeries are performed every day around the world. If the quality of surgical care and safety standards of surgery are poor, this can seriously affect millions of human lives worldwide. However, operating theatre nurses are criticized for caring more about instruments than people. Operating theatre nurses put a greater amount of effort into protecting surgical patients in a technological theatre environment than colleagues in other settings (McGarvey et al., 2000). Surgical site infection, retained foreign bodies, postoperative bleeding and wrong site surgery are just some of the adverse complications in operating theatres (Association of periOperative Registered Nurses, 2007; Schimpff, 2007). The Association of periOperative Registered Nurses has pioneered the establishment of a council on surgical and perioperative safety for cultivating an atmosphere of patient safety (Association of periOperative Registered Nurses, 2002). Therefore, a patient safety programme focusing specifically on surgical safety has been launched globally. It aims at the safest handling and care of surgical patients (World Health Organization 2008). When a culture of safety in operating theatres is built, this supports the open discussion of errors, and patients’ and health care professionals’ safety can be protected (Association of periOperative Registered Nurses, 2006). In addition, the operating theatre’s

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security and quality can be improved without adding any extra burden to current health care resources (World Health Organization 2008).

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POTENTIAL CRISIS IN OPERATING THEATRES The operating theatre is a complex environment. Many threats have existed that have led to a high incidence of medical errors. These errors are unintentional and careless acts that may or may not injure patients (Silen-Lipponen et al., 2004). There are mainly three levels of health care errors (Hoyle 2005): ‘Near miss’ is an error that is likely to happen but is prevented; ‘adverse event’ is a condition that alters a patient’s safety but does not cause harm to the patient; ‘adverse outcome’ is an incident that is harmful to patients. Operating theatre risks are due to a number of factors: the rapid change in health care technology, shrinking financial support, expanded usage (Silen-Lipponen et al., 2005), different surgical procedures performed and various surgical instruments used, the assorted health problems of the surgical patients, the diverse capacities of theatre personnel (Edozien, 2005; Hoyle, 2005) and the theatre environment itself (Abu Zead, 2006). Several kinds of theatre environmental safety hazards are classified: physical, such as fire; chemical, such as sterilizing and antiseptic agents; and biological, such as needles and blades. These hazards may harm patients and even the working staff (Abu Zead, 2006). Among all of them, greater attention should be paid to surgical fires, though their occurrence is rare. This is because fire can cause the most detrimental consequence (Joint Commission, 2003). It is inborn and exists everywhere in operating theatres, but can be avoided with well-developed guidelines and training of perioperative staff. Approximately 100 fire incidents on operative patients have been reported each year, which caused 20 patients to be seriously injured and one or two to die (Association of periOperative Registered Nurses, 2005). Surgical site errors are also caused by operating room staff members themselves. Operating room nurses feel tense and challenged by working in the complex OT environment. This issue also creates a threat to patient safety (Alfredsdottir and Bjornsdottir, 2008). Nurses require high sensitivity, productivity and multiple-functioning capabilities. Simultaneously, they must handle requests from other operating room members, provide surgical instruments, be familiar with surgical technology and worry about patients’ security during operations (Rothrock, 2003; Silen-Lipponen et al., 2005). They become fatigued and lose concentration. In addition, the nurses’ demanding shift work reduces their attentiveness and increases their mental pressure. Studies have also found that insufficient communication among surgical team members and lack of skill among operating room nurses are a common phenomenon. All o fthese factors add to the chance of developing health care errors (Silen-Lipponen et al., 2005). Their ability to predict and control errors are lessened (Alfredsdottir and Bjornsdottir, 2008). When nurses encounter errors, if they cannot handle and solve them at that point, crises may occur (Hoff 2001).

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Local Hong Kong Situation In Hong Kong, the health care system is divided into public and private sectors. Most of the local health care services rely on the public health care system (Health and Medical Development Advisory Committee, 2005). There are a total of 38 public hospitals in Hong Kong. They are managed by a statutory body called the Hospital Authority (HA). Public hospitals are distributed into different clusters according to their location and direction (e.g., Hong Kong West, Kowloon Central and the New Territories East). They are also categorized into two types: major and other. Major hospitals are mainly acute care hospitals with a larger number of beds and more comprehensive medical facilities. There were approximately 340,000 operations done on patients admitted to public hospitals in 2005–2006 (HA, 2007a). The HA has implemented a quality and risk management system to maintain service quality and safety for all staff members and patients (HA, 2007c). It has also introduced a revised reporting and monitoring system on all adverse incidents since August 2007. This new system guarantees a quick response to any patient-harm crisis, thereby reducing the impact on patients, staff and hospitals (HA, 2007b). Crisis management has been well-adopted by the Hong Kong medical professional recently to tackle infectious diseases like avian influenza, with the development of a contingency plan (Health, Welfare and Food Bureau, 2007). The HA has also updated its infectious disease preparedness plan in public hospitals, providing infection control training, assisting in carrying out the latest influenza vaccination programme for vulnerable groups in the community setting, and conducting drills to consolidate the HA’s awareness during infectious outbreak crises (HA, 2007c). From the above literature review, we can see that crisis management can be applied to different settings, including the health care services, whether in hospitals or the community settings. However, the use of crisis management in local nursing professional and operating theatre settings seems to be weak and not fully applied. Therefore, based on the following case scenario involving nurses in a local operating theatre environment, the awareness of crisis management in nursing and operating theatre can be raised.

Case Scenario During a minimal invasive surgery, surgical team members (anaesthetist, surgeon and nurses) were paying full attention to the television monitor which allowed the visualization of the surgery being performed. All of a sudden, sparks came out from the fibre optic light cable connected to the television system. Concurrently, the anaesthetic machine alarm sounded. The patient had no heart rate and a flat electrocardiogram was shown on the monitor. The surgeon shouted to the circulating nurse (who was a new university graduate six months prior) to cut off all power supply of electrical equipments and ordered the nurse assistant to check for the instruments and equipments. The anaesthetist rushed to the patient’s side to check for all possible sources of errors. That junior nurse was instructed by the anaesthetist to run out and call for help. Nurses in other operating rooms ran in. The new nurse stared at the messy environment. She lost control of herself, ran out of the operating room and cried. The patient’s heart rate was finally restored, and activities continued without any other interventions. After the surgery, some of the patient’s skin was found to be lightly burned, and the light cable was found have broken light fibres.

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From the above scenario, although everyone was safe, problems did exist. OR nurses lacked knowledge of electrical safety and emergency handling skills. No formal guidelines were provided to theatre staff on handling surgical fires. Electrical equipment had not been inspected regularly. Nurses lacked confidence in handling clinical situations independently, especially the emergencies. We must learn from this lesson to establish a well-structured fire crisis management plan for operating theatre nurses.

CRISIS MANAGEMENT PLAN IN OPERATING THEATRES

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The plan is summarized in a flowchart. It aims to restore patient’s and staff’s optimal physical (Wiger and Harowski, 2003), psychological functions and their coping abilities (Hoff, 2001). In addition, it prepares OR nurses for future episodes. The plan should encompass both actions in preventing and controlling crises (Tzeng, 2006). It is divided into three phases: emergency, prevention and consolidation/reconstruction. Lastly, in the consolidation and reconstruction phase, evaluation, refinement and improvement of the whole crisis management process and the preparedness plan take place in order to be ready for the next crisis.

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Emergency Phase

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Once a crisis is identified, the theatre nurse in charge acts promptly and decisively to prevent the circumstance from growing worse. People in crisis are always the top priority group to address (Vincent, 2001; Wiger and Harowski, 2003; Harvard Business School, 2004). Their psychological and physical needs are both important, but life should be saved first (Hoff, 2001). Resident physicians are notified to provide emergency medical treatment to ensure the physical stabilization of the people involved. The theatre nurse in charge reports the incident to the hospital administrators (president and chief nursing officer) at once. The chief nursing officer and department head get to the scene right away to express their concern and assess the patient’s and employees’ condition, and to collect information about the crisis. This shows that the hospital is extremely concerned about every employee and client (Harvard Business School, 2004). The presence of nursing heads may provide comfort and support to the staff as well. Hospital administrators then quickly act as the crisis team leaders and call for the establishment of a crisis management committee. This is a particularly efficient way to handle the complicated and unusual tasks during crises (Harvard Business School, 2004). The team members should consist of multi-disciplinary professions (Wiger and Harowski, 2003). The strengths and experience of each member can be fully utilized to reduce the effects of the crisis in all aspects to a minimum. Besides administrative staff, the team encompasses resident physicians, theatre department nursing officers, a psychologist, a public relations officer and a hospital legal representative. The group members must communicate effectively (open, two-way and highly cohesive), share the same goal to resolve the present situation, and prepare for the future crisis (Kozier et al., 2004). They identify and prioritize the problems and victims, discuss the actions and allocate the work of each member to maintain safety and support all victims through four steps: assessment, implementation, follow-up and referral.

Assessment Physicians keep close observation on the surgical patients for physical condition and the burn wounds. When immediate physical problems have been addressed, crisis assessment of the victims is done without delay, by theatre nurses in charge, who have the best understanding of theatre environment, different surgical procedures, reasons for people’s fear of surgery and more familiarity with their staffs’ personalities and abilities. Thus, they are useful in providing a more precise and correct report of the victims’ condition. The assessment helps to evaluate the whole picture of the crisis, the extent to which sufferers are affected by the crisis, understand people’s wants and let them voice their feelings. The new nurse is the first to be approached, as she or he suffers most, followed by personnel including the anaesthetist, surgeon and nurse assistants. Although other theatre nurses are not directly involved in this case, a group meeting for all theatre nurses may be held to allow them to vent their opinions and fears as this event may also impact their emotions. From this group gathering, potential victims may also be assessed and identified for further counselling. As the crisis occurs during surgery when client is put to sleep, the patient knows nothing about the condition. However, the patient has the right to know information regarding his or her medical condition (Hospital Authority, 1999); thus, medical personnel must detail the crisis to him or her and perform an assessment after waking from the surgery.

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Moreover, the committee seeks legal advice from the lawyer for assessing the risks for possible lawsuit and required compensation for the patient, his or her relatives and staff. It also considers the need to clarify the crisis and deliver specific and relevant messages to different parties such as hospital staff, patient and relatives, and public and mass media, as they have different interests regarding the crisis. When updated and correct crisis details are delivered, rumours are inhibited (Harvard Business School, 2004).

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Implementation Doctors provide treatments like wound dressing and medications based on patient and wound condition to prevent infection. Nursing officers have individual meetings with all victims, in a quiet and calm room, which provides privacy and encourages communication (Kozier et al., 2004). Theatre nursing heads can calm victims’ emotions by showing understanding about their experience, speaking genuinely, giving positive facial expressions and light touching to hands or shoulder, and reassuring them that the situation is under control (Wiger and Harowski, 2003). Moreover, active listening plus moderate nodding and eye contact are also necessary. All of these actions promote a trusting relationship and effective communication. Victims are willing to express more. Concurrently, the crisis committee prepares the initial incident report for public announcement. A public relations officer with excellent communication skills and experience, acting as the hospital spokesperson, holds a meeting with all department heads, publishes an internal circular for all hospital staff, and makes direct contact with patient and patients’ relatives to clarify the incident and send a sincere apology and compensations (like a discount on the hospital charges and free follow-up services) on behalf of the hospital, which can reduce patients’ complaints and legal actions (Vincent, 2001). The public relations officer issues a press release to report the case to the public and the mass media. Follow-up and Referral All victims have regular follow-up meetings (once per week) for a one-month period after the crisis with doctors and nursing heads for an assessment of their physical and psychological progress. Those still physically and emotionally unstable are further referred to speciality doctors and hospital clinical psychologists, respectively, for continued treatment and counselling. An information hotline service is set up and regulated by the public relations department for any further inquiries from the public and mass media (Harvard Business School, 2004).

Preventive Phase When people have gotten optimal care, the committee then formulates and executes a fire safety preparedness plan. Good preparation is the solution to future theatre fire safety (Association of periOperative Registered Nurses, 2005). The planning must involve multiprofessional opinions from crisis management team members, operating theatre staff, fire department and medical equipment companies. The committee develops guidelines that clearly define the roles of surgical team members in fire episodes during surgery to ensure the safety of both patients and staff members. It also

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creates a staff development programme on fire safety to ensure that all theatre staff members are skillful and competent in handling fires in the operating room (Association of periOperative Registered Nurses, 2005). Fire service officers from the Hong Kong Fire Services Department are invited to provide fire safety educational talks and training and demonstration courses for theatre staff on basic principles of fire (components of fire triangle), risk factors in the operating theatre that lead to electrical hazards, the concepts, and location and proper use of different types of fire extinguishers. The committee co-organizes with the fire department to develop and execute an operating theatre fire evacuation plan and plan and run regular emergency fire drills for all theatre employees. All staff members can be fully aware of the direction, locations and routes of all fire exits and the meeting place (Fire Services Department, 2003; Association of periOperative Registered Nurses, 2005). The committee evaluates the fire drill and evacuation plans after each fire drill. This reveals its capacity, staff responsiveness and any weakness in emergency situations to make improvements (Joint Commission, 2005). A crisis audit is conducted to classify all potential sources of fire risks in the operating theatre setting through real inspection and complete information gathering from personnel at all levels. Once all risks are recognized, committee members take actions to resolve all potential crises. Based on the scenario, fibre optic light cables plus any kind of electrical equipment should be checked cyclically by a proper technician to make sure it is in good working order. The fire equipment in the OT should be examined and maintained by registered fire department contractors to certify that the equipment works at all times (Fire Services Department, 2006).

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Consolidation and Reconstruction Phase At this phase, after the crisis management plan has been carried out, the crisis team has regular meetings to report updated crisis management progress. For instance, a post-crisis theatre audit is done and risks are identified. A summary report is drawn up and presented. Team members define the possible actions and put them into practice. An operating theatre fire drill is undertaken. After the implementation of all plans, evaluations are done by various parties involved for any shortcomings, and new ideas are incorporated. The plans are revised, strengthened and become more powerful. In order to reduce fire risks in the OT, the plans must be restructured by retesting and reviewing continuously (Harvard Business School, 2004). Fire risk audits, drills and staff training must be held periodically to reinforce the operating theatre staff members’ awareness and knowledge of fire safety.

IMPLICATIONS OF CRISIS MANAGEMENT PRACTICE FOR NURSES From the View of OT Fire Safety to Crisis Management The operating theatre fire crisis example lets us know that a natural threat can lead to an overwhelming outcome even in a small working environment. Hence, we should not overlook

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the power of crises in small settings. Though crises occur on any scale and in any environment, unfair treatment between large and small-scale environments has been demonstrated. Take the attack of the super storm Hurricane Katrina in United States in 2005 as an example. It caused vast destruction of both large cities and small towns. Yet, citizens and businesses in small communities received unsatisfactory assistance for recovery when compared with their larger counterparts (Runyan, 2006). We must admit the truth that crises are unavoidable. Therefore, the primer of all organizations and departments, especially small ones like operating theatres, should put effort into formulating a good crisis management system. It starts from the development of a specific team, identification of potential sources of crises, and establishment of a contingency plan until the resolution of the crisis events with reflections and learning. However, some managers think that crisis management is unimportant, especially those of small-scale organizations/departments. They claim that they do not have enough resources (time and money) and think that crises will not happen to them. Even when crises appear, they assume that they can overcome all of the problems when crises actually appear. The SARS outbreak in 2002 is a lesson to us. This new infectious disease was transmitted from mainland China to Hong Kong through the community to hospital setting. As local hospitals did not have a well-planned infection control policy beforehand and health care professionals lacked comprehensive infection control knowledge and protection, the new emerging disease spread dramatically and took many precious human lives (World Health Organization, 2003). Nonetheless, infectious diseases have existed for centuries and infection control protocol should be well structured, but this is not the case in reality. If health care workers were all well trained, with full personal protective equipment and highly alerted to infectious diseases, the outcome might be totally different. As a result, we should actively empower people in smaller groups to effectively plan and handle crises. Furthermore, natural event crises in the operating theatre setting and the hospital or even community setting all share similar characteristics. They are infrequent and unpredictable, but cause great consequences. These crises significantly affect people’s emotions. Quick responses, good communication and multidisciplinary cooperation are required to solve crises. A leader, with the ability to influence others, make speedy decisions and put people first during the critical time, can effectively move the people involved away from the distress of the crisis and resolve the problem (Klann 2003). However, there is a distinct difference in the attributes of victims involved in an operating theatre and other settings. All people entangled in other settings are alert and conscious. They know that they are in danger and can escape from the crisis. On the other hand, surgical patients encountering fire during the operation are usually under anaesthesia and not awake. They cannot flee from the threat themselves. Their lives are completely dependent upon the operating theatre personnel, especially nurses. Therefore, local nurses must strictly adhere to the Code of Professional Conduct for Nurses. When fire breaks out during surgery, they should make the optimal decision for the patient to safeguard his or her life when the patient is mentally debilitated due to anaesthesia. Nurses should remove sources of fire away from the patient, assist doctors to finish the surgery in the fastest way, supply anaesthetists all necessary equipment and medications to maintain the patient’s breathing, and assist the patient’s transfer and transport out of the operating theatre to a safe area (Association of periOperative Registered Nurses, 2006).

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A Call for Crisis Management Training for Nurses Well-equipped theatre nurses are crucial for providing optimal perioperative patient care. To effectively raise the quality of patient care provision in Hong Kong, nursing education has been upgraded from hospital-based training to four-year university-based training, and a large proportion of enrolled nurses have also joined the conversion program to become degree-level registered nurses (Kirschling, 2003). This helps to increase nurses’ autonomy and status in the health care field. Several studies have suggested that degree nurses have better critical thinking, better communication skills and are more independent. However, they are also perceived to be too theoretical with less focus on practice (Thompson, 2006) and they are also weak in teamwork (Cruess and Cruess, 2006). They know the emergency handling theories, but they have no idea how to handle these crises in real situations. This condition is rooted in the fact that undergraduate programs do not highly prioritize patient safety issues (Flanagan et al., 2004). Therefore, crisis management skills with adequate practice must be addressed starting at the beginning of university nursing training. Nevertheless, it seems unethical for novice nurses to practice any skills on real patients, especially those who are unstable and in life-threatening situations. Patients’ safety is endangered when action is delayed or incorrect treatment is given. It violates nurses’ professional conduct (Nursing Council of Hong Kong, 2002). As a result, university nursing programs should consider having a crisis management module using a high-reality simulated clinical environment with the use of a computerized life-sized patient model that has all of the physiological and psychological functioning and responses of a real human. Under the condition of no time pressure, nursing students can sufficiently exercise the necessary practical skills, such as cardiac life support, and use the actual clinical devices during various complex clinical situations. They can make errors and learn from them by being given immediate intervention under a supervisor’s guidance without imparting harm to real clients (Flanagan et al., 2004). This educational method can benefit the nurses by providing clinical experience and patients by providing the best quality care (Bandali et al., 2008).

LIMITATIONS There are three limitations in this chapter. The operating theatre fire crisis cited is just a single-case presentation. Its crisis management plan may be applicable only to all fires taking place in a similar environment and may not be generalized to all other crises occurring in other settings. This chapter’s crisis management plan seems unsuitable for everyday life, since not all public citizens are admitted to hospital for surgery and fire is really uncommon. Nevertheless, the plan is appropriate for operating theatre health care professionals to prepare for subsequent fire events, since no formal written crisis management plan has yet emerged. Last, but not least, the operating theatre case scenario is just a conceptual framework, with no appropriate research base and proven evidence base. We hope that there will be future research to verify this aspect.

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CONCLUSIONS Operating theatre fire safety is a critical issue for both health care professionals and surgical patients. The crisis management plan involves three phases that aim at preserving the patients’ and nurses’ optimal conditions. Very few researchers have debated the issue of crisis in operating theatres in Asian countries or have written about related crisis management plans. Thus, we attempt to explore deeply into the area. Although this chapter presented only a single case of fire safety, we gain the knowledge that operating theatre fire safety discussion is very limited. A well-organized fire crisis management policy is essential to prepare for any fire potential. In the future, we hope that there will be more sharing and learning from the experience of Western crisis management experts in this aspect, and increasing research addressing operating theatre nursing crisis management. When there is a comprehensive fire safety crisis management plan for operating theatres, patient safety will be largely assured.

ABOUT THE AUTHOR Yvonne is a registered nurse in Hong Kong. She has been working in the operating theatre department of a private hospital for five years. She obtained her bachelor of nursing (honors) degree from the University of Hong Kong. She is keen in promoting health in all aspects. Therefore, she is furthering her study by working towards a master’s degree in health education and health promotion at the Chinese University of Hong Kong.

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REFERENCES Abu Zead M. M. R. (2006) September nurses education: Potential hazards in the operating room. Retrieved from http://lifeinneurosurgery.com/page.aspx?PageID=17 on 29 October 2006. Alfredsdottir H. and Bjornsdottir K. (2008) Nursing and patient safety in the operating room. Journal of Advanced Nursing. 61(1), 29-37. Association of periOperative Registered Nurses (2005) Fire prevention in the operating room: AORN guidance statement. Retrieved from http://www.aorn.org/about/positions/ pdf/SECTI-2e-firesafety.pdf on 3 November 2006. Association of periOperative Registered Nurses (2006) Creating a patient safety culture: AORN guidance statement. Retrieved from http://www.aorn.org/about/positions/pdf/ PatSafetyCulture-2006.pdf on 5 November 2006. Association of periOperative Registered Nurses (2007) Statement of patient safety: AORN position statement. Retrieved from http://www.aorn.org/docs_assets/55B250E0-97795C0D-1DDC8177C9B4C8EB/EBE7F1E7-17A4-49A8-860EBC17C9685DA3/ AORN_Position_Statement_-_ Patient_Safety.pdf on 13 April 2008. Bandali K., Parker K., Mummery M. and Preece M. (2008) Skills integration in a simulated and interprofessional environment: An innovative undergraduate applied health curriculum. Journal of Interprofessional Care. 22(2), 179-189.

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Borodzicz E. and van Haperen K. (2002) Individual and group learning in crisis simulations. Journal of Contingencies and Crisis Management. 10(3), 139-147. Bull R. and FitzGerald M. (2006).Nursing in a technological environment: Nursing care in the operating room. International Journal of Nursing Practice. 12, 3-7. Coleman L. (2006) Frequency of man-made disasters in the 20th century. Journal of Contingencies and Crisis Management. 14(1), 3-11. Cruess R. L. and Cruess S. R. (2006) Teaching professionalism: General principles. Medical Teacher. 28, 205 – 208. Daniell M. H. (2004) World of risk: A new approach to global strategy and leadership. World Scientific, New Jersey. Edozien L. C. (2005) Patient safety in the operating theatre: An overview. Clinical Risk. 11(5), 177-184. Fire Services Department (2003) What to do in case of fire. Retrieved from http://www. hkfsd.gov.hk/home/eng/source/safety/what_to_do.pdf on 25 November 2006. Fire Services Department (2006) Fire protection notice No. 11: Notes on fire extinguishers: Suitability and maintenance. Retrieved from http://www.hkfsd.gov.hk/home/eng/source/ notices/Fire_Protection_Notice_No_11.pdf on 25 November 2006. Fire Services Department (2008). Fire safety. Retrieved from http://www.hkfsd.gov.hk/ home/eng/ safety.html on 25 August, 2008. Flanagan B., Nestel D. and Joseph M. (2004) Making patient safety the focus: Crisis resource management in the undergraduate curriculum. Medical Education. 38, 56-66. Joint Commission on Accreditation of Healthcare Organizations (2005) How to conduct an EM Drill: Part 1: Stressing the system. Environment of Care News. 8(1), 5-11. Kirschling J. M. (2003) Nursing education: Global perspectives. Reflections on Nursing Leadership. 29(4), 20-24. Kozier B., Erb G., Berman A. and Snyder S. (2004) Fundamentals of nursing: Concepts, process and practice (7th ed.). Prentice Hall, Upper Saddle River, NJ. Harvard Business School (2004) Crisis Management: Master the skills to prevent disasters. Author, Boston. Health and Medical Development Advisory Committee (2005) Landscape on health care services in Hong Kong. Retrieved from http://www.fhb.gov.hk/hmdac/english/dis_ papers/dis_papers_lhcshk.html on 27 November 2007. Health, Welfare and Food Bureau (2007) Hong Kong’s preparedness for influenza pandemicprevention and protection. Retrieved from http://www.info.gov.hk/info/flu/eng/files/ hkpippp.pdf on 28 November 2007. Hoff L. A. (2001) People in crisis: Clinical and public health perspectives. (5th ed.). JosseyBass, San Francisco. Hospital Authority (1999) Patients’ Charter. Retrieved from http://www.ha.org.hk/charter/ pceng.htm#Right%20to%20Medical%20Treatment on 1 December 2006. Hospital Authority (2007a) Hospital Authority statistical report 2005-2006. Retrieved from http://www.ha.org.hk/hesd/nsapi/132638.pdf?LO=100cff74a6b7c8d90000000400000015 0000035536838a460000000000010000000000006f626a656374e1e84093e1f8000000004 1b7c8c84093e190408c2d680000000000000008 and type=application/pdf on 30 October 2007.

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Hospital Authority (2007b) Press release: Enhancing patient safety under a just culture. Retrieved from http://www.ha.org.hk/hesd/nsapi/?MIval=ha_view_content and c_id= 133013 and know_chg=FALSE and post=POST on 30 November 2007. Hospital Authority (2007c) Hospital Authority annual report 2006/2007. Retrieved from http://www.ha.org.hk/hesd/v2/AHA/ANR0607/HAAR0607_Eng_1-164.pdf on 22 November 2007. Hoyle A. (2005) A basic guide to patient safety. British Medical Journal Career Focus. 331(7512), 55-56. Joint Commission (2003) Preventing Surgical Fire. Sentinel Event Alert 29. Retrieved from http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_29.htmon 30 November 2006. Klann G. (2003) Crisis leadership. Centre for Creative Leadership. Greensboro, North Carolina. Lalonde C. (2007) The potential contribution of the field of organizational development to crisis management. Journal of Contingencies and Crisis Management. 15(2), 95-104. Mrayyan M. T. (2004) Nurses’ autonomy: Influence of nurses’ manager actions. Journal of Advanced Nursing. 45(3), 326-336. McGarvey H. E. Chambers M. G. and Boore, A. J. R. P. (2000) Development and definition of the role of the operating department nurse. Journal of Advanced Nursing. 12, 1092– 1100. Nursing Council of Hong Kong (2002) Code of professional conduct and code of ethics for nurses in Hong Kong. Retrieved from http://www.nchk.org.hk/conduct/conduct_eng.doc on 6 December 6 2006. Rothrock J. C. (2003) Alexander’s care of the patient in surgery (12th ed.). Mosby, St. Louis. Runyan R. C. (2006) Small business in the face of crisis: Identifying barriers to recovery from a natural disaster. Journal of Contingencies and Crisis Management. 14(1), 12-26. Schimpff S.C. (2007) Improving operating room and perioperative safety: Background and specific recommendations. Surgical Innovation. 14,127-135. Schoenbaum S. C. and Segel K. (2006) Long-term solution to malpractice crises: Reduce harm to patients. Physician Executive. 32(2), 26-31. Silen-Lipponen M., Tossavainen K., Turunen H. and Smith A. (2005) Potential errors and their prevention in operating room teamwork as experienced by Finnish, British and American nurses. International Journal of Nursing Practice. 11, 21-32. Spillan J. E. (2003) An exploratory model for evaluating crisis events and managers’ concerns in non-profit organisations. Journal of Contingencies and Crisis Management. 11(4), 160-169. Stokowski L. A. (2007). Perioperative nurses: Dedicated to a safe operating room. Retrieved from http://www.medscape.com/viewarticle/562998 on 15 April 2008. Thomson D. R. (2006) Nursing in Hong Kong: Issues and challenges. Nursing Science Quarterly. 19(2), 158-162. Tzeng H. M. (2006) Model testing on the crisis interventions and actions to prevent medical disputes: A Taiwanese nursing perspective. Journal of Clinical Nursing. 15, 554-564. Vincent C. (Ed.) (2001) Clinical risk management: Enhancing patient safety. (2nd ed.). BMJ Publishing Group, London. Wiger D. E. and Harowski K. J. (2003) Essentials of crisis counselling and intervention. John Wiley and Sons, New Jersey.

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Wong F. K. Y. (1998) Health care reform and the transformation of nursing in Hong Kong. Journal of Advanced Nursing. 28(3), 473-482. World Health Organization (2003) Severe acute respiratory syndrome (SARS): Status of the outbreak and lessons for the immediate future. Retrieved from http://www.who.int/csr/ media/ sars_wha.pdf on 11 December 2006. World Health Organization (2008) Second global patient challenge: Safe surgery saves lives. Retrieved from http://www.who.int/patientsafety/challenge/ 2d_gp_safety_challenge _nov07.pdf on 4 April 2008.

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In: Health Issues in Chinese Contexts, Volume 1 Editor: Zenobia C. Y. Chan

ISBN: 978-1-61209-385-7 © 2009 Nova Science Publishers, Inc.

Chapter 6

DISCUSSION OF MEDICAL LEADERSHIP STYLES AND ROLES FOR A COMMUNITY GERIATRIC CONSULTANT Julina H.T. Lee and Zenobia C. Y. Chan

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ABSTRACT The implementation of reforming health care design presents an opportunity to evaluate the effectiveness of leaders in the nursing and medical fields. It can examine how leaders are directing changes in health care organisations. Organisation cultures are affected by the values and beliefs of individuals or the organisation. People in working groups are willing to adapt to behavioural changes due to the influence of their leaders. This chapter raises this issue and makes people rethink leadership styles and roles within an organisation. Furthermore, the focus is on the evaluation of the community medical geriatric consultant in the workplace. Discussions on his leadership style and roles illustrate how he can influence team members in behavioural changes and subsequently sustain these changes.

INTRODUCTION Management skills are important to senior nurses in clinical and administrative areas. Nowadays, better education and increased technology in the medical and nursing fields allow professionals to handle management functions in better ways. This also helps them to focus on leadership. For instance, computers can speed up managerial work, help to disseminate information quickly and precisely, and provide a convenient platform for meetings and discussions without travelling unnecessarily. Besides, leaders should have vision, be able to motivate others towards common goals, and have the ability to help their organisations meet the challenges of a rapidly changing world. Traditionally, Hong Kong nurses are not normally involved in the decision-making process. There are seldom papers discussing leadership in the nursing field. There are two objectives to this chapter. The first objective is to address the knowledge gaps between management and nurses in the area of leadership. The second objective is to review

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leadership concepts in the workplace through the case study and discussion of a community medical geriatric consultant. In this chapter, the first author will identify and discuss the effectiveness of different leadership styles and examine the leadership roles within the hospital. Furthermore, there will be an exploration of the relationship between leadership style and sustainable changes with literature reviews. In addition, the first author will do a case study on a geriatric consultant in a community with discussions on his attributes and leadership styles. The first author will then illustrate the pros and cons of the geriatric consultant’s leadership style with literary support. Finally, implications for nursing will be explained.

LITERATURE REVIEW

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What Is Medical Leadership? In Hong Kong hospitals, the Hospital Chief Executive (HCE) is usually a physician. Leadership and administrative skills are crucial for an HCE. But, traditionally, the training of physicians has always emphasised the clinical aspects, and little attention is given to management and administrative skills. Schidlow (2007) said that physicians are independent and self-centred. This may explain the misalignment between healing mission and economic reality. Moreover, physician leaders are always versed in their own institutional philosophy and culture. Therefore, hospital health care systems usually create internal programmes tailored to the needs of this particular group. The leadership in the organisation must be aware of the conflicts between individual physicians and physicians as a group (McAlearney et al., 2005). Ideally, administrative skills should be introduced in the undergraduate medical curriculum and reinforced at the postgraduate medical education level (Atack, 2007). After perusing various pieces of literature, the first author found that there were not many publications or studies on the subject regarding medical leadership in Hong Kong hospitals. Although research studies have been published in this area, they were mainly focused on foreign countries.

Examination of the Leadership Role within a Hospital Robbins (1991) defined leadership as the process of empowering beliefs and teaching others to show their full capabilities by changing their beliefs. Leadership is also defined as a process of persuading and affecting changes in others towards goals. It comprises a wide variety of roles. It requires an influence over organisational culture and an interactive relationship between the leader and his subordinates (Marquis and Huston, 2003). In nursing, leadership is associated with aggressive masculine characteristics (Marriner-Tomey, 1992). There are different roles inherent in leadership. Firstly, the leader should be the figurehead or the coach within the organisation. The leader is an icon within the organisation and he needs to help others to reach an optimal level of performance by coaching. Also, the leader should be a communicator and negotiator who acts as a buffer between different departments. The leader should help members to take on their responsibilities. He should also

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influence or encourage them to express their feelings and give feedback (Raelin, 2003). He is the role model to subordinates during planned changes by viewing changes as challenges and opportunities for self-development. Also, the leader should be a critical thinker, since he plays the most important role in the organisation. Critical thinking refers to reflective thinking with productive and positive direction. Besides, the leader is a risk taker who helps the organisation to solve problems. Therefore, he needs to engage in broad vision and realise the diversity of values as a strategic planner (Brookfield, 1987).

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Identification and Review of the Effectiveness of Different Leadership Styles Different leadership styles can have a big influence on the culture and outcome within an organisation or a work group. White and Lippitt (1959) isolated the common forms of leadership style to be categorised as autocratic, democratic and laissez-faire in different organisations (cited in Sadler, 2003). The behaviour of an autocratic leader shows strong control within the work group. Motivation is by coercion and people must follow his commands. Communication flows downwards and decision making does not involve others. The leader always emphasises status, usually using ‘I’ and ‘you’. Criticism within the team is punitive. As a result, the team has high productivity, reducing frustration in the work group. Self motivation and creativity are scarce because of predictability and a sense of security. This style of leadership is most useful in a crisis situation and is more suitable in large bureaucratic organisations, such as in disciplinary departments (Marquis and Huston, 2003). On the other hand, the democratic leadership style involves less control. Ego and economic rewards are used for motivation. Communication flows up and down. Decisions are made through guidance and suggestions. The leader emphasises ‘we’ rather than ‘I’ and you’. Criticisms are made constructively. This style of leadership is appropriate in teams with extended periods, and promotes autonomy and growth for individual team members. Cooperation and coordination between groups are essential. Compared with autocratic leadership, democratic leadership is less efficient than authoritative leadership due to the time needed for consultation; therefore, frustration may occur for those who want decisions made promptly (Marquis and Huston, 2003). Laissez-faire leadership is a permissive style of leadership with minimal control or even without any control. Motivation and support are given to team members when requested. There is no direction and communication both upward and downward flows between group members. Decision making is dispersed throughout the group. The leader emphasises the group. There are no criticisms. This style is a non-directed leadership. Frustration may occur due to group apathy and disinterest may result. However, it is most suitable for a self-directed or highly motivated group. It makes the group members more creative and productive (Marquis and Huston, 2003). In addition to the above-mentioned leadership styles, Bolman and Deal (2003) described a re-framing way to get narrow and simplified views of leadership. They are structural leadership, human-resources leadership, political leadership and symbolic leadership. Structural leadership refers to rigid bureaucrats doing things according to one’s beliefs. The effect of structural leadership can be powerful and enduring with a clear vision for the organisation. The leader has the ability to pioneer the development of sophisticated internal

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information systems and market research. He or she can focus on the actual implementation and harness human resources fully. In addition, he or she takes into account the possibility of political and symbolic barriers that may occur along the way. Human-resources leaders advocate openness, willingness to listen, mutuality, coaching, participating and empowerment. They are the facilitator and catalyst in motivating and empowering the subordinates. The power comes from talent, sensitivity and the service rather than positional force. Most of the leaders can produce extraordinary results. The leader believes in people and communicates with passion. They are visible and accessible and like to empower others (Bolman and Deal, 2003). Political leadership leads with personal philosophy. Badaracco and Ellsworth (1989) stated that the leaders are realistic and can clearly show their wants and what they can achieve (cited in Salder, 2003). They think carefully about their interests and power and build linkages to key players or stakeholders. They focus on building relationship and networks. This style of leadership prefers persuasion over negotiation. Coercion comes as a last resort (Bolman and Deal, 2003). Lastly, symbolic leadership can be seen as the leadership kaleidoscope. The leaders interpret experience so as to impart purpose and meaning through phrases of passion. They like to distill and disseminate a vision with hopeful and persuasive images for the future, and like to use history (Bolman and Deal, 2003). Generally speaking, different leadership styles can influence the culture and outcome of team work. Thus, leaders should be more dynamic and be responsive to new situations.

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Exploration of the Connection between Leadership Style and Sustainable Change Outcomes Nowadays, organisations need to meet challenges and competition in the health setting. The way to survive is to reshape to meet rapid changes. Thus, the leader needs to break through the resistance to change within the organisation. There are some factors that can effect changes, such as knowledge, technology, social requirements, demands and needs from clients and patients in the health organisation. Also, personal development, habits, preferences and rigidities can also attract people to consider and accept organisational changes (Marriner-Tomey, 1992). The leader should act as a role model with confidence and respond promptly in decision making, as well as identify problems during the change process. Better communication and encouragement in education is the power to make changes. The leader should respect the subordinates through the process of democratic participation (Alinsky, 1989). Furthermore, the leader is a strategic visionary who knows how to allocate human resources, raise awareness level, be conscious of the significance and value of designated outcomes, make subordinates take interest in working within the team or organisation as well as understand what people’s needs are (Bass, 1985). The possibility to achieve the effectiveness of leadership and the maintenance of effective outcomes depend on the leadership styles, behaviour and approaches of the leader. The increase in job satisfaction and morale of subordinates or group members can be used to assess the effectiveness of leadership and can be used to support the change within the organisation.

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CASE STUDY: BACKGROUND OF THE LEADER The consultant is a knowledgeable person with confidence and broad vision. He has worked in a team with related community work for more than thirteen years. He shows enthusiasm in his work. He is a consultant in the geriatric department of three hospitals. He is trustworthy with high recommendations from community partners. He shows courage in the face of challenges with ever-changing policies in the Hospital Authority. He has a positive attitude and elevates team morale by using positive reinforcement. He is a nice person without any trace of a bureaucratic mindset. He is compassionate, warm and emotionally stable even under pressure. He shows concern and respect towards team members. The consultant is using the democratic leadership style within the community team. He allows them the freedom to have different working styles within working guidelines. He shows flexibility in his work as well as towards people. He likes to communicate with front line team members regularly and is a good listener when issues are raised by others. He is a negotiator and often deals with community partnership, such as collaboration with NGOs for nursing services. He is the figurehead and acts as a coach to help team members to reach the team’s goals. Also, he is a strategic planner with vision; for example, in the establishment of the ‘Telephone Nursing Consultation Service’. He is a problem solver who makes prompt decisions whenever the team meets any challenge in community. For example, he promptly educates and disseminates the ‘prevention of flu outbreak guidelines at old-age homes’ during the peak season of the flu. Moreover, the work in the community team is everchanging, and he is a risk taker and accepts changes and challenges within the team.

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DISCUSSION Review of the Pros and Cons of an Effective Leader An effective leader should include a variety of leader attributes with different leadership styles in order to make team members work in harmony, fully and effectively with sustainable outstanding outcomes. The consultant is an open-minded person with different leadership styles. He particularly uses the democratic leadership style because he likes to use the word ‘we’ rather than ‘I’ (Marquis and Huston, 2003). He always gives credit to the team member for their efforts. Also, he shows a willingness to listen to nurses’ issues arising from their jobs. He allows a great range of autonomy to nurses and empowers their health assessment skills through organising ‘health Assessment’ lectures for nurses and boosts their confidence in community work. He uses the human-resources leadership style to negotiate with community parties (Bolman and Deal, 2003). He has a clear vision of present-day community jobs. He understands that community work is challenging for nurses and doctors. He always liaises with key community persons and emphasises that good rapport with partners is an essential element in community work. If he finds a new job too difficult to start with, he uses the persuading method with open discussions rather than the coercion method. His style complies with political leadership (Bolman and Deal, 2003). Finally, he attends a meeting every month with nurses and multidisciplinary personnel and disseminates the latest vision and future job

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planning. Also, he guides the nurses to design jobs through brainstorming. This is called symbolic style in leadership (Bolman and Deal, 2003). The overview of the consultant is that he does his job effectively and gains appreciation through effective leadership. As Wallerstein and Bernstein (1994) said, an effective leader should have a good vision, needs to listen to others’ opinions and engages in group members’ dialogue. Furthermore, the following discussion focuses on the leader’s attributes and roles, to see how the consultant behaves as an effective leader. He is a confident and knowledgeable person and shows responsibility in his work. He seldom takes sick leaves. He is enthusiastic in his work despite having to work in three hospitals. He also joins the community volunteer workers as the chairman of the Community Engagement Symposium, which is organised by the hospital cluster. He is a role model for the team by inspiring hard work. He is also energetic and shows a positive attitude. Although he is busy in his work, he never shows any unstable emotions. As Davison and Martinsons (2002) stated that sharing of beliefs is a social or normative glue, it provides cohesiveness to the organisation and creates a sense of belonging within the team. The team members help each other when difficult issues arise and the nurses are proud to be part of the team. The consultant helps nurses enhance their health assessment skills. For instance, he has held several lectures on health assessment and case discussions with treatments which were led by him or other senior medical officers. He likes to share experiences with others in case conferences each month in order to arouse selfawareness on the job. Raelin (2003) mentioned that the encouragement of feedback can be an enhancement to an organisation. Viewed from a different perspective, the consultant has a broad vision and can be viewed as a pioneer in community work. For example, he established the Telephone Nursing Triage Service within his cluster of hospitals, and other clusters followed. Today, this service has matured. The senior staff in the head office of the Hospital Authority highly appreciates that it can reduce the emergency admission rate for about 40% of patients (Ho, 2006). Also, the utilisation of the High Risk Data Base in the computerised medical system is a success. It helps the team to identify high risk groups needing extra attention while they are at home receiving comprehensive follow-up by the community nursing team. Years later, other clinical departments started showing an interest in this programme. The consultant shows his broad vision, sets high standards of performance and appears assertive in his job. Bolman and Deal (2003) said that all of these are the characteristics of an effective leader. Innovative ideas can help residents receive comprehensive health services in the community. In addition, nurses can enrich their knowledge and teaching skills. Nurses work with enrichment and satisfaction through stimulating work and rotation to various specialised jobs as well as acquiring a variety of jobs with good standards. Nurses can then gain job satisfaction and value in the workplace. Kreitner and Kinicki (2001) stated that this is a method used to motivate staff and gain their job satisfaction, so that the organisational culture will be changed by increasing team members’ motivation and help in reaching high performance standards. The consultant is a critical thinker and strategic planner. He is always aware of the community aspect and uses reflective thinking in order to have positive effect in decision making and problem solving. He makes an effort to avoid the pitfalls of faulty logic (Marquis and Houston, 2003). Also, he is a negotiator and communicator who needs to deal with different parties in the community. Congdon and French (1995) said that to be an effective leader, one should include these roles—for example, the collaboration with a safety link in the

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Telephone Nursing Triage and the Enhance Home Community Care Service with NGOs. In addition, he acts as a coach to help nurses in reaching goals. He is the coordinator of the Community Engagement Symposium, he communicates with different parties in the community and influences team members and partners to understand the vision and future strategies. Kotter (1990) mentioned that this process aligns people and helps them to reach their goals. The consultant helps nurses to meet every challenge and influences the team to be more inspired and autonomous. There is a great cohesion within the nursing group and he shows support in nurse empowerment. He inspires team members to acquire higher-education qualifications. The consultant truly lives up to an ideal leader’s attributes and roles. But due to his busy schedule, he is not always readily accessible. He is considerate of the well-being of all team members but it would be a bonus if he could join activities after work so as to strengthen the bonds within the team. In the first author’s opinion, the consultant is an effective leader and facilitates the optimum functioning in the organisation. He makes team members anticipate and participate in their work. He makes nurses more independent and confident to meet challenges even on their own so that the organisation can achieve sustainable effective outcomes.

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Implications for Nursing Traditionally, in nursing education, nurses are expected to follow orders from doctors. Also, senior staff and supervisors often check and tightly monitor subordinates. Therefore, autonomy is scarce. As a result, nurses tend to be dependent, passive and tend to keep silent when issues arise. In the future, nurses should be more innovative and open minded. Trust within the working group is also essential. Professional training can enhance knowledge and self-confidence. Management and leadership courses are especially useful to junior staff members. Through cultural and behavioural changes, nurses will reach their optimal professional level and be more effective at work in the future owing to the acceptance of change by leadership.

CONCLUSIONS In conclusion, an effective leader should achieve most of the characteristics and appropriate leadership styles in order to make group members work together and accept change in order to achieve goals. Therefore, effective leaders will always produce optimal health services. Also, there are only a small number of scholarly papers written on leadership in nursing. The first author believes that this chapter can make people aware of the leadership roles and styles in organisations. Every organisation has its own leader with different attributes and style, but the most important thing is this: a leader can put everything together in order to complete an effective and sustaining change within an organisation.

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AUTHOR’S BACKGROUND The first author is a Registered Nurse specialising in geriatrics for fourteen years in the Hong Kong Hospital Authority (HKHA). She has been working in a community setting for the past ten years. She obtained her Bachelor of Health Science (Nursing) and Master of Primary Health Care Degrees at the University of Western Sydney. She also holds a PostRegistration Certificate in Gerontological Nursing & Training Programme for CGAS nurses, which she obtained from the Institute of Advanced Nursing Studies (IANS). In addition, she is a dedicated Nursing Specialty Mentor in a CGAS team and an Honourary Teacher responsible for clinical teaching in the Bachelor of Nursing course at the University of Hong Kong.

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REFERENCES Alinsky, S. (1989). Rules for radicals, New York: Random House. Atack, E. (2007). MDs need more management training. Medical Post. 43, 33-34. Badaracoo and Ellsworth (1989) In Sadler, P. (2nd ed.), Leadership (pp. 63-820). London: Kogan Page. Bass, B. M. (1985). Leadership and Performance Beyound Expectation, New York: Free Press. Bolman, L., and Deal, t. (2003). Reframing organisations. Artistry, choice and leadership: Reframing leadership (3rd ed.). San Francisco: jossey-Bass. Brookfield, S. (1987). Developing critical thinkers: Chanllenging adults to explore alternative ways of thinking and acting: What it means to think critically (pp. 3-14). San Francisco: Jossey-Bass. Congdon, G., and French, P. (1995). Collegiality, adaptation and nursing faculty. Journal of advanced Nursing, 21, 748-758. Davison, R., and Martinsons, M. (2002). Empowerment or enslavement? A case of processbased organisational change in Hong Kong. Information Technology and People, 1, 4259. Ho, J. (2006). An evaluation of the effectiveness of Telephone Nursing Consultation Service that utilises the ‘High Risk Elderly Database and Alert System’ and involves relevant stakeholders to address the healthcare needs of the elderly in HKEC, Hong Kong: HKEC CNS and CGAS. Kotter. (1990). Management and leadership: A force for change, New York: Macmillan. Kreitner, R., and Kinicki, A. (2001). Organisational behaviour (5th edition). New York, USA: McGraw-Hill. Marquis, B. L., and Huston, C. J. (2003). Leadership Roles and Management Functions in Nursing – Theory and Application (4th edition). Philadelphia: Lippincott Williams and Wilkins. Marriner-Tomey, A. (1992). Guide to Nursing Management (4th edition). St. Louis: Mosby. McAlearney, A. S., Fisher, D., Heiser, K., Robbins, D. and Kelleher, K. (2005).Developing Effective Physician Leaders: Changing Cultures and Transforming Organisations. Hospital Topics, 83, 11-18.

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Raelin, J. (2003). The development of leaderful practice: Creating leaderful organisation, How to bring out leadership in everyone. San Francisco, USA: Berrett-Koehler Publications Inc. Robbins, A. (1991). Awaken the giant within. New York: Fireside Books. Sadler, P. (2003). Leadership (2nd edition). London: Kogan Page. Schidlow, D. V. (2007). Musings on the nature of Academic Medical Leadership. Physician Executive, 33, 32-34. Wallerstein, N., and Bernstein, E. (1994). Introduction to community empowerment, participation education, and health. Health Education Quarterly, 21(2), 141-148. White and Lippitt (1959). In Sadler, P. (2nd ed.), Leadership (pp. 63-820). London: Kogan Page.

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ISBN: 978-1-61209-385-7 © 2009 Nova Science Publishers, Inc.

Chapter 7

STUDENTS’ VIEWS ON HEALTH PROMOTION Zenobia C. Y. Chan

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CONTEXT The Bangkok Charter for Health Promotion suggested “the National Health Promotion Capacity Wheel which aims to facilitate countries to enhance health (Catford, 2005). The sustainability of a health promotion program (St. Leger, 2005), a human rights approach to health promotion (Chopra and Ford, 2005), and a systematic review of health promotion interventions (Jackson and Waters, 2005) have been emphasized. However, Hong Kong students’ views can provide alternative interpretations of health promotion. This chapter presents my experience teaching health promotion in both an undergraduate social work program (e.g., a course of social aspects of health and illness) and students studying social work. The majority of the students in the master’s level program (e.g., a course on health promotion, and a course ofnprimary health care) are nurses. My teaching approaches are interactive and include lecturing, case studies, group discussions, role playing, movie watching, sharing and reflection. Teaching health promotion requires an integration of various disciplines (Wass, 2000), so multiple sources of materials are selected, broadening the students’ views toward health promotion. My students provided me with a lot of insight into their perspectives on health promotion, and into the particularly Chinese sociocultural context as it plays out in Hong Kong. Submissiveness and obedience are two traditional cultural views influencing students’ attitudes and behaviors toward their study and relationship with lecturers. However, the ideologies of participation have been implemented during my teaching.

GOALS Two goals of this chapter are to encourage our students to question the dominant discourses of health promotion, and to revisit our responses toward our students’ views on health promotion.

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METHODS I always allocate about 30–40% of lecture time to allow my students to give their feedback. After each lecture, I will jot down their comments in my personal journal so as to revisit my beliefs about health promotion. The findings below are selected to show the comments and questions regarding health promotion raised by my students.

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FINDINGS The three elements of health promotion are the following: 1) to collaborate between health and non-health sectors; 2) to address the social determinants of health; and 3) to emphasize the idea that health is everyone’s responsibility (Kellehear, 1999). The students gave the following comments. The potential power struggle between health and non-health sectors cannot be prevented but can be solved by open communication and appreciation of others’ input. Every health profession ensures the permeability of its own professional boundary, allowing others’ input, and tolerates differences and acknowledges the expertise of every colleague working in health sectors and non-health sectors. Hong Kong doctors do not have an adequate social perspective on health and more effort should be put into medical education so as to expand the doctors’ conceptualization of holistic health. Additionally, some citizens count on health providers to manage their health, and the concept of health ownership and empowerment of their health care should be encouraged. There are many different models for health promotion (Egger et al., 1999; Lawrence, 1999; O’Connor-Fleming and Parker, 2001). Community development (CD) is an excellent strategy for health promotion, but most of the current nursing training does not address the rationales and skills for effective CD. They agree that health promotion consists of three main interrelated components: health education, health prevention, and protection (Butler, 2001). Health education is defined as a planned process and it combines a different mode of teaching methods; health prevention can be divided into primary, secondary, and tertiary levels; and health protection consists of legal control and polices achieving the promotion of health and the prevention disease (Butler, 2001). However, health education is the most effective means for achieving the goal of health promotion. Empowerment and positive lifestyle changes for citizens can be fulfilled in a humanistic manner and by a strength-based approach. Health prevention has been perceived as a second means for implementing health promotion. The reason is that prevention is better than cure. Risk reduction and early detection are possible measures for prevention of onset of disease and decreasing the costs of treating disease and disability (Wass, 2000). However, health prevention is not proactive and universal enough because it does not stress that every citizen be concerned with their well-being even when they are healthy—i.e., that everyone needs awareness of health issues and motivation to acquire and maintain lifestyle practices that promote mental, psychological, social and physical well-being. Finally, the majority disliked health protection because it involves regulation, policies and, sometimes, law enactment. Compared with health education and health prevention, health protection is a more authoritative approach to health promotion. It is better to support citizens in taking control of their health and for the government and health professionals to work with and for citizens instead of punishing and controlling their ill-health

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behaviors. In contrast, some argue that health protection measures are important in some circumstances—for example, to protect people from second-hand smoke and by regulating food safety. They found the Ottawa Charter (1986) for Health Promotion to be user-friendly. The Ottawa Charter (1986) sets forth five themes for health promotion: (1) crafting healthy public policy; (2) creating supportive environments; (3) developing personal skills through education and information; (4) strengthening community action; and (5) reorienting health services towards promotion and prevention. However, they had some questions about these themes. Are the above five themes only a slogan? Can they be proven effective by empirical studies? If yes, how can they be researched? What research designs can be formulated? Are there any interrelationships among these five themes? How might such relationships influence each other? In what order should these steps be implemented? On one hand, how can political strategies be used to strengthen governmental action, while on the other, how can we avoid fragmentation of community involvement? Who should be the leaders for health promotion— politicians, scholars, social activists, health professionals, researchers, laymen, or others? How can the power struggles among various disciplines be handled, and the reorientation of health services from treatment to health promotion be achieved? What are the roles of family members and alternative therapies in health promotion? Is it possible to make a health promotion course compulsory for every university student?

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DISCUSSION I learned from my students that I should never stereotype them as they only follow the claims of health promotion without any critical thinking. I find that I can play both roles of educator and learner in the class. My students’ questions drove me to work harder to encourage and enable them to learn more about health promotion. Their questions have demonstrated their courage to question the dominant discourses of health promotion, and there are many unresolved and hidden issues of the claims from the Ottawa Charter. Educators worldwide should start to learn students’ views and conduct research on redefining the concepts and suggesting strategies for health promotion in light of students’ participation. The previous passive learning style of my students has been changed to more active participatory learning by active listening and giving positive feedback.

SUMMARY The most effective means to encourage our students to reflect their own assumptions and challenge the dominant discourses and research results of health promotion are the following: educators should appreciate students’ views; the traditional rigid and authoritative teaching style should be replaced by a humble and partnership teaching style; each lecture should reserve at least 30–40% time for student’s discussions, feedback and reflections; and raising students’ classroom participation and creating a supportive learning culture should be promoted. The academic forum of sharing our teaching experience and our students’ views can revisit the definition of health promotion and how it should be launched.

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REFERENCES

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Butler, J. T. (2001). Principles of health education and health promotion. USA: Wadsworth / Thomson Learning. Catford, J. (2005). The Bangkok Conference: steering countries to build national capacity for health promotion. Health Promotion International, 20(1), 1-6. Chopra, M., and Ford, N. (2005). Scaling up health promotion interventions in the era of HIV/AIDS: challenges for a rights based approach. Health Promotion International, 20(4), 383-390. Egger, G., Spark, R., Lawson, J., and Donovan, R. (1999). Health promotion strategies and methods. Sydney: McGraw Hill. Ewles, L., and Simnett, I. (2003). Promoting health: A practical guide (5th ed.) London: Balliere Tindall. Jackson, N., Waters, E. (2005). Criteria for the systematic review of health promotion and public health interventions. Health Promotion International, 20(4), 367-374. Kellehear, A. (1999). Health promoting palliative care: Developing a social model of practice. Health Promotion Journal of Australia, 9(1), 30-34. Lawrence, C. (1999). The effects of income inequality on health. Australian Health Review, 22, 97-106. O’Connor-Fleming, M. L., and Parker, E. (2001). Health promotion: Principles and practice in the Australian context (2nd ed.). St. Leonards, NSW: Allen and Unwin. St Leger, L. (2005). Questioning sustainability in health promotion projects and programs. Health Promotion International, 20(4), 317-319. Wass, A. (2000). Promoting health: The primary health care approach (2nd ed.), Sydney: Harcourt Brace. World Health Organization. (1986). Ottawa Charter for Health Promotion: An International Conference on Health Promotion. Denmark: WHO.

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In: Health Issues in Chinese Contexts, Volume 1 Editor: Zenobia C. Y. Chan

ISBN: 978-1-61209-385-7 © 2009 Nova Science Publishers, Inc.

Chapter 8

A CALL FOR AUTOBIOGRAPHICAL WRITINGS BY HEALTH CARE RESEARCHERS

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Zenobia C. Y. Chan The qualitative approach to research is a systematic analysis of socially meaningful action, and is employed to discern the understanding and interpretations people use to create and maintain their social worlds (Janesick, 1994; Kopala and Suzuki, 1999). This approach generates an in-depth description of the subjects and their lives in a particular context (Wilkinson and McNell, 1996). Qualitative approaches have come to represent research that develops from a coalition of interests and a recognition of the necessity of diversity in methods of inquiry (Mullen, 1995). Autobiography, for its part, tells a reader how the author perceives the world and understands certain facts. It can be regarded as a powerful and authentic means to represent people’s voices (Joyappa and Martin, 1996; Lindsey, 1997). If autobiography is used by a researcher, times, places, sequences of events, and the emotional status of the researcher all can be reported through such writing. Autobiographical writing is not often mentioned in nursing literature. The aim of this chapter is to illuminate and explore how autobiographical writing may be useful in the work of qualitative researchers in the field of nursing. At the doctoral level, Hofmeyer (2002) explained how she used her personal study experience to suggest that writing can be regarded as a valid method of inquiry. During my study as a doctoral student, I enjoyed the positive effects of autobiographical writing; it helped document my emotions and thoughts about the whole research process. This form of writing gave me the opportunity to reflect on all that was happening, and to reach a better understanding of the research results. Indeed, I would contend that autobiographical writing for health care researchers can counter any potential personal bias during data collection, analysis, and presentation.

COMMONALITIES BETWEEN QUALITATIVE AND AUTOBIOGRAPHICAL WRITING Four characteristics can be found in both qualitative approaches to research and autobiographical writings. The first characteristic is that qualitative approaches and

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autobiographical writing are interdependent. Certainly, writing is one of the means for providing authentic and vivid textual information about research formulation, process, results and implications. It thus provides the in-depth description required by qualitative approaches. Seibold (2000) has stated that the development of qualitative research methods is an ongoing process. By writing and rewriting throughout the research process, researchers can refine their conceptualisation, method, analysis and interpretation via an ongoing process. My doctoral thesis is a case for this illustration (please refer to the last page). This study sought to identify which events in family therapy help or hinder changes in females suffering from anorexia nervosa and their families. The study further intended to discover changes at the symptomatic individual level and the family system level. When I was writing my doctorate research proposal, and formulating the conceptual framework, my emphasis was on revealing the experiences of the patients, the raters and the researcher. While writing (and rewriting!) the research method chapter, I thought about what perspectives my study might have missed. An inspiration came to me: to include the patients’ family members’ perspectives. Therefore, the revised research method was to compile qualitative data by inviting the patients, the families, the raters, and myself to review the videotapes of family therapy sessions. To enrich the understanding of significant events that might not be identified in the family sessions tape reviews, qualitative interviews were conducted for each family at pre-treatment and posttreatment. When I analyzed and interpreted the data, I found that the research method did not adequately answer the research questions. I went back to the conceptualization, modified the method, and collected new data. During this research cycle, writing helped me improve the research design and exercised my critical thinking about how to conduct a qualitative study rigorously. The postmodernist movement and feminist scholars advocate autobiographical exploration of field experience in the research process (Berger, 2001). From these standpoints, the second shared characteristic between autobiographical writing and qualitative research is their use of experience in a context. Researchers’ personal experiences form another rich source of data that provides details of the conduct of qualitative studies. For instance, research results and the researcher’s personal experiences are important, as interactions between results and experience provide opportunities to generate theories that will account for the research results themselves (Spry, 2001). I am a mother, trained as a nurse. I have a nurturing and caring personality and have the ability to connect with and understand research subjects who are females. When I conducted interviews with them and analyzed their answers, I could not isolate my background from my role as researcher. For example, in my series of qualitative studies about anorexia nervosa and women’s studies (Chan, 2002; Chan and Ma, 2002a, 2002b, 2003), I had declared my background and my assumptions toward qualitative inquiry, or importance of writing, or the relationship between participants and researcher, in order to let the readers understand who I am as the author and the researcher and my perspective that might influence the interpretation of the research results. As so, my researcher “self” could be revealed through the writing process and represented in the texts as well. During the research process, the researchers’ emotions cannot be separated from their relationships with the research subjects. Autobiographical writing can present this inner emotional struggle of the researcher through providing a place for them to express their responses to the field. Equally, this form of writing reveals the researcher’s stance and role in the activities of research inquiry.

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.

The third characteristic each approach shares is the power of storytelling. Qualitative research can be regarded as a storytelling approach to research. Each study describes the research participants’ understanding of their world, in combination with an analytical power to explore socio-cultural contexts of both research subjects and researcher. Further, autobiographical writing during the research process allows qualitative researchers to share their research experience and perspectives on data analysis and presentation with their readers. This reveals details about the research process that would otherwise have remained hidden and would have failed to recognise the important elements of the researcher’s roles and experience. To address the fact that the researcher’s stance might lend bias to the enquiry, the researcher’s background, ideological leanings and personal struggles during the research process should be included, because this information allows the readers to know who the author is and how that identity impacts the research. For example, to confess my reflection after the completion of the research, I revisited two points about my relationship with the participant in a case study: (1) I deceived the participant by telling her I ate her homemade mango pudding; and (2) I asked for her forgiveness because I did not eat her pudding for reasons pertaining to my health (Chan and Ma, 2002a). The fourth characteristic is that both approaches speak for the self (of the researcher) and others (research participant). Similarly, qualitative research acquires relevance among people who share a similar meaning system, increasing the likelihood that they will interpret it as socially relevant (Ribbens and Edwards, 1998). Autobiographical writing produces particular versions of identity, framed by social context, including dominant gender relations (Kehily, 1995). Autobiography is a presentation of oneself and oneself in relation to others. It promotes a pluralistic view and aims to produce descriptive data based upon spoken or written words and observable behaviour (Sherman and Reid, 1994). In presenting the self in this way, autobiography is socio-culturally specific. Qualitative researchers who read and reread their own autobiographical notes can achieve a deeper understanding of themselves in relation to their personal backgrounds, their particular frames of reference, and their relationships with the informants. The above characteristics of autobiographical writing parallel those of qualitative research. Researchers’ experiences can be considered rich data sources for understanding studies by revealing the hidden voices and breaking down the strict division between the socalled researchers and participants. More importantly, nursing researchers who do autobiographical writing can enrich their understanding of the research itself by adding to the dimension of social fabric—for example, when the research is conducted in pursuit of social justice, or from a sense of social obligation. Considering the above shared characteristics of autobiography and qualitative approaches, I believe that autobiography can be an effective source of enrichment of sources for qualitative researchers in the field of nursing. I believe that its use will deepen their understanding of the role of researcher, and maintain the necessary sense of reflection during the research process.

REFERENCES Berger L. (2001). Inside Out: Narrative Autoethnography as a Path Toward Rapport. Qualitative Inquiry, 7(4), 504-518.

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Chan, C. Y. Z. (2002). From cooking soup to writing papers: A journey through gender, society and self. The Journal of International Women’s Studies, 4(1), 93-106. http://www.bridgew.edu/DEPTS/ARTSCNCE/JIWS/fall02/index.htm Chan, C. Y. Z. and Ma, L. C. J. (2002a). The secrets of self-starvation. The Journal of International Women’s Studies, 3(2), 1-15. http://www.bridgew.edu/DEPTS/ARTSCNCE/ JIWS/June02/index.htm Chan, C. Y. Z. and Ma, L. C. J. (2002b). Anorexic eating: Two case studies in Hong Kong. The Qualitative Report, 7 (4). http://www.nova.edu/ssss/QR/QR7-4/chan.html Chan, C. Y. Z. and Ma, L. C. J. (2003). Anorexic body: A Qualitative Study. Forum: Qualitative Sozialforschung/Forum: Qualitative Social Research 4(1). http://www. qualitative-research.net/fqs-texte/1-03/1-03chanma-e.htm Elsadda, H. (2001). Discourse on women’s biographies and cultural identity: Twentiethcentury representations of the life of “A”Isha Bint Abi Bakr. Feminist Studies, 27(1), 3764. Hofmeyer, A.( 2002). Using text as data and writing as the method of inquiry and discovery. Nursing Inquiry, 9(3), 215-217. Janesick, V. J. (1994). The dances of qualitative research design: Handbook of qualitative research. Thousand Oaks: Sage. Joyappa, V. and Martin, D. J. (1996). Exploring alternative research epistemologies for adult education: Participatory research, feminist research and feminist participatory research. Adult Education Quarterly, 47(1), 1-14. Kehily, M. J. (1995). Self-narration, autobiography and identity construction. Gender and Education, 7(1), 23-32. Kopala, M. and Suzuki, L. A. (1999). Using qualitative methods in psychology. California: Sage. Lindsey, E. W. (1997). Feminist issues in qualitative research with formerly homeless mothers. Journal of Women and Social Work, 12(1), 57-75. Mullen, E. J. (1995). Pursuing knowledge through qualitative research. Social Work Research, 19(1), 29-32. Ribbens, J. and Edwards, R. (1998). Feminist dilemmas in qualitative research: Public knowledge and private lives. London: Sage. Seibold, C. (2000). Qualitative research from a feminist perspective in the postmodern era: methodological, ethical and reflexive concerns. Nursing Inquiry, 7, 147-155. Sherman, E. and Reid W. J. (1994). Qualitative research in social work. New York: Columbia University Press. Spry, T. (2001). Performing Autoethnography: An Embodied Methodological Praxis. Qualitative Inquiry, 7(6), 706-732. Wilkinson, W. K. and McNell, K. (1996). Research for helping professions. Pacific Grove, California: Brooks Publishing Company.

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In: Health Issues in Chinese Contexts, Volume 1 Editor: Zenobia C. Y. Chan

ISBN: 978-1-61209-385-7 © 2009 Nova Science Publishers, Inc.

Chapter 9

THE PROMOTION OF A HEALTHFUL DIET AMONG MALE RED MINIBUSE (RMBS) DRIVERS IN KWUN TONG Mandy Y. M. Kwan* and Zenobia C. Y. Chan

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ABSTRACT Eating is one of the important activities in human life. Nowadays, people eat less healthfully than before due to an abundance of unhealthful yet tasty food, which is readily available throughout the city. In order to promote a healthful diet (Centre for Health Protection, 2004a; World Health Organization, 2003), a program targeting 20 red minibus drivers in Kwun Tong to increase their knowledge and awareness of a healthful diet will be provided. A registered nurse, a dietitian and the public light bus association will be collaborating together on this program. Talks and consultations will be conducted inside a health centre in Kwun Tong. Free health assessments, snacks packages and pamphlets are included to further encourage and reinforce the message. Further programs to maintain the ongoing effect of healthful dieting will be suggested. Various parties such as the government and the Department of Health can be invited. Or, they can collaborate with each other to maintain the drivers’ health.

BACKGROUND Dining out is a common practice among Hong Kong (HK) workers. The majority of them prefer a quick and large meal that can fill their stomach and allow time for their work. We will be examining one particular group of the population—the professional driver, with particular emphasis on the drivers of public light buses (PLBs). PLBs are one of the common public transports in HK. There are two types of PLBs: red minibuses (RMBs) and green minibuses (GMBs). RMBs have non-scheduled routes and *

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

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service (Environment, Transport and Works Bureau, 2003). RMBs drivers prefer to choose fast food that is convenient, tasty and stomach filling, as this allows them to extend their driving time to earn more money or prepare for heavy traffic (Centre for Health Protection [CHP], 2004a). They also lack understanding of a healthful diet and, thus, they cannot know how to choose a healthful meal. Research has also shown that males, who tend to eat less healthfully, are particularly susceptible to unhealthful diets (The University of Hong Kong [HKU], Social Sciences Research Centre, 2006). Obviously, there is a need to empower male RMB drivers with the knowledge of a healthful diet. At present, the HK government and some organizations have organised programs to promote healthful dieting for students, the elderly, men and the general public (Central Health Educational [CHE] Unit Health Zone, 2006a; Hospital Authority [HA], 2006; Public Light Bus General Association, 2006). In Kwun Tong , a healthful diet campaign was launched in 2005 but only targeted office workers (HK Special Administrative Region [HKSAR] Government, 2005). However, there is no such program that specifically targets drivers in this district. Male RMB drivers in Kwun Tong are chosen for this program. The healthful diet program for male RMB drivers will be conducted in collaboration with a dietitian and a nurse. Talks and consultations on healthful diets and simple health assessments are included. The participants are encouraged to fully participate in each process, and through this program, they will be empowered with related knowledge and skills.

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PROGRAM OBJECTIVES There are two program objectives. Firstly, this program looks to increase the knowledge of male RMB drivers on healthful and balanced diets. Secondly, this program looks to increase their awareness in choosing better and more healthful food. Through this program participants will gain the knowledge to decide whether a food is healthful to eat and the amount of food intake they need per day.

LITERATURE REVIEW Eating is one of the important practices in our daily life. Nowadays, with a variety of tasty foods available, it is convenient for people to dine outside and choose what they want to eat. According to the World Health Organization (WHO, 2003), there is a developing trend that diets are becoming richer in high fat and energy. This unhealthful diet can lead to obesity and overweight. Obesity leads to many non-communicable diseases, such as type 2 diabetes, cardiovascular disease, stroke, and hypertension. In HK, the majority of deaths are related to non-communicable diseases (CHP, 2006). The WHO has pointed out that in order to prevent the above diseases, it is important to provide education on healthful eating patterns and food choices (WHO, 2003). In order to prevent diet-related chronic diseases, WHO recommends an intake of at least five servings of fruits and vegetables per day (WHO, 2003). However, most HK people, especially males, don’t meet this amount. A survey conducted in 2006 revealed that among adults aged 18 to 64, only about one-fifth (22.4%) of them met the daily average intake of

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The Promotion of a Healthful Diet among Male Red Minibuse (RMBs) Drivers… 129 five or more servings of fruits and vegetables. A greater percentage of females (25.9%) than males (17.1%) were able to achieve this target. It was also found that males were less likely to change their dietary habit for weight control than females (HKU, Social Sciences Research Centre, 2006). Similarly, other studies also point out that males’ eating practices were poorer than females. Males usually do not consider the nutrient level of foods. The dietary problems in males include the following: excessive intake of fat, oil and animal protein; lack of fibre; eating out; and eating large or excessive amounts of food per meal (CHP, 2004b; Centre for Nutrition Studies, 2006; Diseases Prevention and Control Division, 2002). Obviously, males are less likely to adopt a healthful diet. A study on professional drivers reported that they had long working hours and need to dine out frequently where the choice of healthful foods is limited. They are used to eating a large amount of food at a time to save time for work. Moreover, they preferred fast food that was tasty, convenient and stomach filling but not healthful (CHP, 2004a). Another study conducted in the UK also showed that one of the barriers to additional fruit and vegetable intake was the limited availability of fruits and vegetables in food shops (Jeyanthi and Sue, 2004). Because of these unhealthful diets, the rate of cardiovascular disease has increased among professional drivers (Bibert, Klerdal, Hammar, Hallqvust and Gustavsson, 2004; Tuchesen, Hannerz, Roepstorff and Krause, 2006). Strengthening community action, developing personal skills and creating supportive environments are three key components of the Ottawa Charter for health promotion (WHO, 1986). In the past, various programs that have addressed unhealthful diets, both for the general public and drivers, were launched under the Primary Health Care (PHC) approach. This includes: the healthful eating intervention at a truck stop for Swedish lorry drivers (Gill and Wijk, 2004); the workplace canteen healthful diet program in Ontario (Dawson, Dwyer, Evers and Sheeshka, 2006); the “five plus a day” program in New Zealand (Ashfielf-Watt, 2006); and nutritional counselling in Italy (Sacerdote et al., 2005). In HK, examples include the territory-wide health campaign launched by the HA (HA, 2006) and the “2 plus 3” carnival for healthful diet campaign launched by the Department of Health (DH) (HKSAR Government, 2005; Hong Kong’s Information Services Department, 2005). The programs focused on educating the population on the skills and knowledge of a healthful diet. The target population was invited and encouraged to participate in the adoption of a healthful diet. Our program focuses on education with particular emphasis on RMB drivers. The following will describe the details of our program.

THE PROGRAM Assessment Stage Needs assessment will be done to assess the actual states, conditions and factors for this program. Normative and expressed needs assessments can be identified for this program. The HK government has revealed that males are less likely to have a healthful diet (CHP, 2004b). Another report shows that there are difficulties for professional drivers to eat healthfully (CHP, 2004a). Moreover, the WHO has mentioned that there is a need to prevent diet-related diseases (WHO, 2003). The above reports identify the normative need for a healthful diet

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program for male drivers. Apart from the normative need, expressed need can be observed. Since RMBs have non-scheduled routes and service (Environment, Transport and Works Bureau, 2003), RMB drivers prefer to choose fast food that is convenient, tasty and stomach filling because it allows them to extend their driving time to earn more money, or to prepare for heavy traffic (CHP, 2004a). This is a common phenomenon that can be observed, which is a kind of expressed need. Before doing the assessment, the target population or community of this program will be defined. People, place and function are the three dimensions of community (Stanhope and Lancaster, 1992). In this program, “people” refers to the male RMB drivers; “place” is selected to be the RMB terminal station in Kwun Tong and the food shops nearby; people within this community provide transportation services by RMBs. Since the objectives of this program are to increase the knowledge and awareness of healthful dieting among the RMBs drivers, assessments are done to assess their knowledge level regarding healthful dieting and their present food choice practices. The components of talk and consultation on healthful dieting are formed according to the knowledge level and the food choice practices, respectively. Questionnaires are distributed and face-to-face interviews are conducted. Self-administered questionnaires are administered to assess their knowledge level of healthful dieting. A dietitian will conduct face-to-face interviews to assess their present food choices. The geography of the target population is an important factor in understanding their relationship with the place (McMurray, 2003). It is common for the RMB drivers to eat at the food shops near the terminal station because they are geographically convenient. The availability of healthful foods is assessed by site visit. The visit targets the food shops near the RMB terminal station. Information on the availability of healthful food is collected, which is important on advising them on choosing healthful food alternatives.

Planning The program will last for 32 weeks starting from definition of the health problem until the completion of the program. The program is to deliver the healthful dieting message to the male RMB drivers. Additionally, if possible, the drivers can pass along the message to their colleagues or families after the program. The place of the program is convenient to the target population in order to facilitate their participation and accessibility (Liamputtong and Gardner, 2003). The program is held in a health centre located in Kwun Tong (United Christian Nethersole Community Health Services [UCNCHS], 2006). Intersectoral collaboration is one of the important elements in PHC. All related sectors, apart from the health sectors, are involved (Tarimo and Webster, 1994; WHO, 1978a). In this program, an registered nurse(RN), a dietitian and the coordinator of the PLB association will collaborate. An RN and a dietitian are recruited from the health centre in Kwun Tong (UCNCHS, 2006). Five volunteers are recruited through the health centre to assist the program. Meetings are organised to discuss the details of this program. The RN is responsible for simple health assessments; the dietitian is responsible for the talk and consultation on healthful dieting; the coordinator of the PLB association is responsible for the recruitment of

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The Promotion of a Healthful Diet among Male Red Minibuse (RMBs) Drivers… 131 male RMB drivers and the application of sponsored souvenirs. Five volunteers are assigned to assist throughout the talk and health assessments. Related pamphlets and posters about healthful diet will be ordered (CHE Unit Health Zone, 2006a). The pamphlets will be delivered to the target population to reinforce the message and facilitate learning (Henry, 1997; Wass, 2000). They are all printed in HK, which will allow the target population to relate to the material culturally and help them easily understand the material (May, 1996). Twenty male RMB drivers will be recruited through the PLB association. Invitation letters and self-administered questionnaires with return envelopes will be mailed to them. The questionnaire is used because it is less costly and requires less time and effort to administer (Polit, Beck and Hungler, 2001). The site visit and health talk will be organised and designed. The drivers will be invited to come to the health centre three times. The purpose of the first visit is participation in a simple health assessment, to attend a talk on healthful dieting, and to have a consultation with the dietitian. The second visit will provide a consultation one week after the talk. The third visit is for evaluation, conducted four weeks after the talk.

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Implementation The health problem is identified and analysed within the first month, from week one to week eight. Literature and research studies are reviewed through the Internet, library database and government library. The normative and expressed needs of healthful diet are identified. Within weeks nine to ten, the audience is identified to be the male RMB drivers in Kwun Tong. In this stage, the need for a program to promote a healthful diet among male RMB drivers in Kwun Tong is confirmed with evidence. The place for organizing the talk and consultation is chosen before the recruitment of the team members. A health centre in Kwun Tong is chosen. The centre can provide a class on healthful eating and provide the health assessment service. The centre is contacted through the enquiry telephone number for making arrangements. An application letter and program proposal is mailed to this centre (UCNCHS, 2006). After contact with the health centre, the next stage is the recruitment of team members. The team members’ recruitment period lasts for three weeks, from week eleven through week thirteen. The RN, dietitian and the coordinator of the PLB association are contacted by phone, and invitation letters are delivered to each party. Five volunteers are recruited from this health centre by means of a poster that is placed on the notice board inside this centre. In weeks 14 to 17, the team members carry out several face-to-face meetings in the health centre to discuss the components of the program. The program includes simple health assessments, a talk on healthful dieting and consultation on diet. In the meetings, each team member has assigned tasks. The RN organises a simple health assessment, which includes blood pressure monitoring, measurement of height and weight, and a blood test for blood glucose level and triglycerides. The dietitian prepares the talk and consultation on healthful dieting. At the same time, three volunteers are assigned to help with the preparation work of the RN and dietitian. One volunteer is assigned to order pamphlets and posters from the CHE unit by letter (CHE Unit Health Zone, 2006a). The remaining volunteers are assigned to prepare healthful snacks and drinks for the tea session and the souvenirs for the program. During the same period, the questionnaire (Appendix 1) and invitation letter are completed.

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The coordinator of the PLB association is assigned to seek sponsorship from his association and the recruitment of male RMB drivers. After the recruitment of 20 male RMB drivers in Kwun Tong, five volunteers deliver the invitation letters and questionnaires to them in the RMB terminal station from weeks 20 to 22. The details of the program are explained. A return envelope is attached and they are asked to return the questionnaire by post. In weeks 23 and 24, a site visit is performed according to the answer to part two, question three of the questionnaire, which assesses the types of food that the drivers usually consume. The volunteers visit the food shops near the station to gather information on the food offered by these shops. The information is passed to a dietitian as a reference for the talk. The dietitian then designs the talk accordingly. The health information from the HK government is adopted inside the talk, which is locally and culturally suitable (CHE Unit Health Zone, 2006b; Food and Environment Hygiene Department, 2006). Furthermore, posters on healthful diet are delivered to the food shops and the RMB terminal station. They are advised to place the posters on the notice boards. This can draw the drivers’ attention to the healthful eating messages (Ashfielf-Watt, 2006). This is also a kind of community involvement in the principle of PHC. In week 25, the drivers are contacted by phone for notice of the talk. They are invited to come to the health centre for participation. The talk (Appendix 2) is held by the dietitian and lasts for one hour and consists of five parts. The dietitian explains the concept of healthful dieting, tips for eating out healthfully and introducing healthful snacks, which they can place inside their RMBs so that they can ‘eat less with more meal’. At the end, there is a questionand-answer session for the drivers to clarify any misunderstandings. After the talk, there is a simple health assessment and individual consultation period. These two activities are processed at the same moment. Those drivers who are waiting for the activities can go to tea sessions where healthful snacks and drinks are provided. The individual consultations are held by the dietitian and each consultation lasts for ten minutes per person. The dietitian collects information on each driver’s usual diet as a pre-assessment and provides specific suggestions regarding their diet. Drivers are encouraged to participate in changing their eating habits. Healthful snacks package and pamphlets are delivered to them to reinforce the message (Ashfielf-Watt, 2006; Henry, 1997). They are advised to pass the message along to their colleagues, friends and families. In week 27, the drivers are invited back to the health centre for individual consultation. The dietitian gives encouragement and provides more suggestions. Lastly, drivers are invited back to the centre for a simple health assessment and a further individual consultation for the evaluation.

EVALUATION Evaluation is done to see whether the program is effective in improving RMB drivers’ knowledge and awareness of a healthful diet. The satisfaction of the program will also be evaluated. The implementation of PHC principles will be evaluated. The self-administered questionnaire is used to assess whether the drivers have improved their knowledge of a

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healthful diet. After they finish the questionnaire, the dietitian will screen the answers. Afterwards, face-to-face interviews with the dietitian will be conducted. Through these processes, the information on knowledge level and eating habits of the drivers can be collected. Active participation in the program and adoption of a healthful diet are important. This is because active participation shows their willingness to change and empower themselves. Participation of the drivers can be evaluated by their attendance at the talk and during the face-to-face interviews. Moreover, the change in eating habits can also show their participation in healthful dieting. This can be evaluated by the face-to-face interviews. The level of satisfaction affects the participation of the drivers. Satisfaction with the program is evaluated by distributing a program satisfaction survey to the drivers. Satisfaction with the talk content, place, time and method of the program will be assessed. There is an element of intersectoral collaboration within this program. The program will include collaboration with a health centre and the PLB association. Comments and opinions will be collected through discussions with the coordinators of each party. Their comments are useful in evaluating the possibility of organising further similar programs with them. Members of the community, including the food shops, are invited to participate in this program. Site visits are conducted to collect their comments on participation in this program. This program is organised by a team of people from different backgrounds. Since they come from different disciplines, they have their own particular comments on the program. In order to collect their comments, a conference will be organised. Each team member has a chance to express his or her opinion and their suggestions for further improvement are documented. The comments collected in the evaluation phase are discussed and recorded for the improvement of the present and future programs. Interviews with the drivers are conducted six months after the completion of the program to evaluate the ongoing effect.

DISCUSSION Achieving the goal of health promotion through an educational program has its difficulties. Educational programs need people’s participation. This program targets male RMB drivers. The limitations are the shifting job nature of the drivers, which may affect their participation in the program. Moreover, because of the size of health centre, the number of participants is limited to 20. Only one district can be covered in the program. Adoption of healthful diet requires knowledge and ongoing encouragement. It is important for drivers to maintain a healthful diet for their livelihood. Therefore, further programs on healthful dieting are needed. After this program, it is suggested that future programs should involve collaboration with the food shops that the drivers frequent. Food shops can provide discounted healthful food for the drivers. In addition, many sectors can also be invited to collaborate. The PLB association is invited to organise more programs to promote their drivers’ health. Health organizations including the DH and HA are also invited to provide specific health screening and education for the professional drivers. The nutritional department of different universities can also be invited to provide opinions to the food shops for the amendment of their menu.

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Different approaches can be used to further promote healthful diet to drivers. In Chinese culture, females like cooking for their husband, thus the males’ habits will affect the entire family. Therefore, the drivers are encouraged to act as a role model and pass along the healthful diet messages to their families. Government support is very effective. If we have a chance, we would like to suggest that the government sponsor the program. Policies on regulating the working hours and methods for RMBs are recommended so that the drivers can have enough time for a healthful diet. Perhaps in the future, if our program is successful, collaboration with other countries can be conducted to promote a healthful diet for drivers.

CONCLUSION The success of this program requires many PHC principles, such as participation of drivers, intersectoral collaboration of different disciplines, and teamwork. Empowerment of knowledge and skills is the first important stage for the adoption of a healthful diet. Through this program, drivers can gain the related knowledge and clearly understand what needs to change in their diet in order to eat healthfully.

ABOUT THE WORKSHOP DESIGNER

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Mandy Y. M. Kwan, a registered nurse, has received 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 community.

REFERENCES Ashfielf-Watt, P. AL. (2006). Fruits and vegetables, 5+ a day: we are getting the message across? Asia Pac. J. Clin. Nutr. 15 (2), 245-252. Bibert, C., Klerdal, K., Hammar, N., Hallqvust, J., and Gustavsson, P. (2004). Time trends in the incidence of myocardial infarction among professional drivers in Stockholm 1977-96. Occup. Environ. Med. 61, 987-991. Centre for Health Protection. (2004a). Men’s Health: Finding of Focus Group Discussion, Detailed Findings-Professional Drivers. Hong Kong Special Administrative Region: Department of Health. Centre for Health Protection. (2004b). 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 Health Protection. (2006). Hong Kong Population Health Profiles Series. Hong Kong Special Administrative Region: Department of Health. Centre for Nutrition Studies. (2006). Nutrition Articles [E-text type]. http://www.sph. cuhk.edu.hk/website/male.htm Central Health Educational Unit Health Zone.(2006a). Educational Resources, Exercises and Nutrition [E-text type]. http://www.cheu.gov.hk/eng/resources/exercise2_Printed.htm

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The Promotion of a Healthful Diet among Male Red Minibuse (RMBs) Drivers… 135 Central Health Educational Unit Health Zone. (2006b). Health Information, Exercise and Nutrition [E-text type].http://www.cheu.gov.hk/eng/info/exercise.htm Dawson, J., Dwyer, J. J. M., Evers, S., and Sheeshka, J. (2006). Eat Smart! Workplace Cafeteria Program Evaluation of the Nutrition Component. Canadian Journal of Dietetic Practice and Research, 67(2), 85-90. 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. Environment, Transport and Works Bureau. (2003). Policy on Public Light Buses [E-text type]. http://www.td.gov.hk/transport_in_hong_kong/public_transport/minibuses/ index. htm Food and Environment Hygiene Department. (2006). Nutrient Values of Indigenous congee, rice and noodle dishes. Hong Kong Special Administrative Region: Food and Environment Hygiene Department. Gill, P. E., and Wijk, K. (2004). Case Study of a healthy eating intervention for Swedish lorry drivers. Health Education Research, 19(3), 306-315. Hawe, P., Degeling, D., and Hall, J. (1990). Evaluating health promotion. Sydney: MacLennan and Petty. Henry, J. M. (1997). Gaming: A teaching strategy to enhance adult learning. The Journal of Continuing Education in Nursing, 28(5), 231. Hong Kong’s Information Services Department. (2005). District healthy workplace campaign launches [E-text type]. http://www.news.gov.hk/en/category/healthandcommunity/ 050307/print/050307en05003.htm Hong Kong Special Administrative Region Government. (2005). 2 plus 3 Carnival for Healthy Diet Campaign. Press Release [E-text type]. http://www.info.gov.hk/gia/ general/200508/27/P200508270096_print.htm Hospital Authority. (2006). Territary-wide Health Campiagn [E-text type]. http://www13. ha.org.hk/healthinfoworld/health_campaign/healthc_01.aspx Jeyanthi, H. J., and Sue, Z. (2004). Reported barriers to eating more fruit and vegetables before and after participation in a randomised controlled trial: a qualitative study. Health Education Research, 19(2), 165-174. Liamputtong, P., and Gardner, H. (2003). Health, social change and communities. Melbourne: Oxford University Press. 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 McMurray, A. (2003). Community health and wellness: A sociological approach (2nd ed.). Sydney: Mosby. Polit, D.F., Beck, C.T., and Hungler, B.P. (2001). Essentials of nursing research. Methods, appraisalm and utilization (5th ed.). Philadelphia :Lippincott Public Light Bus General Association. (2006). Activities [E-text type]. http://www.plbga. com.hk/activities_titbit.htm Sacerdote, C., Fiorini, L., Rosata, R., Audenino, M., Valpreda, Mario, and Vineis, P. (2005). Randomized controlled trial: effect of nutritional counselling in general practice. International Journal of Epidemiology, 33, 209-415.

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Stanhope, M., and Lancaster, J. (1992). Community as client: Using the nursing process to promote health. In Stanhope, M., and Lancaster, J. (Eds.), 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. Geneva: World Health Organization. The University of Hong Kong, Social Sciences Research Centre. (2006). Behavioural Risk Factor Survey. Hong Kong Special Administrative Region: Department of Health. Tuchesen, F., Hannerz, H., Roepstorff, C., and Krause, N. (2006). Stroke among professional drivers in Denmark, 1994-2003. Occup Environ Med, 63, 456-460. United Christian Nethersole Community Health Service (2006). Community Nutrient Services [E-text type]. http://www.community-health.org.hk/B/_0%7E2.htm Wass, A. (2000). Promoting health: The primary health care approach (2nd ed.). Sydney: Harcourt Saunders. World Health Organization. (1978a). Primary health care: Report of the International Conference on Primary Health Care, Alma-Ata, USSR. Geneva: World Health Organization. World Health Organization. (1978b). Primary health care: Report of the International Conference on Primary Health Care, Alma-Ata, USSR. Reproduced in E. Tarimo and E. G. Webbster, (1994), Primary health care concepts and challenges in a changing world: Alma-Ata revised (pp. 107-110). 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. (2003). Diet, Nutrition and the Prevention of Chronic diseases. Geneva: World Health Organization.

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APPENDIX 1. QUESTIONNAIRE Part One: Matching Please decide the amount among the four kinds of foods that we need to intake in a day; just put the alphabet (A), (B), (C) and (D) in the appropriate box. Eat Most Eat More Eat Moderately Eat less

(D) meat, poultry, fish, eggs, dry beans and dairy products (pork, beef, mutton, poultry, fish, shellfish, dry beans, peas, soybeans, eggs, dairy products, e.g., milk, cheese, yoghurt, ice-cream, etc.) (A) vegetables and fruits (all kinds of fruits and vegetables) (B) food high in fat/oil, salts, or sugar and preserved food (butter, peanut oil, corn oil, cream, candy, soft drinks, pickled vegetables, salted fish, seasonings, etc.) (C) grains or cereals (pasta, noodles, oatmeal, rice (red, brown, white), bread, biscuits, starchy vegetables, e.g., potatoes, taro.

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Part Two 1) How many bowl(s) of cooked vegetables do you have in a day? Answer:_______________ 2) How many portion(s) of fruit do you have in a day? (1 portion = 1 medium-size orange or apple) Answer:_______________ 3) Which kinds of foods do you always eat when you dine out? Answer:______________________________________________________________

Part Three Name:__________________ Mobile:_________________ Address:_____________________________________________________________ E-mail:______________________________________________________________

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REFERENCES Central Health Educational Unit Health Zone.(2006a). Educational Resources, Exercises and Nutrition [E-text type]. http://www.cheu.gov.hk/eng/resources/exercise2_Printed.htm Central Health Educational Unit Health Zone. (2006b). Health Information, Exercise and Nutrition [E-text type].http://www.cheu.gov.hk/eng/info/exercise.htm

APPENDIX 2. PROGRAM SCHEDULE A) Talk Content

Method

Welcome session Concept of healthy diet

-Lecture

Time allotted (minutes) 10 15

-Food demonstration

15

Tips for eating out healthy Introduction of Healthy Snacks Question and Answer

10 Discussion

10

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Responsible person 5 volunteers Dietitian

Resources Chairs -Notebook -Projector -Microphone -Chairs

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138

B) Simple Health Assessment Content Simple health assessment

Method

Time allotted 10 minutes /person

Responsible person -3 volunteers -Nurse

Resources -Weight -Ruler -Dilamat -Accu Check Advantage (Roche) -Accu Trend (Roche)

C) Consultation (Individual) Content Individual consultation on diet

Method Face-to-face interview

Time allotted 10 minutes/person

Responsible person -1 volunteer -Dietitian

Resources -Pamphlets* -Souvenirs

D) Tea serving Content Tea serving

Method

Time allotted

Responsible person 1 volunteer

Resources Healthy snacks and drinks

*pamphlets.

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Six topics of pamphlets and posters will be ordered, including ‘Calories’ ‘Healthful Snacks’ ‘Healthy High Fibre Diet’ ‘Eat Smart! Follow the Food Pyramid!’ ‘Cholesterol’ ‘ Enjoy Fruits and Vegetables Every Day, Two Plus Three Is the Way’ Central Health Educational Unit Health Zone.(2006a). Educational Resources, Exercises and Nutrition [E-text type]. http://www.cheu.gov.hk/eng/resources/exercise2_Printed.htm

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In: Health Issues in Chinese Contexts, Volume 1 Editor: Zenobia C. Y. Chan

ISBN: 978-1-61209-385-7 © 2009 Nova Science Publishers, Inc.

Chapter 10

FALL PREVENTION COMMUNITY PROGRAM FOR THE ELDERS IN HONG KONG S. K. Cheng and Zenobia C. Y. Chan

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ABSTRACT As aging population is a global concern, a health promotion program on fall prevention is important. However, this has not yet been fully developed in the primary health care service in Hong Kong. The program described in this chapter advocates positive evolutionary cognitive behavior changes in the elders on the issue of fall prevention. Approximately 100 elderly people living in the Kowloon Central district should participate in a one-year program. The elders should be assessed multidimensionally to identify the determinants of fall by a voluntarily fall prevention team in order to implement various strategies to address motivation and the development of individualized fall preventive measures. Qualitative evaluation should be performed from multiple perspectives. Although the cause-effect relationships of the variables of the elders cannot be discriminated in this program, fall preventive strategies corresponding to the feelings and views of the elders can be emphasized.

BACKGROUND OF THE FALL PREVENTION PROGRAM Aging population is a global concern (Kempton, Beurden, Garner, and Beard, 2000; Dobrzanska, Crossland, Domanski, and Towriss, 2004), resulting in a rise of the demands for health care services. Many of these demands stem from illnesses that can be prevented by implementing some interventions. The most outstanding health maintenance interventions for the elders are fall prevention programs, which can be highly individualized for each municipality (Takahaski and Asakawa, 2005). According to some international studies, about one-third of people over 65 years of age experience a fall at home each year (Yates and Dunnagan, 2001; Ness, Gurney, and Ice, 2003; Chu, Chiu, and Chi, 2006) and ~10% of those who fall experience physical injuries such as facture. Campbell, Borrie, Spears, Jackson,

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Brown, and Fitzgerald (1990) mentioned that fall prevention is the prime target for the elders rather than the medical treatment for people who fall. Hong Kong (HK) has also seen a rapid growth in the elderly population. According to the latest publication from the Centre of Health Protection (CHP) in 2006, the life expectancies at birth for both sexes have steadily increased by about 10 years during the past 36 years. The projected life expectancy in 2033 will be 82.5 years for males and 88 years for females (Hong Kong Government, 2007). This implies that the demands on health care services and the related medical costs will be soared. This great challenge requires the government to study on the health care reform and the related financing arrangements in the long run. In the last couple of years in HK, ~25% of people over 65 years of age experience a fall every year and ~10% of those who fall require medical treatments. The Hospital Authority (HA) expends about two billion dollars in this area each year. Accordingly, the Hong Kong Government (HKG) (2007) mentioned that the governmental health care funding allocation will be shifted from an institution-based approach to a population-based approach. Mobilization of resources from the institutions to the community settings is being encouraged. Nevertheless, until now, primary health care in HK is being undervalued and not comprehensive. In view of the above situation, a one-year community-based fall prevention program for people over 65 years of age should be developed in collaboration with health and non-health governmental and non-governmental organizations (NGOs). It should be implemented in a proactive way to provoke an evolutionary change. The elders should not only be the recipients of the program, but should also be encouraged to share the responsibility for the program. This empowerment approach can arouse self-awareness with respect to their personal thinking during implementation of the program’s activities.

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PROGRAM OBJECTIVES The program should advocate positive evolutionary cognitive behavior changes among the elders in the community on the issue of fall prevention. This can be achieved by addressing self-awareness among the community and the elders, providing some preventive strategies with written information, empowering the elders with regarding to their individual environment of daily living, collaborating with the health and non-health sectors, and enhancing mutual support between the community and the elders. By minimizing the incidence of fall and the related injuries, the health, well-being and quality of life (QOL) of the elders will be improved in the long run.

LITERATURE REVIEW Falling is a serious global problem for the elders (Schoenfelder, 2000), and is on a concomitant rise with the rapidly-growing elderly population (Kessenich, 1998). It has an afflictive effect on the autonomy and QOL of the elders (Dobrzanska et al., 2004), and even significantly contributes to their morbidity and mortality (Robitaille et al., 2005; Conn, 2007). Therefore, the HKG has launched some health promotion programs through the HA to

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implement a fall prevention program for the elders by conducting district-based fall risk home assessment in collaboration with NGOs and by organizing tai chi classes for elders with over 100 community organizations. A “Healthy Exercise for All Campaign” has been launched by the Leisure and Cultural Services Department (2007) with the Department of Health and the Physical Fitness Association of Hong Kong. The concept of primary health care was emphasized by the Health and Medical Development Advisory Committee as a new trend health model. These collaborative health promotion strategies are devised from the Declaration of Alma-Ata (WHO, 1978) and the Ottawa Charter for Health Promotion (WHO, 1986), which were developed by the World Health Organization (WHO), and are the blueprint documents for health promotion throughout the world. Nurses are the ideal people to implement a health promotion program. In the Nursing in Action, the importance of nursing practice in a community was defined as efforts “… to help individuals, families, and groups to determine and achieve their physical, mental, and social potential, and to do so within the challenging context of the environment in which they live and work” (Salvage, 1993, p. 15). Nurses have a variety of useful skills in developing a health promotion program in the community, such as working with different disciplines and promoting community involvement (Anderson and McFarlane, 2000). They are in a unique position to identify the necessity for equitable public health promotion services in the wider community environment (Pike and Forster, 1995). Accordingly, nursing research on investigating the programs and strategies on fall prevention for the elders can minimize the likelihood of falls in long-term care settings (Schoenfelder, 2000). The concept of community development (CD) as described by the Ottawa Charter (WHO, 1986) should be the main framework of the social and community services for strengthening community action (Kenny, 1999). Community participation and empowerment should be emphasized. The elders (as well as their families and the community) should work as partners to identify their concerns and needs on fall prevention within their own individual environmental grounds, to make the necessary resources more accessible, and to facilitate collective actions on the issue of falls and effective control of their lives with self-confidence (Ewles and Simnett, 2003). Their own culture and personal experiences should be respected to enhance their feeling of meaningful social roles and mutual trust throughout the program (Takahaski and Asakawa, 2005). The elders can choose the actual options for their own future as a self-help strategy (Kenny, 1999). Therefore, they should be motivated to promote their own health by their perception of health and its subsequent managements (Ho, Woo, Chan, Yuen, and Sham, 1996; Edelman and Mandle, 1998). They can be empowered to live their final years with integrity by increasing their self-awareness on the importance of fall prevention. They can be facilitated to develop their potentials and to define the priorities for fall prevention strategies. Appropriate skills and lay knowledge should be provided. The availability and accessibility of fall-related resources should be emphasized (Kenny, 1999; Naidoo and Wills, 2003). This bottom-up approach will bring an evolutionary change in a way that is more acceptable to the elders (Kenny, 1999), and is regarded as an essential approach to improve the population equitably by collaborating with the government or professionals (Baum, 2007). As mentioned by Tarimo and Webster (1994), the main problem for the elders is the limited access to health care services caused by lack of financial resources. Therefore, equity should be emphasized as the most fundamental issue in implementing the fall prevention program. More should be given to the most needy and less to the least in need.

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The efforts of the government and societies working together have contributed to significant improvements in health (WHO, 2000). Active collaboration at all levels, whether health or non-health, can strengthen the networks in fall prevention. Common goals are shared, and coordinating strategies are planned and implemented after assessing the needs of the elders on the issue of falls.

NEEDS ASSESSMENT Assessing what the elders need is the first phase of program planning (Naidoo and Wills, 2003) so as to get a comprehensive picture of fall incidents in the community. Their needs can be determined by asking a series of simple fall-related questions through face-to-face interviews, phone contacts and any activities held in community centers. Their environmental, physical, social, psychological, cultural and financial aspects contributing to falls can be assessed with confidentiality before implementing the program. Then, the priorities and responses to specific needs can be identified. Risk groups can be targeted, and the limited resources can be utilized equitably.

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PLANNING First of all, a fall prevention team should be set up, consisting of nurses, social workers, staffs from the elderly health care centers, a physiotherapist (PT), an occupational therapist (OT), a podiatrist, dietitians, a tai chi expert, and a home decorator, to work as a crosssectional collaborative team. Each can contribute knowledge to implement in this program. Meanwhile, the governmental departments and NGOs can be contacted to gather information and resources. Regular meetings can take place to review, discuss and plan the program. Supplementary training should also be offered to the team members if necessary. This one-year program can be a random population-based study performed in the Kowloon Central (KC) district in HK, which has the highest elderly population density of those over the age of 65 (approximately 13.4%) (Hong Kong Census and Statistics Department, 2001). The target sample size can be approximately 100 people. Yau Ma Tei Elderly Health Centre is an ideal location to provide free program services. It is situated in the center of the KC district, where many elderly people live alone. With the aim of advocating positive evolutionary behavior changes on the issue of fall prevention, the participants should be motivated to address their own self-awareness and to reduce the possibility of fall by improving their well-being using various strategies. They can be encouraged to share the responsibility for the program—for example, by being volunteers in the health center—in order to enhance the feeling of mutual support, self-confidence and social roles. Their families and the public are welcomed as the program requires the cooperation of the public. The program can include various strategies and activities, and a number of materials can be developed: posters, printed information sheets with lay knowledge, assessment tools, souvenirs of eco-bags advertising the program and so on. Various activities can take place. For instance, awareness of the elderly and the community on fall prevention can be addressed

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through an exhibition, posters, and the mass media. Fall prevention strategies can be introduced through practical and written information about home safety, a healthful diet, bone health, and exercise.

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IMPLEMENTATION Face-to-face interviews with the participants and their families can be conducted by nurses and other health promoters at the Yau Ma Tei Elderly Health Center with self-designed assessment tools. First, self-perceived health and desires, which are described by the elders, is a good predictor for falls (Ho et al., 1996). Then, self-reported health and non-health lifestyle issues can be assessed through a self-designed questionnaire including questions on cultural habits, dietary habits and nutrition, activities of daily livings (ADLs), types of exercise they are doing and their tolerance, physical health status, experiences of falls, family support network, living environment, financial status and any governmental subsidies. All of these issues are determinants of health in fall prevention (Ewles and Simnett, 2003). At the end of the interview, a souvenir eco-bag publicizing the program can be given as a means of advertising to the public. A district-based fall risk home assessment designed by HA and NGOs (HKG, 2007) can be conducted by the PT, OT, social workers and the home decorator. According to the statistics, the prevalent factors for falls among the elders in HK are loss of balance, tumbling, and slipping and falling because of a crowded environment. Therefore, the home environment of the elderly should be assessed to identify the fall-related risks. Written suggestions on inexpensive home modifications can be provided for reference. A follow-up home visit after home modification can evaluate its appropriateness and effectiveness. A comprehensive picture can be painted through the assessments. Then, dietary advice can be given to the elders by the dietitians based on their individual health problems and dietary habits. The PT and OT can help with suitable strengthening exercises. The social worker can help with applying for financial subsidies if necessary. The podiatrist can provide some advice on foot care and footwear selection. The home decorator can design inexpensive modifications to individual homes. All of these activities can empower the elders to identify their own potential and to eliminate their potential for falls, and to enhance their self-care ability, thereby to reduce the number of falls. Monthly poster sessions, exhibitions and health talks can be held in the Yau Ma Tei Elderly Health Center to raise the awareness of the elders and the community. As mentioned by Ewles and Simnett (2003), mass media is a powerful means of communication that can reach a large number of people. Simple and concise language with pictures can be used for the lay elders and the public. The topics include risk factors for falls among the elders, safety advices for the elders, home-safety advices, safety on using walking aids, elderly nutrition, and fitness exercise programs. The health promoters can explain the related information by providing pamphlets whenever needed. Participation in exercise can prevent falls. Proper posture and exercises can improve balance. Stretching and strengthening exercises can prevent muscle weakness and can protect the joints. The elders should be instructed about the proper way to practice their preferred exercises with the available related resources in the community.

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Tai chi is an exercise that is well-accepted by Chinese elders because it has been a traditional Chinese exercise for more than three centuries (Kessenich, 1998). It is especially good for promoting fall prevention, and is well supported by the elderly health services in HK (Department of Health, 2007). Tai chi experts can teach the elders in the Yau Ma Tei Elderly Health Center every week according to their exercise tolerance. The participants can be encouraged to practice tai chi as a group every day. Body flexibility, stability and slow movement help to strengthen muscles, to train endurance, to stretch the muscles, and to improve balance and mobility. A correct regular practice of tai chi can reduce the risk for falls and can enhance mutual support among the elders during their daily practice. A monthly self-help support group can be organized among the elders as an acknowledgment that they are not isolated from the community. They should be encouraged to express their feelings and share their own fall prevention strategies. Empathy can be used to arouse mutual support. They can also be invited to participate in the fall prevention program as volunteers. This can establish a sense of social usefulness among the elders in stead of a sense of social burden; as a result, can help to minimize the problems of hidden elders, depression and suicide (Gerlock, 2006; Durant & Christian, 2007).

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EVALUATION As mentioned by Baum (2000), a health setting community development project should be evaluated from multiple perspectives. Briefly, they include the participants and their families, the fall prevention team, the government and the collaborative organizations. A face-to-face assessment should be implemented as a baseline. Subsequently, the cognitive behavioral changes should be observed through the weekly self-help support groups and tai chi classes. The record of attendance can provide information on the demand for the program. The participants and their families can be contacted by phone every three months as follow-up to the initial assessment. This comparative method provides information about the extent of the cognitive behavioral changes in the elderly after completing the program. Meanwhile, home visits should be arranged to each participant at the end of the program because it is more accurate to evaluate the outcome of the program by face-to-face interview and home assessment. A questionnaire should be designed and completed by the participants and their families before and after the program. This is the most subjective way to evaluate the program and get feedback. Evaluation is an integral part of developing the program (Naidoo and Wills, 2003). Weekly meetings should be held among the team members throughout the program. The effectiveness of the program and the need for any improvements should be discussed. The use of the resources should be justified on the basis of social justice and equity. The positive impacts and any unexpected negative impacts of the program should be evaluated and the necessary amendments should be made. All of the above data should be evaluated by the government and the collaborative organizations. They can provide some objective advice throughout the program.

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DISCUSSION This fall prevention program has some limitations. The data are based on the cognitivebehavioral changes of the elders as a qualitative nature. Cause-effect relationships of the variables of the elders cannot be distinguished. This program is developed for the glassrod district and may not be applicable to other districts in HK. Recall bias is important, as the elders tend to have poor memory. However, this program is one of the few programs with the aim of preventing falls by various strategies, together with motivating positive cognitive behavioral changes in the elderly.

CONCLUSION An aging population is a common global situation, and preventing falls among the elders has been recognized by the HKG as an important issue. Therefore, a fall prevention program should be developed for the elders to enhance their well-being and QOL. It aims at advocating positive evolutionary cognitive behavior changes among the elders in a community on the issue of fall prevention by addressing their self-awareness, providing preventive strategies with written information, empowering the elders, collaborating with multiple sectors, and enhancing mutual support among the elders.

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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. (E-mail: [email protected])

REFERENCES Anderson, E. T., and McFarlane, J. (2000). Community as partner: Theory and practice in nursing (3rd ed.). Philadelphia: Lippincott. Baum, F. (2000). The new public health: An Australian perspective (2nd ed.) (pp. 185-193). Oxford: Oxford University Press. Baum, F. (2007). Cracking the nut of health equity: top down and bottom up pressure for action on the social determinants of health. Promotion and Education, 14(2), 90-95. Campbell, A. J., Borrie, M. J., Spears, G. F., Jackson, S. L., Brown, J. S., and Fitzgerald, J. L. (1990). Circumstances and consequences of falls experienced by a community population 70 years and over during a prospective study. Age and Ageing, 19, 136-141. Chu, L. W., Chiu, A. Y. Y., and Chi, I. (2006). Impact of falls on the balance, gait, and activities of daily living functioning in community-dwelling Chinese older adults. The Journals of Gerontology, 61A(4), 399-404. Conn, L. (2007). Mind your step! A falls prevention programme designed to reduce falls in those over 75 years. Quality in Ageing, 8(1), 10-21.

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Dobrzanska, L., Crossland, D., Domanski, M., and Towriss, S. (2004). A falls prevention exercise programme in a primary care trust. Quality in Ageing, 5(3), 25-32. Durant, J. T. J., & Christian, O. G. (2007). Caregiving to aging parents. Retrieved February 11, 2009, from http://www.forumonpublicpolicy.com/archive07/durant.pdf Edelman, C. L., and Mandle, C. L. (1998). Health Promotion throughout the lifespan (4th ed.) (pp. 633-663). St. Louis: Mosby. Ewles, L., and Simnett, I. (2003). Promoting health: A practical guide (5th ed.). London: Bailliere Tindall. Gerlock, E. (2006). Discrimination of older people in Asia. Retrieved February 11, 2009, from http://www.ifa-fiv.org/attachments/061_Discrimination%20of%20Older% 20People%20in%20Asia%20-%20Age%20Concern%20England,%20DaneAge%20 Association,%20IFA%202006.pdf Ho, S. C., Woo, J., Chan, S. S. G., Yuen, Y. K., and Sham, A. (1996). Risk factors for falls in the Chinese elderly population. The Journals of Gerontology, 51A(5), M195-M198. Hong Kong Census Statistics Department. (2001). Population age and sex structure 2001. Retrieved January 8, 2008, from http://www.ha.org.hk/. Hong Kong Government. (2007). The Hong Kong Year Book 2006. Retrieved January 8, 2008, from http://www.yearbook.gov.hk/. Kempton, A., Beurden, E. V., Garner, E., and Beard, J. (2000). Older people can stay on their feet: final results of a community-based prevention programme. Health Promotion International, 15(1), 27-33. Kenny, S. (1999). Developing communities for the future: Community development in Australia (2nd ed.) (pp. 3-34). Melbourne: Thomas Nelson. Kessenich, C. R. (1998). Tai Chi as a method of fall prevention in the elderly. Orthopaedic Nursing, 17(4), 27-29. Leisure and Cultural Services Department. (2007). Healthy Exercise for All Campaign: Fitness programmes for older persons. Retrieved January 8, 2008, from http//www. lcsd.gov.hk/healthy/en/senior.php. Naidoo, J., and Wills, J. (2003). Health Promotion: Foundations for practice (2nd ed.). London: Bailliere Tindall. Ness, K. K., Gurney, J. G., and Ice, G. H. (2003). Screening, education, and associated behavioral responses to reduce risk for falls among people over 65 years attending a community health fair. Physical Therapy, 83(7), 631-637. Pike, S., and Forster, D. (1995). Health promotion for all (pp. 3-13, 151-155, 185-196). London: Churchill Livingstone. Robitaille, Y., Laforest, S., Fournier, M., Gauvin, L., Parisien, M., Corriveau, H., et al. (2005). Moving forward in fall prevention: an intervention to improve balance among older adults in real-world settings. American Journal of Public Health, 95(11), 20492056. Salvage, J. (1993). Nursing in Action: Strengthening nursing and midwifery for all. WHO Publications European Series, 48, 15. Schoenfelder, D. P. (2000). A fall preventive program for elderly individuals: Exercise in long-term care settings. Journal of Gerontological Nursing, 26(3), 43-51. Takahashi, R., and Asakawa, Y. (2005). Young-old and old-old motivation in cooperative fall-prevention programmes. Age and Ageing, 34(1), 90.

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Tarimo, E., and Webster, E. G. (1994). Primary health care concepts and challenges in a changing world: Alma-Ata revisited (pp. 19-22). 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, (1994), Primary health care concepts and challenges in a changing world: Alma-Ata revisited (pp. 107-110). 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. (2000). Fifth Global Conference on Health Promotion: Mexico Ministerial Statement for the Promotion of Health: From idea to action. Geneva: World Health Organization. Yates, S. M., and Dunnagan, T. A. (2001). Evaluating the effectiveness of a home-based fall risk reduction program for rural community-dwelling older adults. The Journals of Gerontology, 56A(4), M226-M230.

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In: Health Issues in Chinese Contexts, Volume 1 Editor: Zenobia C. Y. Chan

ISBN: 978-1-61209-385-7 © 2009 Nova Science Publishers, Inc.

Chapter 11

FAT AND FIBRE DIETARY ASSESSMENT TOOL FOR ADULTS IN HONG KONG Queenie P. S. Law* and Zenobia C. Y. Chan

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ABSTRACT Colorectal cancer is becoming a global epidemic. In the last decade, colorectal cancer was the second most common form of cancer in Hong Kong. It accounted for 16% of all new cancer cases in 2004 and is on the rise. In the face of this rising trend of colorectal cancer in adults, there is a pressing need to control any further outbreaks. To do this, one of the most effective strategies in tackling colorectal cancer would be to cultivate healthful living and behaviour. Another effective strategy is the implementation of health education programmes, which will play an important role in promoting behavioral changes in their lifestyle that will lead to more healthful living. In order to fulfill the real needs of the community through health education programmes, needs assessment is crucial. This assessment tool is useful in assessing the needs of the community and evaluating health education programmes. Based on the theory of Lewin’s force field analysis, a dietary assessment tool is designed for recognizing the stage of change in the individual, their driving force and their restraining force in the change process. Although there are many types of dietary assessment tools focusing on measuring food intake habits, this assessment tool is a suitable tool for the Chinese population because it is localized to reflect foods common in an Asian diet, specifically listing common foods in Hong Kong.

INTRODUCTION Colorectal cancer is a global time bomb in our modern society. In the past decade, colorectal cancer is ranked the second most common form of cancer in Singapore and Hong Kong. According to the latest figures released by the Department of Health of Hong Kong, *

Correspondence author: Queenie P. S. Law, RN, MHSc, Clinical Instructor and Nutritionist, School of Nursing, The Polytechnic University of Hong Kong, Hong Kong. E-mail: [email protected]

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colorectal cancer accounted for about 16% of all new cancer cases in 2004 [5]. In the face of the rising trend in colorectal cancer in adults, the need to tackle this problem is a pressing one. One of the strategies to tackle colorectal cancer is cultivating healthful living and to promote healthful eating practices so that people can effectively prevent this disease. Health education programmes will be an important and practical way to promote healthful living and to adopt behavioral change among the Chinese population.

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LITERATURE REVIEW According to the National Cancer Institute, colorectal cancer is a disease in which cancer cells form in the tissues of the colon or in the tissues of the rectum [15]. Colorectal cancer is the second leading cause of cancer-related mortality for both men and women in the United States. For the past ten years, colorectal cancer has also been the second most common form of cancer in Singapore [22] and Hong Kong. Hong Kong recorded 3,582 new cases of colorectal cancer, with 1,996 male cases and 1,586 female cases, respectively, in 2004. The age-standardized incidence rates were 46.1 for males and 31.9 for females per 100,000 standard population [5]. The prevalence of colorectal cancer in Hong Kong is similar to other countries. In Japan, the mortality rate caused by colorectal cancer increased rapidly between 1950 and 2001. During this period, the age-adjusted mortality rate per 100,000 standard population for colon cancer increased 4.9-fold in men and 2.9-fold in women, correspondingly [19]. Evidence from epidemiological studies revealed that intake of dietary fat and meat were positively related to the risk of developing colorectal cancer. According to the American Cancer Society, there are many risk factors contributing to colorectal cancer such as high fat intake, low fibre intake, smoking, excessive alcohol consumption, obesity, and lack of regular physical activity [1]. In addition, according to Emmons et al., who examined 1,247 patients who had been recently diagnosed with adenomatous colorectal polyps by using a follow-up after completion of a baseline telephone survey, behavioural factors were the leading risk attributed to colon cancer. They also found that red meat consumption is a major risk factor for colorectal cancer in 58% of the test subjects [6]. In 1990, Willett et al. published a longitudinal study of 88,751 women aged 34.59 years who did not have cancer or inflammatory bowel disease at the time of recruitment, and found that increasing their consumption of animal fat also increased their risk of colon cancer [22]. The correlation between ingestion of animal fat and colon cancer is highly significant with a P Value = 0.01 and with high relative risk compared with the lowest quintile being 1.89. This study shows that the relative risk for women eating beef, pork or lamb as a main dish every day is 2.49 (95% confidence interval, 1.24 to 5.03), compared with women who consume beef, pork or lamb less than once a month [21]. The authors suggested that their data supported the hypothesis that consumption of high animal fat raised the risk of colon cancer and they recommended that people substitute meats with high animal fat content with fish and chicken [20]. Dietary fibre has been observed to have protective qualities in association with colorectal cancer. Dietary fibre has many components, but is commonly grouped into insoluble and soluble fibre [8]. These components may increase faecal bulk and reduce the transit time

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of faecal matter in the bowel [22]. Epidemiological studies have reported differences in the effect of these components. In a study by Terry et al., it was found that there was no protective quality of fibre in cereals [18], but a protective quality of fibre was consistently found in vegetables and fruits [14]. The best defense against colorectal cancer is to prevent it from happening by establishing a healthful eating lifestyle. Health education programmes are essential in enabling the community to understand the major causes and risks of exposure to colorectal cancer and to practice healthful living to prevent it. The community can be defined as a group of people living in a definite area or a cultural group [2]. In order to fulfill the real needs of the community through health education programmes, needs assessment is crucial. Community participation and self empowerment in needs assessment are encouraged by using the primary health care approach. Rhyne’s group emphasized that community-based primary care was important in combining individual and public health data at the community level, leading to needs assessment, intervention and evaluation [16]. In this chapter, a dietary assessment tool was designed as part of a community needs assessment and evaluation tool of health education programmes. The aim of this assessment tool was used to assess the dietary behaviour of fibre and fat intake among the population.

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DEVELOPMENT OF THE ASSESSMENT TOOL This assessment tool is comprised of five parts. Part A and Part B are the food intake behavioral questionnaires. These parts are modified from the original 33-item fat- and fibrerelated behavior questionnaire [17]. The original 33-item fat- and fibre-related behavior questionnaire was used in earlier randomized clinical trial studies and is used to evaluate modest dietary change associated with low-intensity intervention and to examine the changes of participants’ fat and fibre intake. Part A and Part B of our assessment tool is modified based on Shannon’s group questionnaire and is used to examine the fat and fibre intake behavior of participants in the past month. The following parts were newly developed. Part C of the questionnaire was especially designed to reveal the contributing factors of food choice. Last, but not least, Parts D and E are the food frequency questionnaires (FFQ) which are used to assess the amount of fat and fibre intake of participants. FFQs are used to assess the nutritional status in individuals and in the population. It is developed to capture quantitative data on usual and long-term diets. It is also used to quantify food, nutrient intake and measure historical dietary data. Columns are provided for the amount of food consumed in household measures as well as serving sizes and the frequency of consumption of each item in a “more than once per day”, “daily”, “weekly” or “monthly” format. Consumption of less than once a month is marked as “never” and would be ignored for the analysis [13].

THEORETICAL FRAMEWORK The development of the assessment tool was based on Kurt Lewin’s change theory. Lewin (1951) introduced the three-step change model. Lewin viewed behavior as dynamic

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forces working in opposing directions. Driving forces facilitated change of behavior because they push behavior in the desired direction. Restraining forces hindered change, as this force holds back the change in the opposite direction [11]. The first three parts of the assessment tool are important in revealing the driving forces and the restraining forces of people’s behavior regarding consumption of fat and fibre. According to Lewin, the first step in the process of changing behavior is to unfreeze the existing situation. Unfreezing is necessary to overcome the strains of individual resistance. Unfreezing can be achieved by increasing the driving forces that direct behavior away from an existing situation and decreasing the restraining forces that negatively affect the movement from the existing equilibrium [7]. Some activities in the health programme that can assist in the unfreezing step include: motivating participants by preparing them for change, building trust and recognition for the need to change, and actively participating in recognizing problems and brainstorming solutions within a group [7]. Lewin’s second step in the process of changing behavior is movement. In this step, it is necessary to move the target system to a new level of equilibrium. The last step of Lewin’s change model is refreezing. This step may happen after change has been implemented for a short period of time. People may also revert back to their old equilibrium (behaviors) [11]. In the last two parts, we have investigated the changes of behavior by comparing the scoring of food frequency questionnaires before and after the health programme.

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STRENGTHS AND LIMITATIONS This assessment tool is a self-rated questionnaire and is simple to understand. Quantification of portion sizes is achieved by means of food models as well as by using household measuring utensils such as various sizes of cups and spoons of food items. In other frequency questionnaires, others have covered all commonly consumed foods and drinks that are consumed by all population groups and at all levels of urbanization. The food frequency questionnaire in this assessment tool was specially designed for use by health programmes for assessing fibre and fat consumption only. In addition, it is developed for the purpose of assessing adults. The food items are selected and modified for usage by a targeted adult population. As most of the Hong Kong population is ethnic Chinese, the food lists were localized and adapted to suit the Chinese population. However, this assessment tool required respondents to perform a fairly high-level cognitive task for estimating the usual frequency of consumption and portion sizes. These types of questions could be difficult for some respondents and energy estimated from the food frequency questionnaire might outsize the realm of what was biologically plausible. For improving the validity of the questionnaire, a comparison is suggested between the data obtained from the FFQ with those obtained from a separate three-day food record. For the purpose of this exercise, each one of the three-day food records will be completed for the same people on a continuous three-day basis including two weekdays and one weekend. The relative validity of the FFQ is tested by comparison with three-day food records. Following the analysis and the validation of results, the FFQ will be further modified [10].

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IMPLICATIONS FOR PRIMARY CARE Health promotion and prevention programmes are given a lower priority in the traditional curative health care model in Hong Kong. Furthermore, there are also inadequacies in the traditional medical approach which may neglect the individuals’ circumstances [4]. Health prevention programmes may not reflect the real need of the community if using the traditional medical approach. By adopting the primary health care (PHC) approach, health promotion will be more effective, as PHC focuses on needs assessment, community participation, empowerment and partnership [12]. Our assessment tool was developed using the PHC approach with community participation and empowerment. This assessment tool is part of needs assessment and evaluation. Community members may raise their consciousness and can be empowered through participation in the whole process, including needs assessment, intervention and evaluation. Finally, a positive behavioral change of the community will be adopted.

CONCLUSION Health education programmes are efficient in promoting healthful living and behavioral changes among the population. In order to ascertain the effectiveness of the health promotion programmes, needs assessment is pivotal. We believe that our assessment tool helps health care professionals identify real needs, motivations and barriers of behavioral change in the community so that they can develop strategies to tackle colorectal cancer effectively.

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[2]

[3]

[4] [5] [6]

American Cancer Society. Colorectal cancer facts and figures special edition 2005. Atlanta, GA: American Cancer Society. 2005 [cited 2007 Nov 2]. Available from: http://www.cancer.org/downloads/STT/CAFF2005CR4PWSecured.pdf Art, B., Deroo, L. and Maeseneer, J.D. (2007). Towards Unity for Health Utilising Community-Oriented Primary Care in Education and Practice. Education for Health, 20(2), 1-10. Brodribb, J., Condon, R.E., Cowles, V. and Decosse, J.J. (2005). Influence of dietary fibre on transit time, fecal composition, and myoelectrical activity of the primate right colon. Digestive Diseases and Sciences, 25(4), 260-266. Chan, Z.C.Y. (2006). Primary Health Care in Hong Kong. Education for Health, 19(2), 229-232. Department of Health. Colorectal cancer. 2007 [cited 2007 Nov 2]. Available from: http://www.chp.gov.hk/content.asp?lang=en and id=25 and info_id=51 and pid=9 Emmons, K. M., McBride, C. M., Puleo, E., Pollak, K. I., Marcus, B. H., Napolitano, M., et al. (2005). Prevalence and predictors of multiple behavioral risk factors for colon cancer. Preventive Medicine, 40, 527–534.

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[16]

[17]

[18]

[19]

[20] [21]

[22]

Queenie P. S. Law and Zenobia C. Y. Chan Elder, J.P., Hovell, M.F., Lasater, T.M., Wells, B.L. and Carleton, R.A. (1985). Applications of Behavior Modification to Community Health Education: The Case of Heart Disease Prevention. Health Education and Behavior, 12(2), 151-168. Giovannucci, E., Colditz, G.A., Stampfer, M.J. and Willett, W.C. (1996). Physical activity, obesity and risk of colorectal cancer in women. Cancer Causes Control, 7, 253-263. Heiney, S.P., Adams, S., Cunningham, J.E., McKenzie, W., Harmon, B., Hebert, James, R. and Modayil, M.S. (2006). Subject Recruitment for Cancer Control Studies in an Adverse Environment. Cancer Nursing, 29(4), 291-299. Junko, I., Seiichiro, Y., Hiroyasu, I., Manami, I., Shoichiro, T. and the JPHC FFQ Validation Study Group. (2005). Validity of a self-administered food frequency questionnaire (FFQ) and its generalizability to the estimation of dietary folate intake in Japan. Nutrition Journal, 4(26), 1-10. Lewin, K. (1951). Field theory in social science. New York: Harper. MacDonald, J.J. (1998). Primary Health Care: Medicine in Its Place. London: Earthscan Publications Ltd. Mahshid, D., Nawal, H., Afzal, H.Y., Fathimunissa, N., Salim, Y. and Anwar, T.M. (2005). Development of a semi-quantitative food frequency questionnaire for use in United Arab Emirates and Kuwait based on local food. Nutrition Journal, 4(18), 1-7. Michels, K.B., Fuchs, C.S., Giovannucci, E., Colitz, G.A., Hunter, D.J., Stampfer, M.J. and Willett, W.C. (2005). Fibre Intake and Incidence of Colorectal Cancer among 76,947 Women and 47,279 Men. Cancer Epidemiology, Biomarkers and Prevention, 14(4), 842-849. National Cancer Institution. Colon and Rectal Cancer. 2007 [cited 2007 Nov 2]. Available from: http://www.cancer.gov/cancertopics/types/colon-and-rectal Rhyne, R., Bogue, R., Kukulka, G. and Fulner, H. (1998). Community-Oriented primary Care: Health care for the 21st century. Washington: American Public Health Association. Shannon, J., Kristal, A.R., Curry, S.J. and Beresford, S.A. (1997). Application of a behavioural approach to measuring dietary change: the fat- and fibre- related diet behavioural questionnaire. Cancer Epidemiology Biomarkers Prevention, 6(5), 355361. Terry, P., Giovannucci, E., Michels, K.B., Bergkvist, L., Hansen, H., Holmberg, L. and Wolk, A. (2001). Fruit, Vegetables, Dietary Fibre, and Risk of Colorectal Cancer. Journal of the National Cancer Institute, 93(7), 525-533. Tsubono, Y., Otani, T., Kobayashi, M., Yamamoto, S., Sobue, T. and Tsugane, S. (2005). No association between fruit or vegetables consumption and the risk of colorectal cancer in Japan. British Journal of Cancer, 92, 1782-1784. Willett, W.C. (1989). The search for the causes of breast and colon cancer. Nature, 338, 389-394. Willett, W.C., Stampfer, M.J., Colditz, G.A., Rosner, B.A. and Speizer, F.E. (1990). Relation of meat, fat, and fibre intake to the risk of colon cancer in a prospective study among women. National English Journal of Medicine, 323, 1664-1672. Wong, M.T.C. and Eu, K.W. (2007). Rise of Colorectal Cancer in Singapore: An Epidemiological Review. Royal Australasian College of Surgeons, 77, 446-449

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ASSESSMENT TOOL Part A: Fat-Related Dietary Habits and Behavior Items [17] In the past month, how often did you… (please tick the box that best fits your answer). Yes

No

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II. Avoid fat as a flavouring Eat potato without butter or margarine? Eat bread without butter or margarine? Eat vegetables without oil, butter or margarine?

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III. Minimize fat in meat Remove the skin from poultry before eating? Trim visible fat from meat? Eat baked or broiled chicken? Eat baked or broiled fish? Eat less meat?

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IV. Replace high-fat food with fruits and vegetables Choose raw vegetables instead of traditional snack (e.g., chocolate)? Take more vegetables than meat at lunch? Take more vegetables than meat at dinner? Replace dessert by fruit?

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I.

Substitute specially-made low-fat food Eat low-fat ice cream, non-fat ice cream, frozen yogurt, or sherbet instead of ice cream? Eat low-fat cheese instead of regular cheese? Drink low-fat or nonfat milk instead of whole fat or full cream? Use low-calorie salad dressing, low-fat or non-fat dressing instead of regular dressing? Use yogurt instead of sour cream?

V. Replace high-fat meat with low-fat alternatives Eat a vegetarian dinner? Use vegetables sauce or meatless sauce instead of meat sauce? Eat white meat (chicken and fish) instead of red meat (beef, pork and lamb)? VI. Avoiding high-fat cooking methods Steam, broil or bake food instead of frying food?

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Queenie P. S. Law and Zenobia C. Y. Chan Use meat bone to make soup instead of lean meat Remove skin from meat before adding into soup

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Part B: Fibre-Related Dietary Habit and Behavior Items [17] In the past month how often did you… (please tick the box that best fits your answer).

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I. Cereals and grains Eat high-fibre cereals? Eat cereal (hot or cold) for breakfast or snack? Eat whole-grain crackers, bun or bread? Add bran to casseroles or cereal?

Yes □ □ □ □

No □ □ □ □

II. Fruits and vegetables Eat fruit for breakfast or snack every day? Eat fruit for breakfast or snack every week? Drink fruit or vegetable juice instead of soft drink? Have vegetarian meals or dinners?

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III. Substitute high-fibre for low-fibre food Eat whole-wheat instead of regular pasta or noodles? Eat red rice or brown rice instead of white rice?

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IV. Add high fibre garnish into casseroles Use mushroom, wood ear or lotus buds in casseroles? Add beans into soups, congee or rice? Add fruits into casseroles? Add melon into casseroles?

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Part C: Contributing Factors of Food Choice Please tick the box(es) that best matches your answer. (You can choose more than one.) 1. Please state the advantage(s) of eating high fibre containing food. □ High in vitamins □ Low in calories □ Increase bowel movement □ Prevention of chronic diseases □ Increase satiety □ Protective value of against cancer □ Others: please state______________ 2. Please state the disadvantage(s) of eating high-fat food. □ Increase chance of chronic diseases □ High in calories □ Increase chance of cancer □ Increase uric acid □ Increase body fat □ Increase blood cholesterol □ Others: please state______________

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3. Please state the reason(s) you can’t eat high–fibre-containing food. □ Bad flavor or texture □ Lack of choice □ Economic reason □ Inconvenience to buy □ Lack of skill to cook □ No time to buy □ Eating out □ Others: please state______________ 4. Please state the reason(s) you choose high-fat food. □ Good flavor or texture □ Lack of choice □ Economic reason □ Convenience to buy □ Easy to cook □ No time to buy □ Eating out □ Others: please state______________

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Part D: Food Frequency Questionnaire (Assessment of Fibre Intake)

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Part E: Food Frequency Questionnaire (Assessment of Fat Intake)

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In: Health Issues in Chinese Contexts, Volume 1 Editor: Zenobia C. Y. Chan

ISBN: 978-1-61209-385-7 © 2009 Nova Science Publishers, Inc.

Chapter 12

WHAT IS A THREE-HOUR WORKSHOP ON STRESS MANAGEMENT?

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Zenobia C. Y. Chan Everyone encounters different degrees of stress from multiple sources. Stress can be both positive and negative in our daily life. When stress exceeds our ability to handle it and causes ill feelings, it’s time to pay attention to its effect on our health. Among various types of work, teaching is one of the most stressful (Arikewuyo, 2004; Brown, Cochrance and Cardone, 1999; Chan, 2002). Teachers who experience chronic stress may suffer from emotional exhaustion (Schwarzer, Schmitz and Tang, 2000). The roots of teacher stress have been studied, as have teachers’ coping strategies (Austin, Shah, and Muncer, 2005). A variety of somatic problems due to teacher stress have been identified in Hong Kong, while social support and self-efficacy were identified as effective means of managing stress (Chan, 2002). An actual description of how teachers can use such means was lacking, however. A survey of 3,466 teachers in Nigeria suggested that when the teachers considered their work role as not comprising the entire part of their life, they experienced less stress (Arikewuyo, 2004). Hong Kong teachers may not have the same conception. Based on my own teaching experience and contact with more than 800 teachers in the past five years, the majority find that their work consumes half or more of their waking hours. Many of them said that they regard their teaching work as their first or second priority (some said their family or their personal interests are the first priority). In light of this, how can Hong Kong teachers continue to give their work this much importance, but experience less stress? Some stress management workshops have been found to be very effective for learning coping skills; participants reported a sense of empowerment in handling their stress (Brown, Cochrance and Cardone, 1999). In this chapter, I will discuss the possibility of bringing such a workshop to a secondary school setting, and offer a detailed description of the workshop content, process and possible outcomes in a Chinese society such as Hong Kong. On a practical level, literature and guidelines for teaching about health do not describe how to run a three-hour workshop on stress management. The importance of the health care profession reaching out to and serving the public has been stressed (Coffman and Henderson, 2001). However, there is a dearth of ideas about how to use our expertise to help secondary

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school teachers identify and relieve their stress in their own work setting. More importantly, both teachers’ and students’ views should be included when exploring what constitutes effective teaching and learning (Melrose, 2004). Continual review of our teaching strategies allows us to improve the quality of teaching and learning. This brief communication was written to address this area of health education. As a health educator, I believe in serving the community by advocating in-house training for other professionals on the importance of acquiring the knowledge and skills of promoting health and preventing illnesses. In August 2005, I was invited to organize an in-house training workshop on stress management for secondary school teachers (N=60) in Hong Kong. This training experience motivated me to share my teaching methods and the contents of this workshop, to show what stressors those teachers faced in their daily life, to highlight the common stress management strategies they used, and to share their reactions to the workshop.

TEACHING METHODS AND WORKSHOP CONTENTS This was a three-hour morning workshop from 9 a.m.–12 noon. I divided the workshop into four sections:

Section One: Ice-Breaking (30 Minutes) Objectives: To build rapport with the participants. To identify the participants’ learning needs.

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To attract the participants’ attention and allow room for self-reflection, the following questions were asked at the beginning of the workshop: Do you always feel anxious? Do you view life in a negative way? Do you always compete with other people? Do you always fight against time? Do you experience some of the following signs and symptoms: headache, low back pain, fatigue, poor appetite or overeating, mood swings, insomnia, reduced interest in social activities and even suicidal thoughts? Do you like yourself and appreciate life? Do you like being a teacher and enjoy teaching? This workshop aimed to offer some insights and answers to the above questions and, more importantly, to expand the participants’ view and understanding of what stress is and how to cope with it.

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Section Two: Lecture (45 Minutes) Objectives: To review literature related to stress and how it presents the biopsychosocial effects of stress on ourselves, our families and society (e.g., Freund and McGuire, 1995; Hall, 1990; Hui and Chan, 1996; Mo, 1991). To illustrate the signs and symptoms of burnout (Maslach and Leiter, 1997; Schwarzer et al., 2000). A PowerPoint presentation with colorful photos and large type was used in order to present ideas visually and in a relaxed atmosphere.

Break (15 Minutes) The school’s health education team leader prepared some healthful refreshments (e.g., milk, juice, wheat biscuits, and jelly) for the participants.

Section Three: Discussions and Sharing (60 Minutes) Objectives: To encourage communication and mutual support among the participants.

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The participants were divided into five groups of 12 members, each of which then formed a circle. By random assignment, each group was given one of the following topics for discussion: A. What are the common stressors you give yourself? B. What are the common stressors you face in your family? C. What are the common stressors you encounter in your workplace? D. What are some effective stress management strategies you have experienced? (Note: Two groups had the same question for discussion.)

Section Four: Reflection (30 Minutes) Objectives: To reflect on the origins of stressors To learn some new strategies for stress management To allow the participants to share what they learned in the workshop To encourage the participants to share any comments Personal and shared reflections enhance the interactive communication process, in turn empowering the learners/participants (Kai, Spencer and Woodward, 2001). All participants came together in one big circle for this section. This offered them the opportunity to participate with the entire group, and allowed the workshop to be learner-driven. I sat in the

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circle as a listener, observer and facilitator. They learned about their own stress situations and were able to discover suitable solutions for managing them.

STRESSORS AND STRESS MANAGEMENT STRATEGIES In our discussions, the participants expressed that most stressors come from three areas: the individual him- or herself, their families and their work.

Individual

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Some of the participants believed that their own desire for perfection and demands they placed on themselves for their own success caused them great stress. For example, four of them said they were pursuing postgraduate studies in education or counseling, and had to attend classes once or twice a week. Another two stated that they evaluated their own teaching techniques and revised their teaching materials frequently in order to improve the quality of their teaching. One participant was about 16 weeks pregnant and was experiencing many uncomfortable symptoms, such as fatigue, mood swings and vomiting. She said she had never felt so ill before and it was extremely hard for her to work, but she needed the job for financial reasons. One male participant mentioned that his stress was due to a lower limb operation for which he was now pursuing rehabilitation, but he did not enjoy the mobility he had in the past. He could not play sports—for example, running. This post-operative experience made him quite depressed. These examples show us that stress can be due to personality traits or physical health.

Family Two female teachers experienced difficulty managing their combined roles of wife/mother and teacher. Both commented that family members—especially their mothers-inlaw who lived with them both—expected them to be ideal housewives, i.e., arranging family affairs and managing housework. Even though both of these women had hired domestic help, the expectation that they fulfill this traditional female role was still very high in their own family. One of the participants started to cry when she talked about how her husband would get angry with her for not arriving home earlier, as the whole family had to wait for her to have dinner together. Hers was a traditional Chinese family that expected to have dinner at a round table where all could share their stories of the day. She was made to feel guilty for returning home late, even though the reasons for her tardiness were school-related: meetings and homework that had to be graded. Several participants mentioned that their family stress was due to their parents’ aging or chronic diseases; one of them had to visit her parent after work three times per week. Family expectations and their own family roles were one of the main sources of stress.

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Work As for stress in the workplace, a majority of the participants blamed a demanding workload and administrative work, meetings and professional training requirements that drove them to exhaustion. Some mentioned that they had reached the point of burnout. Three forces acted on them: students’ expectations of their teaching quality, the principal’s expectations of their performance, and the pressure to prepare students to achieve great success with public examinations and other competitions (e.g., gardening, music and voluntary community work). The Education and Manpower Bureau of Hong Kong assesses school performance frequently; this added to their anxiety. In fact, most of them spent over half of their time at school, and this demanding work setting made them feel tired and powerless. Therefore, it is unfair to conclude that Hong Kong teachers’ high stress level is due solely to work or education reform. Research should be done with a broad enquiry into what the stressors actually are. Assuming that teacher stress stems only from their workload is not constructive; it simply labels teaching as a “stressful” profession. Qualitative, exploratory research on this topic should be promoted.

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Stress Management The teachers’ stress management strategies included reading fiction and comics; playing sports such as badminton, football, tennis and table tennis; singing; painting; eating in restaurants; doing yoga, hiking, cycling, or swimming; taking a sauna; talking with family and friends; cooking; meditating; sleeping; traveling; shopping; playing with their children; visiting old friends; and other activities. Most of them considered their ways of managing stress effective; however, they stated that there was no time for them to participate in those activities. An exploratory study of two high school teachers suggested that the more physical exercise the teachers do, the lower the intensity of the stress they experience (Austin et al., 2005). Some participants believed that stress management was the key, but the nature, severity, intensity, and duration of the stressors were the problem. They felt that removing the root causes of stress or tackling them directly would be the most effective strategy. Others wished to take up some type of stress management together with their workmates. A few mentioned that they did not take up additional activities in order to cope with stress because they already felt their lives were out of control, and suffered a lack of motivation due to the repetitive nature of their teaching work and uncertainty over job security.

PARTICIPANT RESPONSES Evaluation of a workshop’s effectiveness is worthy in medical and health education (Ibbotson, Grimshaw and Grant, 1998). I believe that learning and teaching is an ongoing and two-way communication. Participants’ feedback allows me to reflect on my strengths and limitations, while the process of providing it allows the participants to revisit their learning

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process and evaluate its outcomes. In the final section of this workshop, the participants were invited to share their views, and their opinions were much appreciated. There were mixed responses to the workshop. Basically, two categories were identified. Positive responses relating to the content and process of the workshop found favor with the interactive style of teaching and learning and the opportunity to get to know each other better. The lecture was considered useful, and the discussion section offered insight as they were encouraged to identify their stressors and discover useful stress management skills on their own and with their workmates. The workshop allowed them to greet each other just after the summer holiday. One participant praised the structure of the workshop and how the time was managed, but he disliked lectures or workshops that ran overtime. Negative responses included one participant who said it was time consuming to attend the workshop when he still had a pile of students’ work to be marked. Another found it artificial to have a stress management workshop in the workplace itself, suggesting that it would be better to have a picnic in the countryside or a retreat of several days to relieve their stress. Some said that three hours were inadequate to tackle multiple origins of stress; others said that it was too hard to ensure the positive effects of the workshop. Indeed, Brown et al. (1999) stated that, for stress management, one full day or two half-day sessions would be the appropriate length for participants’ learning and reflection.

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CONCLUSION Teacher-training organizations should be encouraged to provide stress management tools to their members (Arikewuyo, 2004). In this brief paper, I wish to share with the readers what I did and how the participants responded to a three-hour workshop on stress management for teachers in a Chinese context. I learned a lot from them and their feedback encouraged me to rethink how health education should be structured. I would like to welcome all of you to share with me your suggestions for how to run such workshops, with the goal of achieving health education through an interactive teaching and learning process. I would be delighted to hear from you, especially if you run similar workshops. Please share with me how you manage yours, and what you do differently. I am interested in integrating different styles of organizing health workshops that have the same mission: education for health.

REFERENCES Arikewuyo, M. O. (2004). Stress management strategies of secondary school teachers in Nigeria. Educational Research, 46(2), 195-207. Austin, V., Shah, S. and Muncer, S. (2005). Teacher stress and coping strategies used to reduce stress. Occupational Therapy International, 12(2), 63-80. Brown, J. S. L., Cochrane,R. and Cardone, D. (1999). Large-scale health promotion stress workshops: Promotion, programme content and client response. Journal of Mental Health, 8(4), 391-402. Chan, D. W. (2002). Stress, self-efficacy, social support, and psychological distress among prospective Chinese teachers in Hong Kong. Educational Psychology, 22(5), 557-569.

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Coffman, J. and Henderson, T. (2001). Public policies to promote community-based and interdisciplinary health professions education. Education for Health, 14(2), 221-230. Freund, P. E. S. and McGuire, M. B. (1995). Health, illness, and the social body: A critical sociology. New Jersey: Prentice Hall. Hall, C. M. (1990). Women and identity: Value choices in a changing world. New York: Hemisphere Publishing Corporation. Hui, E. K. P. and Chan, D. W. (1996). Teacher stress and guidance work in Hong Kong secondary school teachers. British Journal of Guidance and Counseling, 24, 199-211. Ibbotson, T., Grimshaw, J. and Grant, A. (1998). Evaluation of a programme of workshops for promoting the teaching of critical appraisal skills. Medical Education, 32, 486-491. Kai, J., Spencer, J. and Woodward, N. (2001). Wrestling with ethnic diversity: toward empowering health educators. Medical Education, 35, 262-271. Maslach, C. and Leiter, M. P. (1997). The truth about burnout. San Francisco, CA: JosseyBass. Melrose, S. (2004). What works? A personal account of clinical teaching strategies in Nursing. Education for Health, 17(2), 236-239. Mo, K. W. (1991). Teacher burnout: Relations with stress, personality, and social support. Education Journal, 19, 3-11. Schwarzer, R., Schmitz, G. S. and Tang, C. (2000). Teacher burnout in Hong Kong and Germany: A cross-cultural validation of the Maslach Burnout Inventory. Anxiety, Stress, and Coping, 13, 309-326.

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In: Health Issues in Chinese Contexts, Volume 1 Editor: Zenobia C. Y. Chan

ISBN: 978-1-61209-385-7 © 2009 Nova Science Publishers, Inc.

Chapter 13

TEACHING CRISIS MANAGEMENT IN HEALTH CARE Zenobia C. Y. Chan

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RATIONALES There is a dearth literature identifying the content and skills for teaching a crisis management course in health care settings. With a view to raise attention in medical education about the need for teaching crisis management and the importance of addressing students’ learning experience, this chapter aims to describe a course comprising four threehour evening sessions on crisis management delivered in February–March 2006 for 18 master’s degree students who were either a nurse or a teacher studying health education and health promotion at the School of Public Health in Hong Kong. More importantly, it highlights the teaching skills and then explores the opportunities for applying crisis management in health care settings in order to respond to natural and man-made crises effectively and promptly.

BACKGROUND Many times crises are unpredictable and inevitable. In the past few years, we have experienced profound worries and pain from various types of crises. The most influential impacts of infectious diseases and natural disasters are cases that are worthy of revisiting in order to prepare us for responding to crises calmly and effectively. We have learned the invaluable lesson that a proactive mentality and holistic management are key in coping with crises and preventing the progression of crises. For example, during the tsunami in 2004, the furious sea caught the whole world completely by surprise on the morning of Boxing Day (Boston Globe, 2005). Without a comprehensive early warning system, an earthquake off Sumatra triggered an unexpectedly devastating and destructive tsunami that killed tens of thousands of people across South Asia (South China Morning Post, 2005). Secondly, in the SARS outbreak (Severe Acute Respiratory Syndrome,

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a viral respiratory illness caused by a corona virus, called SARS-associated corona virus [CDC, 2003] in 2003, the virus spread through many countries in Asia, North America, South America, and Europe beginning in March 2003 and caused 1,755 people become ill and 399 people to die (DH, 2004). Thirdly, avian flu is an infection appearing naturally in birds (Davies et al., 2005). In humans it causes symptoms similar to human influenza such as fever, cough, sore throat, muscle aches and shortness of breath (Sheff, 2005). Fourthly, food poisoning is defined as acute illnesses developed through consumption of contaminated food or drink (Centre for Health Protection, 2004). In the above four types of health-care-related events, certainly crisis management could handle the sudden tragedy, minimize lifethreatening effects and control the progress of damage effectively and in a timely manner. As a part of life, we encounter crises at the personal, familial or workplace levels. We also have to overcome them in order to maintain our physical, psychological and social wellbeing. A crisis is an unplanned event that triggers a real, perceived, or possible threat to safety, health, and environment; or to the organizations’ reputation and credibility (Covello, 1995). Crisis management is regarded as a means of controlling the unexpected as best as it can (Virginia Department of Emergency Management, 2001). Are crises our friends or foes? In fact, crises can be regarded as our friends because they test our limits in response to pain and chaotic situations, they ignite our potentialities such as our strengths when encountering adversity, and they let us acknowledge the limitations of human beings. On the other hand, crises are our foes. They cause us different degrees of anxiety and suffering, they destroy victims’ physical health, and they lead to social instability. Within the mission of humanitarian work and the nature of professionalism, teachers, health care workers, and social service providers should play a pivotal role in responding to crises. I am always delighted to promote health at the societal level and offer practical training to my participants. I hope that this crisis management course can inspire my participants’ conceptualization and equip them with practical skills to respond to different severities of crises.

COURSE OBJECTIVES This course has the following objectives: to identify a crisis in a timely manner; to respond to a crisis systematically; to activate the crisis management team collaboratively; to view the victims and their family in their context multi-dimensionally; to alleviate the grief and psychological trauma of the victims empathetically; and to evaluate the effectiveness of the crisis intervention comprehensively.

COURSE STRUCTURE AND CONTENTS All sessions were arranged from 6:30 p.m.–9:30 p.m. on Mondays in February and March, 2006. The average attendance rate for each session was about 89%. In general, each session was started with a 90-minute lecture with a PowerPoint presentation on theories and concepts of crisis management. Each session focused on a particular theme. Session One focused on theories and model of crisis management; Session Two was devoted to formation

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of a crisis management team; Session Three discussed implementation of crisis management strategies; and Session Four focused on evaluation of the effectiveness of crisis management and follow-up care. After the lecture, a 15-minute break was provided. Then, a 15-minute video on a chosen topic was given, such as tsunami in Session One, SARS in Session Two, Avian Flu in Session Three, and Food Poisoning in Session Four. The rationales for choosing the health care topics were to cover a range of health-care-related issues, including natural disasters, infectious diseases and acute medical conditions; and to discuss the need for and application of crisis management on the global and local levels. Followed by the video show, groups of four or five students were formed for an approximately 25-minute group discussion regarding a specific topic by random assignment. Four discussion topics were provided in each session, as follows:

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Lecture One on Tsunami: Overall various theories and models of crisis management a. Which of the theories that you learned about in this lecture can handle a tsunami better than the others? Give your group’s justifications. b. Can your group develop a model that is similar or different from the theories you learned tonight in order to minimize the damage of a tsunami? c. Critique the pros and cons of each theory you learned tonight in respond to a tsunami. d. Does your group think crisis management is the only way to handle a tsunami? Lecture Two on SARS: Formulation of a crisis management team a. What professions and parties should be invited to the crisis management team for combating SARS? b. What are the considerations and skills for setting up a crisis management team for handling SARS? c. Perform a role-play to demonstrate the communication skills within the crisis management team in a meeting on handling SARS. d. How do you handle the power struggle and improve the cohesiveness within the crisis management team? Lecture Three on Avian Flu: Implementation of crisis management strategies a. Suggest some crisis management strategies for dealing with bird flu locally. b. Suggest some crisis management strategies for dealing with bird flu globally. c. Formulate a list of effective crisis management strategies for combating bird flu by priority with rationales d. What are the potential opportunities and hurdles for your selected crisis management strategies in handling bird flu? Lecture Four on Food Poisoning: Evaluation of the effectiveness of crisis management and follow-up care a. Which evaluation tools and criteria will your group adopt in evaluating the effectiveness of crisis management for food poisoning? b. What is the follow-up care for victims and their families after food poisoning?

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170 c.

Which parties should be involved in the evaluation process in crisis management of food poisoning? d. How do you make use of the evaluative results in order to revise the crisis management plan for future food poisoning episodes? After group discussions, each group was encouraged to share its argument and feelings toward the assigned discussion topic in front of the class. Also, the groups invited other groups’ and my feedback in order to critically analyze its assumptions, strengths and limitations on conceptualization and application of crisis management. Usually about three minute was suggested for each group presentation followed by two minutes for asking for feedback from fellow classmates and the lecturer. Finally, each session was concluded in the last 15 minutes to sum up the key concepts and observations, and the students were motivated to offer their views regarding crisis management. For example, was there anything that they already knew on this topic? Was anything new to them? How will they apply the learning to their workplace and daily life? Was there a significant learning experience in this lecture? Which ideas from their group members or others strike them most, and why? Lastly, I introduced the next session’s key content for them to think about beforehand.

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CONCLUSION This was a 12-hour short course on crisis management in health care that has many limitations, such as lacking a chance for practice in an actual health care setting and no evidence base to verify the process and outcome of the usefulness and acceptability of this course from the students’ perspective. However, I hope that my effort in writing this chapter can demonstrate the content, organization and discussion topics of a tailor-made crisis management course for Chinese master’s level students. A future medical education plan should at least consider the need for including crisis management for undergraduate and postgraduate level students because of the growing trends of infectious diseases and the unpredictable natural disasters. Such courses can equip our students with a sound knowledge base and practical skills as well.

REFERENCES Boston Globe (6 Feb 2005). A tsunami generation rebuilds. Centers for Disease Control and Prevention. (2003). Retrieved from http://www.cdc. gov/ncidod/sars/factsheet.htm on 22 April 2006. Centre for Health Protection, HKSAR. Health topics, food poisoning 2004 June 1. Retrieved from http://www.chp.gov.hk/content.asp?lang=en and info_id=43 and id=24 and pid=9 on 22 April 2006. Covello V. Risk communication paper. Opening the Black Box Risk Conference, McMaster University, 1995.

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Department of Health. (2004). Latest figures on 2003 Severe Acute Respiratory Syndrome Outbreak. Retrieved from http://www.info.giv.hk/dh/diseases/ap/ eng/infected.htm on 22 April 2006. Davies K, Higginson R. Evolution and healthcare impact of a 21st century avian flu pandemic. British Journal of Nursing 2005; 14(20):1006-1068. Sheff B. Avian influenza: Are you ready for a pandemic? Nursing. 2005; 35(9):26-27. South China Morning Post (6 Jan 2005). Amid the devastation, a chance for peace. Virginia Department of Emergency Management. (2001). School crisis management exercise development guide. Virginia: Virginia Government Publishing Service.

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In: Health Issues in Chinese Contexts, Volume 1 Editor: Zenobia C. Y. Chan

ISBN: 978-1-61209-385-7 © 2009 Nova Science Publishers, Inc.

Chapter 14

HEARING THE VOICE OF A MARRIED WORKING MOTHER’S FEAR OF LOSING HER HOUSEMAID S. F. Chan and Zenobia C. Y. Chan

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ABSTRACT Many Hong Kong married women are involved in the labor force. The employment of full-time overseas housemaids is, therefore, very prevalent in some of these families, especially where there are children and/or elderly relatives. Without their assistance in doing the housework, taking care of the children and the elderly, the wife might not be able to work outside of the home. This chapter reports on an interview with a Hong Kong married working woman with babies living with her husband’s family who felt worried that her Indonesian housemaid would either refuse to renew the contract or would become pregnant after her renewal of the contract. This interview consisted of a preparation stage, a process stage and an outcome stage. By applying an integration of counseling skills—including Rogers’ person-centered model, Krumboltz’s “soft” behaviorism, and gestalt therapy, along with some communication techniques—her worries were explored and clarified. Both short-term goals and long-term goals were set as the outcome of the interview. More attention should be paid to the difficulties most married working women face in balancing their roles in their family and career.

BACKGROUND In most Hong Kong families with children, both the husband and wife have to work, necessitating the employment of a full-time maid in order to cope with the housework and looking after children and/or elderly relatives (Lo, 2006). More than 200,000 overseas workers are employed as full-time housemaids for this purpose by families in Hong Kong (Chiu, 2007). It is not uncommon to locate one from one’s own neighborhood. While a bad employment relationship between the employing family and the housemaid may cause a series of troubles (e.g., abuse and violence by the employers or child abuse and infanticide by the housemaids) (Ching, 2006; Parry, 2006), there are also some potential troubles even in good employment relationship.

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This chapter reports on an interview with a local married working woman with two babies living with her husband’s family with 10 family members and a helpful Indonesian housemaid. She was greatly worried that the young housemaid would either not renew the contract because of the heavy workload or that she would become pregnant after renewing the contract. A pregnant housemaid from overseas is safeguarded under maternity protection (Labour Department, 2000), meaning that her job may be protected. In addition, the married woman also felt nervous about expressing her own ideas on the issue to her husband’s parents. Many local married working women find it difficult to attain a satisfactory work–life balance between family and career. More attention and health policies (e.g., family-friend policy at the work place) are needed to release their pressure from balancing the multiple roles of being a wife, mother, daughter-in-law, daughter, employee and herself (“Conditions Take”, 2006; Luk, 2006; Ng, 2006; Wong, 2006).

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LITERATURE REVIEW The employment of working wives and mothers outside of the home is no longer the exception but the rule beginning a few decades ago. More and more mothers of preschool children are involved in the labour force in the West and East (Hite, Hurst and Zambrana, 1979; Mariko, 1989; Ryan and Martinez, 1989 and Siegel and Haas, 1963). Despite the reasons for working (family financial support, job enjoyment or possession of higher social status value), the dual roles of parenting and maternal employment have confronted the traditional social expectations of mothers (Hite, Hurst and Zambrana, 1979). Most working mothers find it stressful to cope with the multiple demands of their employer, family functioning, financial support, husband-wife relations and childcare. The burgeoning of in-home housemaids may be the by-product of maternal employment. Like many other places (Kuwait, Saudi Arabia and Singapore), foreign domestic helpers (the majority of whom are from Indonesia, the Philippines or Thailand) in Hong Kong are usually introduced through recruiting agencies in their own countries and Hong Kong. They are normally recruited for two-year contracts that are renewable upon mutual agreement between the employer and the housemaid. The employer is required to provide return flight tickets, free medical treatment, board and lodging facilities in addition to salary (Labour Department, 2008). The housemaids are responsible for general household chores, and taking care of babies, children and elderly relatives. They are entitled to local Labour Holidays, but the working hours are not fixed. Their main goal in working overseas is to improve their income. These foreign domestic helpers are a relatively homogenous immigrant subgroup in terms of gender, socioeconomic, educational and occupational background. Many studies indicate that some of the housemaids may develop stress-related disorders (acute situational disturbance) or depressive symptoms during their employment in countries like Brazil, Kuwait and Santiago due to ethnicity, homesickness, harassment, isolation because of linguistic barrier, limited access to their own social network, low occupational level and low self-esteem (Alowaish, Fido, Mohsen, Razik and Zahid, 2002; Ei-Sayed, Fido, Mohsen, Razik and Zahid, 2004; Fichter, 1963 and Sales and Santana, 2003). Although disputes caused by irregular payment of agreed-upon salary, no leave pay, inadequate or

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Hearing the Voice of a Married Working Mother’s Fear of Losing Her Housemaid 175 poor-quality food, unduly long working hours, abuse and violence by the host families or child abuse and infanticide by the housemaids (Ching, 2006; Parry, 2006) have been seen in the local newspapers, these are exceptions. The relationship between the employing family and the housemaids is somehow characterized by mutual cohesion rather than servitude, especially in small families where there are only parents and their children. Without the assistance of a housemaid with housework and taking care of the children and elderly relatives, the wife can hardly participate in employment outside of the home.

RATIONALE OF THIS CHAPTER This chapter reports on an interview with a local working mother of two babies who expressed her difficulties when the contract of her helpful Indonesian housemaid came to an end. Further studies should be conducted in understanding the difficulties of coping with multiple roles of a working mother and in encouraging male participation in domestic work.

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ORGANIZATION OF THIS INTERVIEW This chapter consists of four parts: (a) the case profile; (b) the conceptualization; (c) the interview; and (d) the discussion. It aims at presenting an interview with the married working mother. There were three stages in the interview: preparation, process and outcome. The preparation stage involved a brief description of the verbal consent and the physical setting for the interview. The process stage and the outcome stage were further divided into the beginning stage, the middle stage and the ending stage during which the integrative counseling skills (Culley and Bond, 2004), some essential factors from “the five stages of counselor development” (Mobley, 2005) and some communication skills were applied. A discussion on the strengths and limitations of the interviewing skills and some implications followed.

CASE PROFILE The interviewee comes from a middle-class family with 13 family members living in an approximately 2,000-square-feet privately-owned apartment in Hong Kong. An Indonesian housemaid in her twenties has worked for a two-year regular contract in this family since 2005. Her contract was due to end early in 2007. Not only does the housemaid need to do the routine housework, but also to take care of the two little babies and two elderly relatives in their eighties. Knowing that the housemaid felt exhausted by the heavy workload, the family decided to employ a second housemaid. However, it took almost a year before another housemaid was willing to come and work for this family with 13 members. At last, that housemaid returned home after working for just one month due to serious homesickness. Since then the family has not attempted to find another maid. At the time of writing, the mother of the babies was greatly worried that the housemaid would leave at the end of her two-year contract. Even if the housemaid agreed to renew the

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contract, she was also afraid that her young housemaid might become pregnant after her return to Indonesia during the mandated vacation leave. Under such circumstances, no one would be available to take care of her babies and the elderly. Working as a teacher, the mother was also very busy in preparing materials for her students after school hours and on weekends. She has already found it hard to cope with the housework, taking care of the babies as well as her work on Sundays when the housemaid is on holiday, so she feels anxious when imagining how the days without the housemaid would be.

PRESENTING ISSUES This was an interview with a married working mother in her early thirties who lives with her husband’s family, totaling 13 members. She revealed her worries about losing the assistance of the housemaid by either her refusal to renew the contract in early 2007 or her pregnancy after renewing the contract. It would be impossible for her to take care of her babies, do the housework as well as her job without the aid of a housemaid. However, she was nervous about expressing her ideas on the issue to her husband’s parents. Her difficulties in balancing the roles of a mother of the two babies, a wife of her husband, a teacher of her students and a daughter-in-law in this family were also prevalent among most of the local married working women. Some communication and counseling skills were applied during this interview.

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THE THREE STAGES OF THE INTERVIEW There were three stages in the interview: preparation, process and outcome. The preparation stage involved a brief description of the verbal consent from the interviewee and the physical setting for the interview. The process stage included the verbal setting prior to the formal start of the interview, followed by the beginning stage and the middle stage (Cullye and Bond, 2004). The ending stage (Culley and Bond, 2004) referred to the outcome in the interview. Throughout all of the stages, some communication techniques, integrative counseling skills (Culley and Bond, 2004) and some essential factors from “the five stages of counselor development” (Mobley, 2005) were applied.

PREPARATION The working mother is a friend of the first author. We have known each other since we were studying in secondary school. Some time before, during a telephone conversation, she expressed her worries that no one would take care of her babies or do the housework if the housemaid refused to renew the contract with the family. Therefore, I invited her to sit for an interview. The purposes of this interview were explained to her and her verbal consent was obtained before the start of the interview.

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Hearing the Voice of a Married Working Mother’s Fear of Losing Her Housemaid 177 The interview was conducted on a Saturday afternoon at the first author’s home, which provided a comfortable, quiet and confidential setting for the interview. Just the two of us were present during the interview to ensure confidentiality. We were sitting face-to-face at each extremity of a long sofa about 2.5 feet apart so as to allow eye-to-eye contact and touch for emotional support when necessary (Gorden, 1998). Sitting on the same sofa indicated that both the interviewer and interviewee had the same status and power (Gorden, 1998) which facilitated expression. Cups of warm tea, snacks, tissue paper and a digital tape recorder (for up to 70 hours) were placed on the small cabinet behind my back so that they could be used when necessary but remained a minimal distraction (Gorden, 1998). No desk was found nearby to minimize physical and etiquette barriers (Gorden, 1998). Clear vision of facial expression was provided by the optimum lighting (Gorden, 1998) under the sheer curtain near the window. We were dressed in causal clothing to encourage in-depth expression under a relaxing environment during the interview.

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PROCESS Prior to formally starting the interview, the objectives and duration, the reasons for selection as the interviewee, the grounds for the need for certain types of background demographic information, the reasons for tape recording, the confidentiality (Gorden, 1998, pp.52–58) and anonymity of the interview were explained to her. The objectives of the interview were clearly explained to her to avoid too much expectation from the interview (Gorden, 1998). After all, the purposes of the interview were to give some comfort and advice based on some communication and counseling skills. The interviewee was informed about the duration of the interview and the availability of breaks and snacks so that she would have a picture of the schedule of the interview. Although the suggested time for the interview was half an hour, the time pressure (Gorden, 1998) on the interviewee was reduced by telling her that she could continue until she wanted to stop. The housemaid was not a relative of the employing family; however, her role was indispensable to the normal functioning of the family, especially when the wife was out for work. This phenomenon was also very common to other local working women. This explained why my friend was selected for the interview. Some personal demographic background information (Gorden, 1998) of her family was mentioned in the family tree diagram. For ethical considerations, high confidentiality and anonymity were assured. Her verbal consent was obtained prior to the tape recording (Gorden, 1998), which would be destroyed after writing this chapter.

The Beginning Stage This stage consisted of i) establishing a working relationship, ii) clarifying and defining the problems, and iii) making an assessment by exploration, prioritizing and focusing, and being concrete (Culley and Bond, 2004, pp. 59–77). Listening skills and body language (Barker and Gaut, 1996; Cole, 1993; Gorden, 1998, pp. 65–115), and counseling models from Stage I—Rogers’ person-centered model (George and Cristiani, 1995, pp. 57–66; Kirschen-

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baum, 2004; Mobley, 2005, pp. 59–82) and Stage II—Krumboltz’s soft behaviorism (Mobley, 2005, pp. 94–119) according to Mobley’s five stages of counselor development were applied. (I): Oh! You look tired, M, how are you feeling [eye contact, in sympathetic tone]? It was a comfort opening to the interview. Appropriate eye contact made her aware that she was now being addressed and her reply was expected (Barker and Gaut, 1996). (M): Well… I just feel better today! Today, Saturday, is my recharging day [emphasized tone] after the five-day work week at school. The most tiring days are on Sundays when my Indonesian housemaid is on holiday. Haai [the sound of a sigh, frowning, shaking her head]. (I): What happens to you on Sundays [a minor frown, in a curious facial expression]? There was no need to ask her questions one by one; an open question here helped to draw out the full story (Cole, 1993). I could also explore more about her background and daily life by opening up this topic (Culley and Bond, 2004). The “matching” skill in body language can build rapport between us. It was used when I followed her facial expression with a minor frown (Cole, 1993). My curious facial expression indicated my interest in her topic (Cole, 1993; Gorden, 1998).

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(M): Well, I am the “bun bun” (housemaid) on Sundays when the housemaid is on holiday [looking exhausted, her head down]! I have to get up very early as usual to … you know, I haven’t got much personal time [she moves her hands during a series of descriptions, with an exhausted facial expression]. (I): Wao! You really [in emphasized and rising tone] have a lot to do, M! Working from day to night is definitely a tiring task [eyes opened wide, head leaned a bit forward]! There are some core characteristics in establishing a working relationship; they are acceptance, understanding, genuineness and trust (Culley and Bond, 2004, pp. 59–64). I have some advantages in gaining trust and showing genuineness to the interviewee because we are best friends and have known each other for a long time. I showed my acceptance, congruence and empathic understanding (Rogers’ person-centered model) to her situation by replying to her that “Working from day to night…tiring task” (Culley and Bond, 2004; Gerorge and Cristiani, 1995). All of the other body language, such as the emphasized and raising tone to the word “really”, my eyes opened wide and head movement helped me show the genuineness and empathy of my response to her descriptions (Cole, 1993). Congruence, empathy and genuineness are also the key essentials in Rogers’ person-centered model that guide a clinician to understand and see things from the subject’s perspective (Mobley, 2005). (M): So I can’t imagine what will happen if the housemaid refuses to renew the contract for this family. Then, who will take care of my babies, the elderly and do all the housework? Even though there are 11 adults in this family, nine of them are out during the daytime! No

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Hearing the Voice of a Married Working Mother’s Fear of Losing Her Housemaid 179 one is free and available to take up the housemaid’s duties! I need do work—I can’t take her place all of the time! (I): Hmm… [looking at her and nodding my head] I grunted and nodded my head (Cole, 1993, p.159) to indicate my acknowledgement with active attending and listening techniques, which is important in Rogers’ person-centered model (Mobley, 2005), so she was encouraged to continue her expression. Silence technique (George and Cristiani, 1995) was applied here. I didn’t say a word, since I could feel that she was going to say something more. I expressed this by looking at her and expecting her to continue. (M): [A pause before she continues] You know, given the same salary, they would rather work for a small family with three to four members rather than 13 [in emphasized tone] members! It’s very normal [shrugging her shoulders, palms facing out]!

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(I): With the same salary but heavy workload, you feel worried that your housemaid would not renew the contract. In this case, no one would take care of your babies, the grandparents and do the housework when you’re out at work [eye contact, in neutral tone and pace]. I restated the gist of her worries here to check my understanding and give her an active listening response (Cole, 1993). It was certain that active listening skills could encourage her to elaborate further, which helped to draw out the full story (Cole, 1993). My expression “You feel…” was a way to show empathy according to Rogers’ person-centered model (Mobley, 2005). At the same time, I made use of this chance to clarify and define her problems before making an assessment and planning for solutions (Culley and Bond, 2004). Problem definition was also one of the essentials in Krumboltz’ soft behaviorism (Mobley, 2005). After exploring her problem with an open question, a concrete definition of the problem would lead to goal setting later (Mobley, 2005). A neutral tone and space offered a relaxing mood for more expression. (M): Yes…my mother-in-law has asked the housemaid’s intention but she hasn’t decided yet. Even if she would renew her contract after May, we should give her a statutory leave for about a month before the new contract continues. You know, my summer holidays come only in June and July each year. Who is going to take care of my babies in May then? Moreover, the housemaid is so young that she may be pregnant after returning from Indonesia during the vacation leave. I’ve heard these similar cases from the some magazines and Web sites! The master family was required to spend extra money to send the pregnant housemaid back home and the consequence was that no one could take care of the children and do the housework [frowning and looking puzzled]. (I): [After a while, in sincere tone] You’re now worrying about two issues. Firstly, you feel worried that your housemaid will not renew the contract. Secondly, you feel worried that even if your housemaid will renew the contract, she may be pregnant after the vacation leave.

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Either of the circumstances would mean that there would be no one to take care of your babies, the elderly and other housework. These are your concerns [in neutral tone and pace]. I waited a while to ensure that she did not continue before I went on. Again, I restated the gist of her worries to check my understanding and give her an active listening response (Cole, 1993). My expression “you feel…” was a way to show empathy (Mobley, 2005). I then clarified and defined her problems by prioritizing and focusing on the problems (Culley and Bond, 2004; Mobley, 2005). She mentioned her mother-in-law, money issues, and troubles that a pregnant housemaid would bring to her. Since it was impossible to deal with every concern at once, her problems were prioritized and focused into two points (Culley and Bond, 2004).

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(M): Absolutely, Catherine [glad to be understood]! I could have made some decisions if I were the hostess of this family [sounding confident]…. [After a few seconds] Perhaps, I would not wait but would have looked for another new housemaid from the agency. I would have requested someone who is middle-aged, so I would not need to worry about her potential pregnancy. Also, I would offer a higher salary as an attractive point to compensate for the heavy workload in this family with 13 members… Anyway, these are my own ideas. I have no idea what my mother-in-law and father-in-law are going to do [sounding a bit resentful]! Her first response further assured my understanding of her troubles. Now, I knew that she had her own ideas regarding the two problems! However, she did not have the courage to put them into action, as she thought that her status of “daughter-in-law” did not empower her to do so. At this stage, her problems became concrete and explicit (Culley and Bond, 2004). These favored unambiguous goal setting according to Krumbolit’s soft behaviorism (Mobley, 2005). What I needed to do was to let her to empower herself to express her own ideas to her husband’s parents (George and Cristiani, 1995). After assessment, I found that no professional counseling or referral was needed in this case (Culley and Bond, 2004). However, I guessed that she should empower herself to set her goals and put them into action instead of waiting in a passive position. In addition, her husband might help.

The Middle Stage This included i) reassessing the problems and ii) maintaining the working relationship by applying challenging techniques, which consisted of deeper exploration, confrontation, selfdisclosure, immediacy and communicating core values (Culley and Bond, 2004, pp. 97–134). Listening skills and body language (Cole, 1993; Barker and Gaut, 1996, pp. 45–99), and some counseling models from Stage I—Rogers’ person-centered model (Bozarth and Glauser, 2001; George and Cristiani, 1995, pp. 57–66; Mobley, 2005, pp. 59–82) and Stage II— Krumboltz’s soft behaviorism (Mobley, 2005, pp. 94–119) according to Mobley’s five stages of counselor development were also applied. (I): Being a married working woman and having two babies is never easy, M! Even though I haven’t yet had a baby, I’ve already felt quite exhausted when balancing my roles as

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Hearing the Voice of a Married Working Mother’s Fear of Losing Her Housemaid 181 a wife, a daughter-in-law, a daughter, an employee and a student at the same time. Therefore, I fully understand that you must be in a more difficulty situation since you have two babies and, most importantly, you’re living in your husband’s family with 13 members [eye-contact, I touch her hands gently]… From what you say, it sounds like it’s not easy to express your feelings to your husband’s parents. We communicated the core values (Culley and Bond, 2004) through the same status of “a married working woman”, a wife, a daughter, a daughter-in-law and an employee. I tried to show more empathic understanding of her own frame of reference and unconditional positive regards (Rogers’ person-centered model) by saying “I understand you must be …” (Mobley, 2005). Through active listening skills, the hidden, unexpressed and covert messages were disclosed by saying “not easy to express your feelings to your husband’s parents”. I also tried to probe into the problem by deeper exploration (Culley and Bond, 2004) of how she got along with her husband’s parents living in the same apartment. Since we have known each other since we were studying in secondary school, a gentle touch here showed my comfort and support (Barker and Gaut, 1996).

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(M): You know... I’ve just lived in this family for two years! I can say I am a late comer, so I think it should be my task to adjust my lifestyle to this family. My mother-in-law and father-in-law have long been the masters in this family and they’ve handled and run everything very well. In this case, how can I express my opinions to them [looking nervous]? I’m so afraid that I would offend them if I say so [she looks embarrassed to continue]… (I): Hmm… this situation also happens to me as well, M! I am very careful in my speech and behavior when I meet my mother-in-law and father-in-law. After all, I grew up in my own family with a different culture and norms. I don’t know if the same message would mean the same thing in another family. Anyway, you haven’t expressed your opinions to your husband’s parents since you think you’re not the hostess in the family. I wonder whether his parents would think you’re indifferent to the family issues, being the mother of the babies [sitting in a relaxed position with my hands on my lap]. She felt a bit embarrassed when she mentioned her relationship with her husband’s parents. Therefore, I also self-disclosed and shared (Culley and Bond, 2004) my feelings in getting along with my husband’s parents. My intention here was to increase her ease and trust (Gorden, 1998), to allow further deeper exploration and probing into the problem. It could also maintain and make our relationship closer by letting her know that I was on her side (Culley and Bond, 2004) through the same “daughter-in-law” role and same core values. Moreover, I also paved my way to reassess and reframe the problem by bringing her a new perspective and position in relation to the problems (Culley and Bond, 2004) when I said “different culture and norms…”. I then confronted the discrepancies (Culley and Bond, 2004) by raising the question “…indifferent to family issues…”. The intention was to make her understand the possible outcome from another perspective. A relaxed position encouraged her to be more comfortable with further expression while minimizing distractions by putting my hands on my lap.

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(M): Of course, I’m not indifferent to the family issues [I nodded my head at once]! But…it seems so odd to sit down and then discuss the issues with my husband’s parents, Catherine [frowning]! And I’m not sure whether they’ll accept my opinions [full of worries]. (I): Good communication can avoid some unexpected misunderstandings between people. Above all, the benefits of your babies should be at the top of the agenda. What’s your husband’s viewpoint [calm tone, leaning my body a bit forward]? I confronted the idea that misunderstanding could be a drawback of being silent. Immediacy was used when I said she should do something for her babies, since I understand she really cares a lot for her babies (George and Cristiani, 1995). As I believed her husband’s advice and support could give her a new perspective into these issues, I asked for her comment (Culley and Bond, 2004). I leaned my body to show my attention and belief that her husband could help (Cole, 1993). (M): I haven’t mentioned the issue to him and he hasn’t discussed it with me so far. Well…if I show initiative in this issue, I think he would help me to some extent [she expressed her understanding of her husband’s characteristics, followed by a cup of tea…]!

OUTCOME

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The Ending Stage This consisted of i) deciding on appropriate change, ii) implementing change, iii) transferring learning into action and iv) ending by goal setting, action planning, and follow-up actions (Culley and Bond, 2004, pp. 135–166). Some techniques of Stage II—Krumboltz’s soft behaviorism (Mobley, 2005, pp. 94–119) and Stage III—gestalt therapy (Cramer, Hansen and Rossberg, 1994; George and Cristiani, 1955; Mobley, 2005, pp. 189–197) from Mobley’s five stages of counselor development were also applied. (I): [After a short break] I believe genuine communication between each other in a family is essential in the long term, irrelevant of your status in the family, and everyone should participate in family issues to increase warmth and unity. If you think your husband may help, you may understand more about your husband’s parents from your husband before raising your opinions to them. I tried to turn negative thoughts into positive thoughts (i.e., appropriate change) (Culley and Bond, 2004) by let her know that communication and participation are essential in the long term (Afifi, Olson and Armstrong, 2005). Moreover, I also tried to make her feel empowered to initiate change because she was already a part of the family. To implement the change (Culley and Bond, 2004), her husband’s assistance could help. She might also transfer the learning (Culley and Bond, 2004) of communication or participation into other aspects in the long term.

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Hearing the Voice of a Married Working Mother’s Fear of Losing Her Housemaid 183 (M): You think I should raise the issue and express my opinions to them? (I): Isn’t that what you desire? You’ve got some perfect and feasible ideas that can solve the worries completely! Anyway, there are always costs and benefits to change. If I were you, I would discuss the opinions with my husband before raising it to his parents. This would be my short-term goal. In the long-term, I would persuade them to hire a healthy middle-aged woman as the housemaid. I might also prepare some real cases of housemaids’ pregnancy from the Internet to support my ideas. Also, the four of you might go to a quiet place to discuss the issue to avoid any unnecessary embarrassment. Of course, it’s up to your own discretion. I know that you know what to do. During the goal setting, I tailor-developed both short-term and long-term goals based on her previous opinions. The goals were and should be what she wanted according to Krumboltz’ soft behaviorism (Culley and Bond, 2004; Mobley, 2005). Some practical details for action planning were also suggested (e.g., Internet searching and a quiet place for discussion). I also explained there were always pros and cons when deciding on appropriate change (Culley and Bond, 2004). According to gestalt therapy, the client is capable of making choices and governing his or her own life effectively (Cramer, Hansen and Rossberg, 1994; George and Cristiani, 1955; Mobley, 2005). After all, these were her family issues, the decision should be made by herself. (M): Hmm… I’ll consider your kind suggestions. They sound great [in deliberating].

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(I): You may ring me or come again any time you feel the need. I am always ready for further discussion, M! And I hope I can hear some good news from you next time [with smile].… Even when the counseling session comes to an end, the counselor should always let the client contact him or her when necessary. Since this was a nonprofessional and informal counseling session with one of my best friends, there would not be a formal ending stage in this interview. We would meet again and again throughout life. Therefore, I would follow up by inviting her to contact me when necessary for further discussion instead of having the interview come to an end.

STRENGTHS AND LIMITATIONS There is no fixed model in counseling skill. Each scenario is so specific that the application of the counseling skill varies with the type of person and the kind of problem at that particular time. It has been said that counseling works better if more than one theory is applied (Mobley, 2005). In this interview, some skills from the integrated theory models of counseling (Culley and Bond, 2004) and the five stages of counselor development (Mobley, 2005) were applied during the process stage and outcome stage. The strengths of my interviewing skills have been discussed in the interpretation parts. In brief, I made use of some communication and counseling skills to explore and understand her

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problems from her perspective, reassessed the problems by introducing her to some new perspectives, and then set the goals based on her desire while the judgment was left to her. In further interviews, it would be better to invite her husband together with her to the interview. This would be the Stage IV—counseling with more than one person in the five stages of counselor development (Mobley, 2005). Counseling with her family members could let the counselor understand the full scope of the story by studying the interactions among all of the members involved. Moreover, the counseling could have been divided into several sessions instead of one. Any progress could be revealed and discussed in the next session. I could also have invited her for brainstorming when discussing the details in action planning and asked for her comments after the goal setting.

IMPLICATIONS

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The World Health Organization’s definition of health is the most commonly accepted one, in which health refers to a complete state of physical, mental and social well-being (positive health), not merely the absence of disease or infirmity (negative health) (WHO, 2005). In view of the growing importance of women’s health as promoted by the WHO (WHO, 2007), more attention should be given to local working women in attaining their work-life balance in order to achieve well-being in their lives. While the advocacy of a fiveday work week by the government is an attempt to reduce stress and improve the quality of family life, promotion of flexible job opportunities such as freelance work, flexible arrangements in working hours and extending the retirement age are some of the measures that would allow both parents to spend more time devoted to child care and family life (Ng, 2006).

CONCLUSION Although there are many theories and studies of human communication (Anderson, 2005; Littlejohn, 1996; Sillars, 2005), little is found specifically in the communication efficacy between a mother-in-law and a daughter-in-law, which is sometimes very important in Chinese societies. No one would deny the importance of a good relationship and communication within a family (Afifi, Olson and Armstrong, 2005), especially between a wife and her husband’s parents, which not only can reinforce the marriage of the young couple, but also create harmony for the generations and therefore improve the well-being of everyone in the family. Further investigation and studies should be conducted in these areas.

AUTHORS’ BACKGROUND 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 more than ten years.

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REFERENCES Afifi, T. D., Olson, L. N. and Armstrong, C. (2005). The chilling effect and family secrets; examining the role of self protection, other protection, and communication efficacy. Human Communication Research, 31(4), 564-598. Alowaish, R., Fido, A.A., Mohsen, M.A., Razik, M.A. and Zahid, M.A. (2002). Psychiatric morbidity among housemaids in Kuwait: The precipitating factors. Annals of Saudi Medicine, 22(5-6), 384-387. Anderson, K. (2005). The grandparent-grandchild relationship; Implications for models of intergenerational communication. Human Communication Research, 31(2), 268-294. Barker L. L. and Barker, D. A. (1996). Communication (7th edition). Boston: Allyn and Bacon. Bozarth, J. D. and Glauser, A. S. (2001). Person-centered counseling: The culture within. Journal of Counseling and Development, 79(2), 142-147. Ching, F. (2006, September 14). A cop-out on maids’ rights. The South China Morning Post, EDT14. Chiu, T. (2007, February 5). Maids march over fees fears. The Standard, M03. Cole, K. (1993). Crystal clear communications: skills for understanding and being understood. New York: Prentice Hall. Conditions take toll on working mother. (2006, July 1). The South China Morning Post, P58. Cramer, S. H., Hansen, J. C. and Rossberg, R. H. (1994). Counseling: theory and process (5th edition). Boston: Allyn and Bacon. Culley, S. and Bond, T. (2004). Integrative counseling skills in action (2nd edition). London: SAGE. Ei-Sayed, A.A., Fido, A.A., Mohsen, M.A.M., Razik, M.A. and Zahid, M.A. (2004). Psychiatric morbidity among housemaids in Kuwait. Medical Principles and Practice, 13, 249-254. Fichter, J.H. (1963). The career of housemaids in Santiago. The American Catholic sociological review, 24(2), 153-166. George, R. L. and Cristiani, T. S. (1995). Counseling: theory and practice (4th edition). Boston: Allyn and Bacon. Gorden, R. L. (1998). Basic interviewing skills. Prospects Heights, Ill: Waveland Press, Inc.. Hass, M. B. and Siegel, A.E. (1963). The working mother: A review of research. Child Development, 34(3), 513-542. Hite, R.L., Hurst, M. and Zambrana, R.E. (1979). The working mother in contemporary perspective: A review of the literature. Pediatrics (Special article), 64(6), 862-870. Kirschenbaum, H. (2004). Carl Rogers's life and work: an assessment on the 100th anniversary of his birth. Journal of Counseling and Development, 82(1), 116-124. Labour Department (2008). Importation of Labour. Foreign domestic helpers. Retrieved July 31, 2008, from http://www.labour.gov.hk/eng/plan/iwFDH.htm Labour Department (2000). Publications. List of international labour conventions applied in the Hong Kong Special Administrative region. Retrieved December 18, 2003, from http://www.labour.gov.hk/text/eng/public/iprd/report00/a3.htm Littlejohn, S. W. (1996). Theories of human communication. Belmont: Wadsworth Publishing Company.

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Lo, C. (2006, March 8). A day for women to cheer and do more. The China Daily Hong Kong Edition, P02. Luk, M. (2006, October 7). Taking worry out of work. The South China Morning Post, P20. Mariko, F. (1989). “It’s all mother’s fault”: Childcare and the socialization of working mothers in Japan. Journal of Japanese studies, 15(1), 67-91. Martinez, G.A. and Ryan, A.S. (1989). Breast-feeding and the working mother: A profile. Pediatrics, 83(4), 524-531. Mobley, J. A. (2005). An integrated existential approach to counseling theory and practice. Lewiston: Edwin Mellen Press. Ng, P. (2006). Measures need to encourage more births. The China Daily Hong Kong Edition, P02. Parry, S. (2006, July 5). First person. The South China Morning Post, CITY2. Sales, E.C. and Santana, V.S. (2003). Depressive and anxiety symptoms among housemaids. American journal of industrial medicine, 44, 685-691. Sillars A. (2005). Communication and understanding in parent-adolescent relationships. Human Communication Research, 31(1), 102-128. Wong, N., (2006). Family “still a priority” for working women. The China Daily Hong Kong Edition, P02. World Health Organization (WHO). Women’s health. Retrieved 2007, from http://www. who.int/topics/womens_health/en/ World Health Organization (WHO). Re-defining health. Retrieved December 5, 2005, from http://www.who.int/bulletin/bulletin_board/83/ustun11051/en/

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Chapter 15

INVISIBLE INSTABILITY OF HONG KONG CITY AND HUMAN RELATIONSHIP: REPRESENTATION OF VIRUS IN HONG KONG FILMS Chan Ka Lok Sobel* Department of Journalism and Communication, Chu Hai College of Higher Education Department of English Communication, School of Social Science and Humanity, University of Macau, Macau

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INTRODUCTION Dr. Georgios Pappas (2003) said that cinema is an art of the 20th century, and there has been much progress in infectious diseases and microbiology in the 20th century. The discovery and widespread use of antibiotics coincided with the appearance and spread of the “talking pictures”; the incidence of and problems associated with antibiotic resistance increased in parallel with the threat to cinema presented by television; the HIV epidemic coincided with the “VCR epidemic” in the early 1980s; and the beginning of the 21st century saw a bright future lying ahead both for science, in the form of molecular genetics, and for art, in the form of the digital revolution.1 It seems that there is an invisible and microbiologic relationship between cinema and diseases and virus. This relationship can be called “bioterrorism in films”, according to Pappas’ term. In the common sense, films about different kinds of virus are sometimes called “dead city” films, as a city infected with virus would become a dead city in which people stay at home to prevent the spread of virus in public places. Among Western films, there are many about virus, including the well-known films The Andromeda Strain, based on a novel by Michael Crichton (dir: Robert Wise, 1971); Contagion (Russell Manzatt, 2001); Outbreak (Wolfgang Petersen, 1995); The Cassandra Crossing (George Cosmatos, 1976); The Plague * 1

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(Luis Puenzo, 1992); Killing Moon (John Bradshaw, 2000), etc. In reality, a city infected with virus is also a serious study of its governing capability and crisis management. During the spring 2003 SARS outbreak in Hong Kong, its people faced an unprecedented crisis and overwhelming helplessness and hopelessness, along with the love and selflessness of its medical professionals. This chapter is a chronological study of the representation of virus in Hong Kong films.

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CHRONOLOGICAL REVIEW Yesterday, Today and Tomorrow (dir: Long Gang, 1970), according to Stephen Teo (1988), is loosely based on Albert Camus’ The Plague (la Peste). It depicts a Hong Kong infested with plague-carrying rats. The territory is soon struck down by the dreaded pestilence. During production in 1968, director Long Gang (well known for his right-wing views) was threatened by the left wing, who accused him of “inciting” the public with an apocalyptic vision of Hong Kong. The distributors deliberately held the film back for two years and finally released it in a drastically cut version approved by the censors. This film is well known for its interpretation of the 67 riots that caused a lot of panic and crisis in regimentation in Hong Kong. 1:99 Movie Collection (co-directors, 2003) depicts Hong Kong city in turmoil during the March 2003 SARS epidemic. Every Hong Kong citizen is living under unprecedented psychological trauma. Everyone distrusts each other, and is afraid of being infected with SARS. At the same time, medical staff and courageous patients are regarded as our selfless heroes. We trust them. Trust and distrust are mixed in our emotions and beliefs. In April 2003, with the support of HKSAR, Federation of Hong Kong Film Workers kicked off 1:99 Shorts, commissioning 11 one-minute short films by celebrated film directors, thereby raising the morale as well as the awareness of the people of Hong Kong.2 In this collection, film directors revived the favorite grassroots oldies from the 1970s and 1980s: Tsui Hark’s Of a Cause (animation) revokes the iconic Master Q; Alex Law and Mabel Cheung recall Hong Kong’s past hero in Family of Heroes; and Johnnie To and Wai Ka-fai celebrate the remarkable qualities of the optimism, hard work and perseverance of the people of Hong Kong in Rhapsody. By recalling the past, they hope that Hong Kong is restored to its brightest glory. Andrew Lau and Alan Mak present a similar vision in A Glorious Future. Most film directors prefer to face SARS in a humorous and comedic way, e.g., Gordon Chan’s Until Then, Joe Ma’s Who’s Miss Hong Kong?, Stephen Chow’s Hong Kong—A Winner, and Teddy Chen’s Smile. Only Peter Ho-Sun Chan’s Spring 2003 is a serious drama. The Miracle Box (dir: Adrian Kwan Shun-Fai, 2004) was produced by a Hong Kong Christian communication company called Media Evangelism. According to Kozo’s review3, respect can easily be given to The Miracle Box, a Christian-themed drama that chronicled the life and times of doctor Joanna Tse, who was martyred by the outbreak of SARS in 2003. Her story was an inspirational one, promoting hope in the face of adversity along with religious faith. As portrayed by Ada Choi Siu-Fun, Joanna Tse was a angel-like doctor, putting her responsibilities and love above all else, and never giving up when the people around her do. 2 3

http://sensasian.com/product.php/en/V7673H/ http://www.lovehkfilm.com/reviews/miracle_box.htm

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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. Kozo’s review is based on the fact that The Miracle Box is a gospel film that aims to preach Christian values and beliefs. Actually, The Miracle Box is a romance film. It was also successful at the box office (HKD 6,535,338) and received positive film reviews at the time of its release. Ebola Syndrome (dir: Herman Yau, 2006) tells the story of a restaurant worker named Ah Kei (Anthony Wong Chau-Sang) who murders his boss and his wife and escapes to South Africa to work as a cook in a Chinese restaurant. One day, he rapes and murders a black girl who is infected with the Ebola virus. He has no idea that he has become a carrier of the disease. Later, he kills his new boss and the boss’ wife and minces their bodies into so-called Chinese hamburgers. To escape arrest, he flies back to Hong Kong and continues to spread the Ebola virus. Ebola Syndrome is produced as a B-movie, full of foul language, violence, blood and sexual content; the film falls into the third film category. Wong Jing is the producer of this low-budget film, which can be classified as Hong Kong exploitation or cult film. Anthony Wong plays a depraved rapist and vivisectionist. He is one in 10,000 among those who are unaffected, but becomes a carrier of Ebola virus. The character symbolizes one who does not die and eventually becomes the most dangerous dead. His return to Hong Kong is actually a fatal invisible threat to Hong Kong City and its people.

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INVISIBILE INSTABILITY IN HONG KONG CITY AND HUMAN RELATIONSHIPS By reviewing the above Hong Kong films, the representation of virus is not merely a matter of virus outbreak, spread and threat. Hong Kong films do not pay much attention to the medical and scientific accuracy of the diseases and virus. This is clearly not the case, as Dr. Georgios Pappas (2003) confirmed that most depictions of infectious diseases in cinema are inaccurate. Even the most sincere efforts tend to be marred by extreme scientific inaccuracies, and the premise of epidemics involving unknown viruses of dubious origin that cause apocalyptic events serves to instill the public with fear, which may turn to panic when similar situations arise. Control of the content of film is neither feasible nor ethical. Therefore, specialists should be alert to the effect that cinema has on morphing public opinion and the concepts involving medicine that are presented, and efforts toward informing the general public should be intensified.4 Due to the Chinese culture and the Hong Kong context, Hong Kong films adversely reflect the invisible unstable regimentation and crisis management of the Hong Kong government. Yesterday, Today and Tomorrow criticizes the medical system and is a metaphor of Hong Kong in 1997. Even Ebola Syndrome attacks the legal system and police force indirectly. On the other hand, 1:99 Film Collection is supported by HKSAR. Therefore, it promotes the optimistic mood and spirit in overcoming SARS. Most film directors preferred a nostalgic treatment, with humor and comic style, to encourage the people of Hong Kong during that time. The Miracle Box promotes the sacrifice and love of Christian doctor Joanna Tse, whom the Hong Kong people will miss forever. 4

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Virus separates people, as we do not know who is carrying the invisible virus, so people lose trust and intimacy in human relationships. Films act to bring back love and trust.

AUTHOR INFORMATION Institutional Affiliations Assistant Professor and Program Coordinator of Electronic Media Department of Journalism and Communication in Chu Hai College of Higher Education in Hong Kong Assistant Professor Department of English Communication, School of Social Science and Humanity, University of Macau Academic Qualifications PhD in Film Studies (Hong Kong Baptist University, 2005) MA in Film Director and Theory (Beijing Film Academy, 1999) BA in Film and Television (Hong Kong Baptist University, 1996) Certificate in Film Production (Hong Kong Film Directors Guild Training Center, 1995) Certificate in Film and TV Scriptwriting (The Chinese University of Hong Kong School of Continuing Studies, 1994)

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REFERENCES Films Yesterday, Today and Tomorrow (dir: Long Gang, 1970) 1:99 Movie Collection (co-directors, 2003) The Miracle Box (dir: Adrian Kwan Shun-Fai, 2004) Ebola Syndrome (dir: Herman Yau, 2006)

Article Teo Stephen (1988). Politics and Social Issues in Hong Kong Cinema. In Changes in Hong Kong Society Through Cinema (pp. 38-40), Hong Kong: The Urban Council.

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Chapter 16

A WORKSHOP PROGRAM SUPPORTING A CHANGE IN THE “HEART AND ART” OF THE BEREAVEMENT SERVICE WITHIN A WORKPLACE Miranda M. M. Leung and Zenobia C. Y. Chan

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ABSTRACT In order to promote the team spirit of the “Heart and Art” of the bereavement service within every Pediatric and Adolescent Medicine Department (P and AM Department) in Hong Kong, a slogan competition is launched prior to the commencement of a series of bereavement workshops. Six half-day workshops are proposed, to be held on every Tuesday morning in Hospital X. Each workshop has a different main theme related to bereavement services in the P and AM department. The normal grieving process and grief responses of different genders, with theoretical support, are discussed by reflective learning and experience sharing. Methods for breaking the bad news to the patient and the family members are discussed. Ways to talk with children about anticipated and sudden death are explored as well. Care and major issues before and after death are explained in details. Funeral arrangements among different cultures are illustrated by experts or videos. Methods to help ourselves or our colleagues overcome the frustration of the loss of the clients we cared for (“Care for the Carer”) are also explored. Appropriate attitudes and counseling skills for bereavement in the P and AM department are expected to be cultivated through team spirit building from the series of workshops and the slogan competition.

INTRODUCTION Bereavement care services have been recognized in Hong Kong for many years as essential for clients. The Hospital Authority Convention’s focus on bereavement care was carried out in 1998. Only hospice care, palliative care and some oncology units have been well developed as units specializing in care for the dying. However, there is a lack of sufficient training and support in pediatric units. The P and AM Department provides services that cover a wide range of clients, ranging in age from newborn to 17, including neonatal,

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pediatric, and adolescent patients; as well as medical, surgical, orthopedic, psychiatric, and other kinds of pediatric patients. In spite of the advancement of high technology, the death of a pediatric patient is sometimes unavoidable. The bereavement service has been developed since 1997 in the P and AM Department of Hospital X. Six half-day workshops are proposed to promote bereavement services in all P and AM departments within and outside Hospital X. A slogan competition is held in Hospital X prior to the workshops to enhance the spirit of bereavement services.

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LITERATURE REVIEW The bereavement care provider is a form of leader for the dying patient and the bereaved families. We may call it “value-driven leadership” (Sadler, 2003). Bereavement or mourning is defined as the state of experiencing loss of loved one (Leming and Dickinson, 2007; Servaty-Seib, 2004). Bereavement service is a kind of caring service towards the bereaved persons to help them to go through a grieving process (Aragono, 2007). Work as a bereavement care provider is very meaningful. According to the Kübler-Ross five-stage theory of dying process, the dying person as well as his attached family members will go through denial, anger, bargaining, depression and acceptance (Servaty-Seib, 2004). It is very challenging to take care of these people. If we understand more about the four tasks of mourning, we feel more competent in taking care of the bereaved person. The mourning or grieving process consists of the following four elements: accepting the reality of the loss, experiencing the pain of grief, assuming new social roles, and reinvesting in new relationships. They must be accomplished in order to really go through the grieving process (Leming and Dickinson, 2007). According to Senge (1990 and 1995), a leader should work as a designer, a teacher and a steward. Senge even points out that a leader should have a vision and share the vision by identifying the creative tension (gap between the goal and the reality), and then try to motivate and facilitate the relevant persons to achieve success. This is the reason that we design this program in a series of workshops and a slogan competition. Acting as a trainer, we present our willingness as a steward always to put our clients’ need as a first priority. As Bolden, Gosling, Marturano, and Dennison (2003) criticize that the “solo leader” is no longer appropriate for the rapidly-changing work environment, we agree with Bolden et al. that “team leader” should be more suitable for team building. The team leader is both personand task-oriented (Martin, 2003). That is why we selected a half-day morning workshop to allow more colleagues to attend, and refreshments are also provided for the participants. Moreover, knowledge and skills of bereavement care cannot be obtained by attending only lectures or readings, so we design a series of comprehensive and interactive workshops related to bereavement services. A workshop allows participants to learn by reflection (Boud, Keogh, and Walker, 1998), group discussion, role play, observation and experience sharing. A workshop provides an opportunity for the participants to learn interactively and effectively (Mumford, 1997). In order to gain success, effective and sustainable change outcomes are expected. According to Lewin’s change model, a change process includes “unfreezing”, “moving” and “refreezing” stages (Graetz, Rimmer, Lawrence, and Smith, 2002). According to the current

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situation in the Neonatal Intensive Care Unit (NICU) of Hospital X and Special Care Baby Unit (SCBU), most of the bereavement cases have been followed by three to five key nursing staff members (according to the NICU death record of Hospital X) from 1997 to the present. We should change this condition by unfreezing the norm, moving more frontline nurses toward competency as a bereavement care provider or facilitator by motivation and empowerment, and refreezing a new norm by effective team building. As a result, a high team spirit of “Heart and Art” in our daily nursing care would be established. Although it is more difficult for us to effect a similar change in other hospitals, their nursing staff could be a change agent by influencing their colleagues in the future if they have the advantage of the learning opportunity offered by our department. It would be a greater success for our clients if more pediatric nurses in Hong Kong are capable of bereavement care. The study suggests that parents can effectively cope with the death of their infant, and medical staff can do more to improve the end-of-life care for infants and their families (Brosig, Pierucci, Kupst, and Leuthner, 2007). Bereavement service is a kind of psycho-socio therapeutic service for bereaved persons. The aim of the service is to help the bereaved persons go through the grieving process so that they can return to their normal daily life with minimum negative effects from the loss of their loved one (Leming and Dickinson, 2007). The nursing workshops on the “Heart and Art” of the bereavement service in the P and AM department should be supported. All participants of the workshops are expected to learn by reflective learning, shared vision and skills to act as a “bereavement care ambassador” through motivation and empowerment to be a leader for bereaved persons/families in their working environment.

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WORKSHOP OBJECTIVES There are three main objectives of the program: to share the vision of care for the dying patient and the bereaved persons in order to build a team-approached bereavement service; to facilitate and encourage the frontline staff to equip themselves as a bereavement care ambassador; and to exchange experiences in the child bereavement service in order to acquire continuous quality improvement (CQI) in bereavement service for different P and AM departments in Hong Kong.

TARGET PARTICIPANTS All nursing staff of P and AM departments in Hospital Authority (HA) hospitals and private hospitals are welcomed. Forty to fifty participants are expected for each series of bereavement workshops.

DATE AND DURATION In order to facilitate more nursing staff members to attend the workshops, a half-day workshop is more appropriate. Only morning sessions are selected, considering the better

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mental and physical status of each nursing staff member, which would enable better learning outcomes. It is suggested that six half-day morning workshops will be held on consecutive Tuesdays from 08:30 to 12:30. Different afternoon (p.m.) schedules of other hospitals have been considered. Some participants may be required to leave the workshop early if their p.m. duty begins at 13:00. This is the rationale for 90% attendance as justification for earning an attendance certificate. The nursing leader of P and AM department of each HA hospital and the Departmental Operational Manager (DOM) are encouraged to approve their nursing staff’s application for a study day (SD) depending to the unit’s situation. This is a demonstration of our management’s support and appreciation for the staff members who work and study hard for our patients.

OUTLINES OF WORKSHOPS Day 1

Normal grieving process and grief responses

Day 2

How to break the bad news to the patient and the family members

Day 3

How to talk with children about anticipated and sudden death

Day 4

Care and major issues before and after death

Day 5

Funeral arrangements for different cultural beliefs

Day 6

How to help ourselves or our colleagues overcome the frustration of the loss of the clients (“Care for the Carer”)

EXPECTED LEARNING OUTCOMES AND WORKSHOP CONTENTS

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Every workshop has a main theme and different expected outcomes. Following are the content and expected outcomes of each workshop from Day 1 to Day 6. Day 1 Workshop on “Normal Grieving Process and Grief Responses”: to identify our own feelings about loss and grief, the physical and emotional effects of the loss and grief; to examine and develop a deeper understanding of the needs of grieving families and how grief affects the families; to understand the different grief responses within different genders. “Stage approach to mourning” and “dual process model of coping with bereavement” are the main theories related to bereavement (Servaty-Seib, 2004). These theories will be applied in the workshop. Day 2 Workshop on “How to Break the Bad News to the Patient and the Family Members”: to increase confidence and skills in the process of breaking bad news; to develop insight and awareness (Holland, Dance, MacManus, and Stitt, 2005) into the needs of grieving families; to enhance the communication and listening skills to help the bereaved families. Ways to break the bad news are discussed in the workshop (Farrell, Ryan, and Langrick, 2001). Day 3 Workshop on “How to Talk with Children about Anticipated and Sudden Death”: to learn the value of practical tools and resources for effective communication with different ages of pediatric clients; to share experiences and to explore a child-centered bereavement best practice towards anticipated or sudden death of a loved one; to gain and

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explore the possibilities of the gift aspect of organ donation with the support of both patient and relatives. Children of different ages require different methods of communication about bereavement (Turner, 2005; Rathkey, 2004). Knowledge and skills related to ways to communicate with children of different ages in bereavement care are provided. Day 4 Workshop on “Care and Major Issues before and after Death”: to promote the awareness of the need of facilitating family presence at resuscitation; to become familiar with the major procedures after patient death, such as last office, patient/body identification, death document arrangements, and funeral arrangements; to enhance the awareness and skills to make the body look peaceful and natural (Leming and Dickinson, 2007). Reference to the NICU and SCBU Nursing Procedure Guidelines of Hospital X. Day 5 Workshop on “Funerals Arrangement for Different Cultural beliefs”: to gain an insight into the rites and rituals of death and mourning within Hong Kong cultures; to develop knowledge and skills required to handle the needs and wishes of the bereaved families in an appropriate and respectful way according to their cultural beliefs; as professional carers, to increase the awareness of our own needs in spiritual beliefs and to explore ways to support ourselves and others. Funerals and different cultural beliefs affect people’s reaction to the loss of a loved one (Chow, 2006; Hayslip and Peveto, 2005). Day 6 Workshop on “How to Help Ourselves or Our Colleagues Overcome the Frustration of the Loss of the Clients (“Care for the Carer”): to examine what draws us to the work we do, recognize our own needs in exploring the different ways to support and help ourselves and others; to identify ways to make use of active listening and assertive skills to increase self confidence and be an advocate for ourselves and others; to provide an opportunity to network and share our experiences. Self-awareness, relaxation exercises and counseling skills are then reinforced (Boud, Keogh, and Walker, 1998; Servaty-Seib, 2004).

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JUSTIFICATIONS FOR THE WORKSHOP Two neonatal death (NND) cases have just occurred recently. After breaking the bad news that their babies were going to die, both sets parents were encouraged to bring something for their babies, such as hats, socks, clothing, and blankets, to facilitate them in fulfilling their parental roles. However, discrepancies in handling these cases were found. Some of the nursing staff members placed only the hat and the blanket on the babies and some even changed the hospital gown instead of private clothes, neglecting baby’s belongings that were brought in by the baby’s parents. On the other hand, another dying client named “HH” was treated in a more appropriate way, allowing his mother even to bathe and embrace him while he was still alive in the last few hours (Oriental Daily Headline, 2008). This gap (Ewles and Simnett, 2003; Hsieh, 2004) among our nursing staff was noted and is the reason that we are trying to build a team spirit to provide appropriate interventions for the dying clients and their bereaved families. In another case, a bereaved mother from another HA hospital suffered the death of her newborn baby a week after her premature delivery. When she knew Hospital X always allowed the mother to hold her baby before and after the baby’s death, she felt very unhappy and even angry that she was not offered a chance to hold her baby even once. This is another reason for our proposal that the target participants should also include other HA nursing staff

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members of P and AM departments. It is expected that this will motivate HA-wide P and AM department nurses to provide appropriate bereavement care those in need. The P and AM Department of Hospital X may become a role model as a change agent (Kotter, 1990) to build an effective team to support bereavement care for the clients. In addition, a primary health care program called “Project ENABLE”, providing education on life and death, has been planned and promoted by the Center of Behavioral Health of The University of Hong Kong since 2006 and is sponsored by the Hong Kong Jockey Club Charities Trust (Centre on Behavioral Health, 2008). A workshop called “Train the Trainer” for bereavement care is promoted for the public. As professionals with pediatric specialty training, we should lead our colleagues, whether they are working in HA or private hospitals, to gain updated knowledge of bereavement care and skills for our specific group of pediatric patients and their families. Thus, all pediatric nurses from other hospitals are welcomed in order to share and exchange our experiences in bereavement service through continuous quality improvement (CQI); and to contribute to all levels of pediatric patients in Hong Kong. In order to fill the gap among pediatric nursing staff members of Hospital X; to widely promote bereavement care services for pediatric patients and their families among HA hospitals; and to provide an opportunity for both HA and private hospitals to have a CQI program in bereavement services; a series of workshops entitled “Six Half-Day Nursing Workshops on the ‘Heart and Art’ of the Bereavement Service in the P and AM Department” are proposed.

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TEACHING MODES Effective learning comes from good teaching methods and self-motivation (Boud, Keogh, and Walker, 1998). An effective learning process consists of self-experience, reviewing past experience, drawing conclusions the learning from the experience, and then finding a new way to act in the future (Mumford, 1997). Varieties of teaching modes are applied in the workshops, including self-reflection, experience sharing, group discussion, role play with observers, a video show and critique, selection of or voting on a slogan, and so on.

DISCUSSION The program design is structural, comprehensive, creative and symbolic (Bolman and Deal, 2003), and it will not be successful if there is a lack of management support (Mok and Au Yeung, 2002). As a learning organization, management should always provide support and a protective shield for both internal and external customers (Alinsky, 1989). Kreitner and Kinicki (2001) state that job satisfaction can be identified as five models: need fulfillment, discrepancies, value attainment, equity and dispositional/genetic components. The proposed program motivates, empowers and recognizes the pediatric nurses as bereavement care ambassadors, so that the participants’ needs of fulfillment, equity, and value attainment are met. Management support makes them feel empowered rather than enslaved (Davison and Martinsons, 2002). Directive leadership sometimes is effective and

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efficient, but lacks space for staff development and personal growth (Sadler, 2003). Instructions and guidelines are not enough for team spirit building. The proposed program offers a chance to expand the original bereavement team within or even outside the P and AM Department of Hospital X. Revising the guidelines for bereavement service in each neonatal/pediatric ward of different hospitals for enhancement after these interactive learning workshops is highly recommended. According to Alinsky (1989), the rules for effective change include communication and education, staying within the experience of people, serving as a protective shield, getting people involved, and respecting individual’s dignity and contributions. The six half-day workshops create a chance for staff communication and education, and facilitate the staff to go through their experience by reflective learning. A slogan competition invites all staff members to get involved in the promotion of bereavement care. The reward system is the recognition of their participation and contributions.

CONCLUSION

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The program is expected to benefit all participants including P and AM department nursing staff members in both Hospital X and other HA hospitals as well as private hospitals. It will also be supported by “Project ENABLE” to provide education on life and death. It is worth introducing to other colleagues in order to have the opportunity to gain their insights through this bereavement training program. CQI service on bereavement care is promoted, and the team spirit of the “Heart and Art” of the bereavement service in every P and AM department in Hong Kong will be enlightened. The success of the program depends on the support of management and the participants.

AUTHOR’S BACKGROUND Miranda M. M. Leung, RN, RM, holds a diploma in NICU, a bachelor of nursing degree, and a master degree in primary health care. Miranda is an experienced nursing officer, caring for a wide range of patients in private and public hospitals in Hong Kong. Providing holistic and family-centered care for patients is her mission. Her experience in counseling pretermlabor women, anxious parents, teenage mothers and bereaved families is extensive. She is entitled as an “ENABLER” to offer Life and Death Education after completed the training in the “Project ENABLE” organized by The University of Hong Kong. Miranda has also been a mentor of Guangdong nurses in NICU training in Hong Kong and has participated in Chinese Traditional Nursing seminars held in mainland China. She can be contacted by email at [email protected]

REFERENCES Alinsky, S. (1989). Rules for radicals (pp. 98-125). New York: Random House.

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Aragono, A. (2007). Transforming mourning: A new psychoanalytic perspective. In B. Willock, L. C. Bohm, and R. C. Curtis (Eds.), On deaths and endings: Psychoanalysts’ reflections on finality, transformations and new beginnings. London, New York: Routledge. Bolden, R., Gosling, J., Marturano, A., and Dennison, P. (2003). A review of leadership theory and competency frameworks. UK: University of Exeter Centre for Leadership Studies. Bolman, L. G., and Deal, T. E. (2003). Reframing organizations: artistry, choice and leadership (3rd ed.) (pp. 334-365). San Francisco: Jossey-Bass. Boud, D., Keogh, R., and Walker, D. (Eds.). (1998). Reflection: Turning experience into learning (pp. 7-17). London: Kogan Page. Brosig, C. L., Pierucci, R. L., Kupst, M. J., and Leuthner, S. R. (2007). Infant end-of-life care: The parents' perspective. Journal of Perinatology, 27(8), 510-516. Centre on Behavioral Health (2008). Project ENABLE. HK: University of Hong Kong. Retrieved Mar 31, 2008 from http://cbh.hku.hk/enable/ Chow, A. Y. M. (2006). The bereavement experience of Chinese persons in Hong Kong. Ph.D. dissertation, University of Hong Kong. Hong Kong. Retrieved April 1, 2007, from Dissertations and Theses: A and I database. (Publication No. AAT 0809463). Kreitner, R., and Kinicki, A. (2001). Organizational behavior (5th ed.) (pp. 204-235). New York: McGraw-Hill. Davison, R. M., and Martinsons, M. G. (2002). Empowerment or enslavement: A case of process-based organizational change in Hong Kong. Information Technology and People, 15(1), 42-59. Ewles, L., and Simnett, I. (2003). Identifying health promotion needs and priorities. In Promoting health: A practical guide (5th ed.) (pp. 102-120). London: Bailliére Tindall. Farrell, M., Ryan, S., and Langrick, B. (2001). “Breaking bad news” within a paediatric setting: an evaluation report of a collaborative education workshop to support health professionals. Journal of Advanced Nursing, 36(6), 765-775. Graetz, F., Rimmer, M., Lawrence, A., and Smith, A. (2002). Managing organisational change (pp. 89-130). Milton, Qld: John Wiley and Sons. Hayslip, B., and Peveto, C. A. (2005). Cultural changes in attitudes toward death, dying, and bereavement. New York: Springer. Holland, J., Dance, R., MacManus, N., and Stitt, C. (2005). Lost for words: Loss and bereavement awareness training. London, Philadelphia: Jessica Kingsley Publishers. Hsieh, W. P. (2004). Organizational commitment in Taiwan and its relationship to transformational leadership. D.B.A. dissertation, Nova Southeastern University, United States: Florida. Retrieved April 1, 2008 from Dissertations and Theses: A and I database. (Publication No. AAT 3158668). Kotter, J. P. (1990). A force for change: How leadership differs from management (pp. 3-18). New York: Macmillan. Leming, M. R., and Dickinson, G. E. (2007). Understanding dying, death, and bereavement (6th Ed.). Belmont, CA: Thomson Learning Academic. Martin V., (2003). Leading change in health and social care. London: Routledge. Mok, E., and Au-Yeung, B. (2002). Relationship between organizational climate and empowerment of nurses in Hong Kong. Journal of Nursing Management, 10(3), 129-137.

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Mumford, A. (1997). Individual and organizational learning: The pursuit of change. In C. Mabey, and P. Iles (Eds.), Managing learning (pp. 77-86). London: International Thomson Business Press. Oriental Daily Headline (2008, April 18). Mother’s love affects many netizen. HK: Oriental Daily. (Chinese version). Rathkey, J. W. (2004). What children need when they grieve: The four essentials: routine, love, honesty, and security. New York: Three Rivers Press. Sadler, P. (2003). Leadership (2nd ed.) (p. 63-82). London: Kogan Page. Senge, P. (1990). The leader’s new work: Building learning organizations. Sloan Management Review, Reprint Series, 32(1), 7-23. Senge, P. (1995). The fifth discipline. The art and practice of the learning organisation (pp. 205-232). Sydney: Random House. Servaty-Seib, H. L. (2004). Connections between counseling theories and current theories of grief and mourning, Journal of Mental Health Counseling, 26(2), 125-145. Turner, M. (2005). Someone very important has just died: Immediate help for people caring for children of all ages at the time of a close bereavement. London, Philadelphia: Jessica Kingsley Publishers.

APPENDIX 1

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Questionnaire

Date:_________

Thank you for your support in completing the questionnaire. This purpose of this survey is to collect information from you in your bereavement services. All information collected will be kept confidential.

1.

Where are you working? ‰ ‰ ‰

2.

Hospital X P and AM Department Other HA hospital Other hospital

How many years have you worked in the P and AM Department? ‰ ‰ ‰ ‰ ‰

Less than 3 years 3 to less than 5 years 5 to less than 10 years 10 to less than 20 years 20 or more than 20 years

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200 3.

Have you attended any bereavement lectures or workshops? ‰

4.

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‰

No

Relevant to work To enhance your knowledge and skills in bereavement care To improve your ward services in bereavement care To gain CNE points To acquire a recognition as a “Bereavement Care Ambassador” Others (please specify) _____________________________________ ________________________________________________________

No religion Buddhist Catholic Christian Others (please specify) __________________________

How many patients in your ward died in the past three years? ‰ ‰

8.

Yes

What is your religion? ‰ ‰ ‰ ‰ ‰

7.

No

What are your intentions in attending this series of bereavement workshops (you can have more than one selection)? ‰ ‰ ‰ ‰ ‰ ‰

6.

‰

Have you attended any bereavement lectures or workshops related to pediatric clients and their families? ‰

5.

Yes

None (please go to question 10) Others (please specify the no.) __________________________

Of those patients who died in the past three years, how many died accidentally and/or suddenly? Answer __________________________________________________

9.

Of those patients who died in the past three years, how many of them were taken care of by you? Answer __________________________________________________

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10. During your service in the P and AM Department, did you encounter a patient death in your ward? ‰ ‰

Yes (please go to question 11) No (please go to question 13)

11. You feel competent to take care of these dying patients and their families. ‰ ‰ ‰ ‰ ‰

Strongly agree Agree Half and half Disagree Strongly disagree

12. You tend to endure pain or frustration in silence or tell someone of your feelings and thoughts. ‰ ‰ ‰ ‰ ‰

Strongly agree Agree Half and half Disagree Strongly disagree

13. How many funerals have you attended in the past three years?

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Answer __________________ 14. Did you feel distress or discomfort during the funeral? ‰

Yes

‰

No

15. Do you think you and your colleagues need psychological support for the frustration over patients who have died? ‰ No (Reasons: ____________________________________________) ‰ Yes (Suggestions: _________________________________________ _______________________________________________________ )

16. Sudden death or anticipated death: which seems more tragic? ‰ ‰

Sudden death (Why? ______________________________________) Anticipated death (Why? ___________________________________)

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17. Do you find any difference in the bereavement services among different hospitals? ‰ Yes (How? ________________________________ ‰ No 18. Do you think your ward should revise the bereavement services? ‰

Yes

‰

No

19. Are you willing to be one of the advocators of bereavement services inside your ward? ‰ Yes ‰ No 20. Are you willing to explore the possibility of organ donation during bereavement services inside your ward? ‰ No ‰ Yes (Please give reasons) ____________________________________ _________________________________________________________

*Please answer questions 21–30 after completing the series of workshops. 21. You think the series of workshops is well organized.

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‰ ‰ ‰ ‰ ‰

Strongly agree Agree Half and half Disagree Strongly disagree

22. You think the series of workshops is worthy for recommendation to others. ‰ ‰ ‰ ‰ ‰

Strongly agree Agree Half and half Disagree Strongly disagree

23. You feel the series of workshops empowers you to provide bereavement service in your ward. ‰ Strongly agree ‰ Agree ‰ Half and half ‰ Disagree ‰ Strongly disagree

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A Workshop Program Supporting a Change in the “Heart and Art”… 24. You feel the duration of each workshop is appropriate. ‰ ‰ ‰ ‰ ‰

Strongly agree Agree Half and half Disagree Strongly disagree

25. You feel the trainers are good in teaching. ‰ ‰ ‰ ‰ ‰

Strongly agree Agreed Half and half Disagree Strongly disagree

26. You feel the environment is good for learning. ‰ ‰ ‰ ‰ ‰

Strongly agree Agree Half and half Disagree Strongly disagree

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27. You feel the resources and facilities are good and enough for the workshops. ‰ ‰ ‰ ‰ ‰

Strongly agree Agree Half and half Disagree Strongly disagree

28. You are satisfied with the series of workshops. ‰ ‰ ‰ ‰ ‰

Strongly agree Agree Half and half Disagree Strongly disagree

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29. Any other comments? ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

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30. Any suggestions? ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

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In: Health Issues in Chinese Contexts, Volume 1 Editor: Zenobia C. Y. Chan

ISBN: 978-1-61209-385-7 © 2009 Nova Science Publishers, Inc.

Chapter 17

TWO-DAY WORKSHOP ON DEVELOPING CRITICAL THINKING IN NURSES May M. Y. Li* and Zenobia C. Y. Chan

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ABSTRACT Complex nursing problems confronting nurses today demand the need for critical thinking (CT) skills. CT is essential to leadership since it is underpinned by responsible thinking that facilitates the development of problem-solving skills. Supporting staff to think critically is necessary to improve patient care and decrease sentinel events. In Hong Kong, limited training exists for nurses to understand and utilize CT concepts and skills. CT training for nurses is, therefore, timely and relevant for nursing professional development. The contexts of this workshop, including the rationale, content, teaching modes and evaluation methods, are outlined. This workshop aims at promoting understanding by nurses on the importance of leadership and CT in health care settings, helping nurses to cultivate critical thinking and enabling them to apply CT skills in clinical practice. Emphasis on innovative, interactive, experiential and participatory approaches underpinned by a supportive learning environment will help nurses develop CT skills. Participants will be targeted to 30 registered nurses with more than five years’ working experience in hospitals belonging to the Hospital Authority.

BACKGROUND In Hong Kong, the nursing structure is hierarchical and autocratic nursing leadership is common. Nurses have little autonomy and authority to make decisions at work. Traditional values of authoritarian attitude will be ineffective to promote change or improve work performance in nursing. Complex nursing problems confronting nurses today demand the need for critical thinking (CT) skills. CT is essential to leadership since it is underpinned by responsible thinking that facilitates the development of problem-solving skills (Beeken, Dale, *

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

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Enos, and Yarbrough, 1977; Brigham, 1993; Glen, 1995; Miller and Malcolm, 1990 as cited in Lemire, 2005). The National League for Nursing (1992 as cited in Vaughan-Wrobel, O’Sullivan, and Smith, 1997) included CT as a required outcome measure in the accreditation of nursing degree programs. To think critically is necessary to improve patient care and decrease sentinel events (Hansten and Washburn, 2000). New nursing graduates may lack the confidence to explore alternatives for clinical or organization problems (Ignatavicius, 2001). Experienced nurses need facilitation in CT as they may base their practice on habits rather than exploring new and advanced patient care. In Hong Kong, little training exists for nurses to understand and utilize CT concepts and skills. We propose an innovative workshop to enhance CT training for nurses since it is timely and relevant for nursing professional development.

WORKSHOP OBJECTIVE Our workshop objectives focus on promoting understanding by nurses on the importance of leadership and CT in health care settings, helping nurses to cultivate critical thinking, enabling them to learn CT concepts and skills, thereby facilitating their practice of CT skills.

TARGET PARTICIPANTS

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Target participants will include 30 registered nurses with more than five years’ working experience in hospitals belonging to the Hospital Authority (HA), as they are potential leaders in developing CT skills.

EXPECTED LEARNING OUTCOMES At the end of the workshop, participants will be able to learn the concepts and implications of leadership and CT in the workplace. They will be able to develop knowledge and skills in CT that contribute to nursing practice and will be able to apply critical thinking in the workplace.

RATIONALES A leader is a person who influences people to move and achieve goals, and leadership is defined as a process of influence in an organization (Carroll, 2006). Leadership roles are crucial in influencing people to achieve shared visions and goals (Bass, 1985; Yukl, 2002 as cited in Sellgren, Ekvall, and Tomson, 2006) and these roles have a significant impact on organizational commitment to enhance the organization’s competitiveness (McGuire, and Kennerly, 2006). Western leadership emphasizes liberalism, democracy, participation, empowerment and individualized consideration (Bass, 2002; Chemers, 1997 as cited in Cheung and Chan, 2005). Chinese leadership places more emphasis on interpersonal

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relationships and a hierarchical organization (D’Souza, 2003; Hofstede et al., 2002; Hui and Graen, 1997; Smith et al., 1997 as cited in Cheung and Chan, 2005). Compared with Western leadership, Chinese leadership tends to be more hierarchical and autocratic. Leadership contributes to the success and failure of an organization (Lok and Crawford, 2004). Three subprocesses of leadership within an organization involve establishing direction, aligning people, motivating and inspiring (Kotter, 1990). Leadership in nursing was described as a vehicle influencing and shaping health policy and nursing practice (Sullivan and Decker, 2005 as cited in Feltner, Mitchell, Norris, and Wolfle, 2008). Meanwhile, CT has been defined as purposeful, self-regulatory judgment resulting in interpretation, analysis, evaluation and inference as well as explanation of the evidential, conceptual or contextual considerations upon which judgment is based (Facione, 1990 as cited in Facione and Facione, 1996). CT is also defined as a purposeful, outcome-oriented and evidence based thinking process (Ignatavicius, 2001). CT is the ability to solve problems by using creative, intuitive, logical and analytical cognitive processes (Snyder, 1993 as cited in Hansten and Washburn, 2000). Thinking critically requires the acquisition of knowledge, reasoning and rational appraisal skills, analytic problem solving ability and reflective thinking (Lemire, 2005). Six CT skills include interpretation, analysis, evaluation, inference, explanation and self-regulation (Facione and Facione, 1996). Ignatavicius (2001) described these skills as follows: Interpretation involves clarifying the meaning of a patient’s behaviour and analysis is about identifying a patient’s problems. Evaluation is ascertaining expected patient outcomes, while inference concerns drawing conclusions through monitoring the patient’s health condition. Explanation refers to the ability to justify actions and selfregulation is the process of examining one’s practice and improving it if required. CT has been nationally recognized as essential to knowledge development and professional judgment to address the challenges of the 21st century (Facione and Facione, 1996). CT skills are required for clinical decision making in important situations that are often time limited (Facione and Facione, 1996). Nurses must think critically in order to handle complex clinical tasks effectively. Critical thinkers are creative, innovative and actively engaged in life (Brookfield, 1987). Inquisitiveness, self-confidence, open-mindedness and honesty are dispositions exhibited by critical thinkers, and without such dispositions one is unlikely to apply learned CT skills (Falsion, 1990; Falsion et al., 1995 as cited in Lemire, 2005). Great critical thinkers in Western countries, such as Isaac Newton, Charles Darwin, Albert Einstein and Bill Gates, are good models for people to learn from. The CT skills of staff can be positively and negatively affected by personal or workplace variables (Ignatavicius, 2001). If policies in the workplace are too restrictive or do not allow staff to make decisions, staff may not be empowered to think critically (Ignatavicius, 2001). A study by Shell (2001 as cited in Lemire, 2005) showed that nursing graduates lack the ability to think critically. Nurses who are constantly learning will enrich CT skills (Ignatavicius, 2001). Knowledge may contribute to increased CT (Martin, 2002) so supporting staff in educational training will be important to develop CT potential. CT is a long-term developmental process that needs to be practised, nurtured and reinforced continuously over time (Ignatavicius, 2001). Learning to think critically expands a person’s thought processes, since reflective scepticism in CT refers to individuals who are sceptical and do not take things for granted (Brooksfield, 1987 as cited in Simpson and Courtney, 2002). With nurse leaders as role models, staff can benefit from their CT skills (Ignatavicius, 2001). Based on past and current nursing training, locally designed workshops

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that specifically meet the needs of nurses in developing CT skills are scarce. Our workshop is necessary to support nurses in learning and applying CT skills to cope with the challenges of their work. It can serve as on-going training and a reflective process of nursing practice to develop nurses’ CT skills to meet various patients’ needs.

WORKSHOP CONTENT Our workshop content will be evidence-based and supported by literature. The first part will include an introduction and warm up at the beginning. Warm up questions, e.g., “Who do you think is an outstanding leader? Why?” and “Is a leader born or developed?” (Evans and Evans, 2002, p. 25) will be used in group sharing for icebreaking. CT is essential to leadership in nursing to face the changing demands of health care services. The main themes of the workshop will all be related to leadership and CT for nurses, which include leadership and implications, concepts of CT and leadership, CT skills and factors affecting CT ability. The final part of our workshop will provide opportunities for participants to share some key learning, achievement and evaluation. Workshop content is illustrated in the table below. Workshop Content Objectives

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Time 09:00-9:30am 09:30-10:30am 10:30-10:40am 10:40-11:00am 11:00-11:30am 11:30-11:40am 11:40-12:20pm 12:20-12:30pm 12:30-14:00pm

14:00-15:00pm 15:00-15:10pm 15:10-16:10pm 16:10-16:30pm 16:30-17:00pm

Day-One 1. Promote understanding by nurses on the importance of leadership and CT 2. Help nurses to cultivate CT Topics -Overview of workshop objectives and content and warm up -Lecture with PowerPoint on leadership -Break -Lecture on leadership and implications -Video show and group discussion -Break -Case sharing about leadership -Question and answer -Lunch break

Day-Two 1. Enable nurses to learn CT concepts and skills 2. Facilitate nurses to practise CT skills. Topics -Recap of day one and briefing of day two content -Lecture on six CT skills and implications -Break -Journal discussion -Video show and group discussion -Break -Group exercise on clinical scenario I -Question and answer -Lunch break

Day-One -Lecture on concepts on CT and leadership -Break -Group game -Summary, question and answer -Feedback on Day-One

Day-Two -Peer sharing on factors affecting CT ability -Break -Group exercise on clinical scenario II -Summary, question and answer -Feedback on Day-Two, complete evaluation form and issue certificate of attendance

Our workshop will be conducted both in English and Cantonese. We will adopt various teaching methods to stimulate participants’ learning and interactions between the trainer and participants. One of the most beneficial aspects of the workshop will be the sharing of personal and collective experiences (Farrell, Ryan, and Langrick, 2001). Drawing learners’ past experiences will empower the current situation (Knowles, 1980 as cited in O’Connor, 2006). Activities will therefore include experience sharing from individuals and groups, case-

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sharing for self-reflection of individual work experiences, group discussions and group exercises on clinical scenarios. Multi-media, e.g., PowerPoint teaching, video and journals will be used to facilitate learning. Lecture is the oral transfer of knowledge from the teacher to students (Shor and Freire, 1987). Lecturing will still be critical since the facilitator will throw questions and lead discussions to challenge participants’ thinking instead of merely passing along information to them. Evans and Evans (2002, p. 25) suggested questionnaires to assist participants to reflect their own experiences about leadership, e.g., “What is the most outstanding quality of a leader?”. Individual participants will be invited to share their experiences to allow others to learn from his/her experiences. Participants can present a short story about their ineffective and effective leaders and why she/he is selected. Other participants in turn can give their opinions and comments. Reflection is vital in learning, and only learners themselves can reflect on their own experiences (Boud, Keogh, and Walker, 1998). Encouraging learners to use their experiences as a resource for their own or for others’ learning is valuable (Cheren, 1978; Cheren and Feldman, 1974; Mast and Van Atta, 1986 as cited in Congdon and French, 1995). Personal awareness and interpersonal awareness by interactive communication and sharing will be necessary to enhance a leaderful organization (Raelin, 2003). Active participation in groups should be encouraged to offer opportunities to establish contacts with members (Congdon and French, 1995). In addition, 15-minutes video sessions will be selected from the one-hour series “The Apprentice” by Pearl Channel of Television Broadcast Limited Hong Kong as a teaching medium. In this episode summary, the Gold Rush Team and the Synergy Team have to organize different activities to benefit charitable organizations. Both of the team leaders and teammates need to collaborate and compete with each other to achieve their goals. This episode demonstrates different leadership and critical thinking skills in team leaders and teammates in handling complex tasks. When people talk and listen to each other, alignments are created that can invent new realities in conversation and bring about action (Kofman and Senge, 1993). Small group discussions about the exchange of ideas regarding problems, approaches and multiple ways of perceiving situations encourage problem solving, decision making and critical thinking (Gaberson and Oerman, 2007). Participants may gain some insights into leadership and CT skills after seeing this video and having group discussions. Further, a group game will be designed for participants to exercise critical thinking skills. Sugar and Takacs (2000) suggested that games create an interactive learning experience to engage participants into active players and translate inactive information into playful learning experiences. By participating in a team game, teammates undergo a shared experience that can be observed, acknowledged, discussed and learned (Sugar and Takacs, 2000). The trainer will divide the participants into groups of six. Brainstorming a topic will be about identifying health determinants, risk factors and protective factors for patients with diabetes. The trainer will ask each group member to develop a list of as many items as possible suggested by the topics on the game sheet. Groups will receive one point for each different item and a bonus of five points for each item that no other groups have mentioned. The aims of this game include motivating participants to create as many options as possible and demonstrating a brainstorming method that helps critical thinking. The group with the highest number of points at the end of the game will win and gifts will be awarded to each group member. Learning will become participant-driven and each group will have its own lessons to learn. Once the game starts, the trainer will make sure that group members follow the rules and then

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monitor the group process. During the game’s process, the trainer will assist participants in looking at what effective and ineffective behaviours gain or hinder the achievement of goals. After the game, the trainer will help the participants reflect on learning from what they have done. A PowerPoint slide of the player instructions and rules for this game will be displayed. Gifts, five each for flip-chart size game sheets, flip chart boards and markers for groups will be prepared. In addition, clinical scenarios will be used to nurture CT skills and reinforce CT attributes in nursing practice. A scenario provides an assimilated opportunity to explore the challenges in a safe way (Farrell et al., 2001). Learning on or through the job is the best way for individual learning (Mumford, 1997). Participants will be facilitated in practising CT in clinical scenarios. Clinical Scenario I will be about setting up a new programme to promote safe drug administration to patients in a hospital. All participants will act as the organizing members for this programme. The trainer will invite the participants to consider what the issues will be, which qualities of leadership can help solve the expected problems and suggestions for this programme. The trainer and co-trainer will stay with the groups periodically to clarify queries and let the participants reflect on what they think and feel. Participants will be guided to assist them to use the CT skills previously shared in the workshop. For Clinical Scenario II, the trainer will invite a participant to provide a typical case scenario that other participants will likely encounter in the workplace. Through these group exercises, interactions among participants and trainer/co-trainer, practice of CT skills, experiential learning and active participation will be enhanced. A mentoring relationship will also be taken on by the participants to promote their leadership and CT development.

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PREPARATION In the preparatory stage of our workshop, a committee will be formed and led by the trainer. Members will include a co-trainer and support staff. The workshop outline (Appendix 1) and application form (Appendix 2) will be e-mailed to registered nurses of HA hospitals. Needs assessment will be done by inviting applicants to write down on the application form what they would expect to learn in the workshop. Putting participants’ needs as the top concern will be learner-centred and will use a self-empowerment approach. The budget for this workshop will be HK$80,000. The trainer will write to XX Laboratories and The XX Bank Foundation to apply for sponsorship for expenditures on hotel accommodations, breakfast and lunch, and return travel tickets from Hong Kong to Macau for participants and the trainer. Application fees paid by participants will cover the expenditures on stationery, sundries, handouts, materials and gifts for the game. A portable personal computer, PowerPoint materials, video, handouts, 10 markers, 50 sheets of flip chart paper, game materials and gifts will be prepared.

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APPLICATION PROCEDURES Applicants need to complete the application form and mail it with a cheque to the Human Resources Department of XX Hospital. The workshop outline (Appendix 1) and application form (Appendix 2) are attached. Successful applicants will be notified by letter and email.

EVALUATION METHODS Evaluation is an essential part of the educational process and it provides evidence of how well learning objectives are achieved (Morrison, 2003). Evaluation questionnaires (Appendix 3) focusing on participants’ satisfaction with the workshop and the trainer will be collected from participants before the end of workshop on day two. Since feedback provided insights into the effectiveness of skills shared (Farrell et al., 2001), participants’ verbal feedback will be collected during the workshop and before the end of each day’s session. Committee members’ feedbacks will also be collected to improve the workshop.

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DISCUSSION Since this is a two-day workshop, there can be considerably difficult for hospitals to release staff to attend. Limiting the number of staff from the same hospital and early notice to successful applicants may help facilitate attendance. Sponsorship offers will also be attractive to the applicants. In addition, a refund of part of the application fee and certificate of attendance for 100% attendance will attract participants and minimize the dropout rate in our workshop. Moreover, a comfortable environment in the hotel may provide a more relaxing and enjoyable atmosphere for participants. Our workshop will adopt a targeted approach to ensure meeting the needs of participants. It will be characterized by experiential learning and active participation. Learning is enhanced when there are opportunities to experience ideas and concepts in practice (Simpson, SkeltonGreen, Scott, and O’Brien-Pallas, 2002). Personal involvement is essential for the development of competence (Simpson et al., 2002). All workshop activities will link theories and practice. Participants will be offered opportunities in the form of games, experience sharing, group discussions and group exercises which help them bridge theory with practice. A collaborative approach by involving one trainer and one co-trainer in the workshop will allow more experiences to be shared from different clinical backgrounds (Farrell et al., 2001). Self-reflective learning will be supported throughout the workshop activities. All activities will challenge, stimulate and deliver value to help participants actively use CT in daily practice. Trainers and participants will be engaged as partners in learning. Knowles (1980 as cited in O’Connor, 2006) proposed that an effective learning environment is characterized by physical comfort, trust, respect, freedom of expression and acceptance of differences. Teachers should aim to provide an environment in which learners feel free to express themselves (Hutchison, 2003). The trainer will establish a positive learning atmosphere of respect for participants by encouragement of participation and giving constructive feedback. Room temperature, adequate ventilation and lighting, and seating

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arrangements will be addressed, as all of these enhance the learning environment (Hutchison, 2003). Leaders are responsible for learning as they need to expand their capabilities to shape their future (Senge, 1990). Having CT ability is essential in understanding personal relationships, envisioning alternatives and organizing a more productive workplace (Brookfield, 1987). This workshop will definitely benefit the participants in cultivating and developing CT skills.

CONCLUSION There is a great need for CT development among nurses due to significant changes in health care systems and workplace challenges. Supporting nurses in thinking critically is a priority in improving health care quality. Nurse leaders should play a vital role in promoting staff members to become expert critical thinkers. CT is a timely aspect of professional development and must be facilitated through creative methods. This workshop has highlighted needs, rationales, content, format and evaluation with an emphasis on innovative, interactive, experiential, and participatory approaches and a positive learning environment. Staff training will be significant in providing support to nurses for better practice in health care settings. Our workshop is justified since there is limited training developed in Hong Kong to promote CT skills in nurses.

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AUTHOR’S PROFILE May Li is an advanced practice nurse of the Community Psychiatric Nursing Service at United Christian Hospital, Hong Kong. She has attained a bachelor’s degree in health science (nursing) and a master’s degree in primary health care. She is currently an adjunct tutor and nursing specialty mentor.

REFERENCES Boud, D., Keogh, R., and Walker, D. (1998). What is reflection in learning? In D. Boud, R. Keogh, and D. Walker (Eds.), Reflection: Turning experience into learning (pp. 7-17). London: Kogan Page. Brookfield, S. (1987). Developing critical thinkers: Challenging adults to explore alternative ways of thinking and acting. San Francisco: Jossey-Bass. Carroll, P. (2006). Nursing leadership and management: A practical guide. New York: Thomson Delmar Learning. Cheung, C. K., and Chan, A. C. F. (2005). Philosophical foundations of eminent Hong Kong Chinese CEOs’ leadership. Journal of Business Ethics, 60, 47-62. Congdon, G., and French, P. (1995). Collegiality, adaptability and nursing faculty. Journal of Advanced Nursing, 21, 748-758. Evans, A. L., and Evans, V. (2002). Leadership workshop. Education, 123 (1), 18-30.

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Facione, N. C., and Facione, P. A. (1996). Externalizing the critical thinking in knowledge development and clinical judgment. Nursing Outlook, 44 (3), 129-136. Farrell, M., Ryan, S., and Langrick, B. (2001). “Breaking bad news” within a paediatric setting: an evaluation report of a collaborative education workshop to support health professional. Journal of Advanced Nursing, 36 (6), 765-775. Feltner, A., Mitchell, B., Norris, E., and Wolfle, C. (2008). Nurses’ views on the characteristics of an effective leader. AORN Journal, 87 (2), 363-372. Gaberson, K. B., and Oermann, M. H. (2007). Clinical teaching strategies in nursing (2nd ed.). New York: Springer Publishing Company. Hansten, R., H., and Washburn, M. J. (2000). Facilitating critical thinking. Journal for Nurses in Staff Development, 16 (1), 23-30. Hutchison, L. (2003). Educational environment. In P. Cantillon, L. Hutchinson, and D. Wood (Eds.), ABC of learning and teaching in medicine (pp. 39-41). London: BMJ Books. Ignatavicius, D. D. (2001). 6 critical thinking skills for at-the-bedside success. Nursing Management, 32 (1), 37-39. Kofman, F., and Senge, P. (1993). Communities of commitment: The heart of learning organizations. American Management Association. Kotter, J. P. (1990). A force for change: How leadership differs from management. New York: Macmillan. Lemire, J. A. (2005). Leader as critical thinker. In H. R. Feldman and M. J., Greenberg (Eds.), Educating nurses for leadership (pp. 51-66). New York: Springer Publishing Company. Lok, P., and Crawford, J. (2004). The effect of organizational culture and leadership style on job satisfaction and organizational commitment. The Journal of Management Development, 23 (4), 321-328. Martin, C. (2002). The theory of critical thinking of nursing. Nursing Education Perspectives, 23 (5), 243-247. McGuire, E., and Kennerly, S. M. (2006). Nurse managers as transformational and transactional leaders. Nursing Economics, 24 (4), 179-185. Morrison, J. (2003). Evaluation. In P. Cantillon, L. Hutchinson, and D. Wood (Eds.), ABC of learning and teaching in medicine (pp. 12-14). London: BMJ Books. Mumford, A. (1997). Individual and organizational learning: The pursuit of change. In C., Mabey, and P. Iles (Eds.), Managing learning (pp. 77-86). London: Thomson International Business Press. O’Connor, A. B. (2006). Clinical instruction and Evaluation: A teaching resource (2nd ed.). Boston: Jones and Bartlett Publishers. Raelin, J.A. (2003). Creating leaderful organizations: How to bring out leadership in everyone. San Francisco: Berrett-Koehler Publications Inc. Sellgren, S., Ekvall, G., and Tomson, G. (2006). Leadership styles in nursing management: Preferred and perceived. Journal of Nursing Management, 14 (5), 348-355. Senge, P. (1990). The leader’s new work: Building learning organizations. Sloan Management Review, Reprint Series, 32 (1), 7-23. Shor, I., and Freire, P. (1987). A pedagogy for liberation: Dialogues on transforming education. Sydney: Berlin and Garvey. Simpson, E., and Courtney, M. (2002). Critical thinking in nursing education: Literature review. International Journal of Nursing Practice. 8, 89-98.

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Simpson, B., Skelton-Green, J., Scott, J., and O’Brien-Pallas, L. (2002). Building capacity in nursing: Creating a leadership institute. Canadian Journal of Nursing Leadership, 15 (3), 22-27. Sugar, S., and Takacs G. (2000). Games that teach teams: 21 activities to super-charge your group. San Francisco: Jossey-Bass Pfeiffer. Vaughan-Wrobel, B. C., O’Sullivan, P., and Smith, L. (1997). Evaluating critical thinking skills of baccalaureate nursing students. Journal of Nursing Education, 36 (10), 485-488.

APPENDIX 1. TWO-DAY WORKSHOP ON “DEVELOPING CRITICAL THINKING IN NURSES” Workshop Outline Date: Time: Venue: Function Room 1, G/F, The XX Hotel, Macau Target participants: 30 Registered Nurses with more than five years’ working experience in hospitals belonging to the Hospital Authority.

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Trainer: Miss May Li, Advanced Practice Nurse of United Christian Hospital Co-trainer: Miss M. Leung, Nursing Officer of United Christian Hospital Workshop objectives: 1. To promote understanding by nurses on the importance of leadership and critical thinking in health care settings 2. To help nurses cultivate critical thinking 3. To enable nurses to learn critical thinking concepts 4. To facilitate nurses to practise critical thinking skills Language medium: English and Cantonese Accreditation: 12 CNE points and certificate of attendance for participants meeting 100% attendance. Cost: This workshop will be sponsored by XX Laboratories and The XX Bank Foundation. Applicants are only required to pay HK $500 and HK $300 is refundable for those with 100% attendance in the workshop. Accommodations, meals and return transport from Hong Kong to Macau will be included.

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APPENDIX 2. TWO-DAY WORKSHOP ON “DEVELOPING CRITICAL THINKING IN NURSES” Application Form Name:________________________(English) _____________________(Chinese) Title: Mr. / Mrs. / Ms / Miss Department/Hospital: _____________________________________________________ Date of nursing registration: ________________________________________________ Mailing Address: ________________________________________________________ _______________________________________________________________________ Email Address: __________________________________________________________ Telephone: _____________ (Home)_____________________(Office) _____________ Cost: This workshop will be sponsored by XX Laboratories and The XX Bank Foundation. Applicants are only required to pay HK $500 and HK $300 is refundable for those with 100% attendance in workshop. Accommodation, breakfast, lunch and return transport from HK to Macau will be arranged and included. I wish to attend the workshop. I enclosed a HK$ cheque no. _______________________ Bank: __________________ as registration payable to “Finance Department, XX Hospital”.

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Please mail completed registration form with cheque to: Human Resource Department, XX Hospital. Enquiry: Miss M. Li Deadline for registration: Successful applicants will be informed by letter and email on or before date XX. Details for transport and accommodation arrangement will be announced by mail and e-mail after deadline. Please give your suggestions of what you would expect to learn in this workshop: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________

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APPENDIX 3. TWO-DAY WORKSHOP ON “DEVELOPING CRITICAL THINKING IN NURSES” Evaluation Form Workshop Date: Name (optional): _________________________________________________________ Strongly Agree agree 1

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Neutral

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Disagree Strongly disagree

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5

Please circle the rating for each of the following items.

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1. Has this workshop achieved the objectives stated below? (a) Promoting understanding by nurses on the importance of leadership and critical thinking in health care settings. (b) Helping nurses to cultivate critical thinking thinking concepts and skills. (d) Facilitating nurses to practise critical thinking.

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2. Has the trainer facilitated your learning in this workshop?

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3. Is the workshop duration appropriate?

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4. Is the learning environment supportive?

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5. Are you satisfied with “Leadership and Implication”?

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6. Are you satisfied with “Concepts in critical thinking and leadership”?

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7. Are you satisfied with “Six critical thinking skills and implications”?

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8. Are you satisfied with “Factors affecting critical thinking ability”?

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9. What are the good points that are most useful and applicable in your workplace? ____________________________________________________________________________________ ____________________________________________________________________________________ 10. What topics should be added or deleted from this workshop? ____________________________________________________________________________________ ____________________________________________________________________________________

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11. Are there any areas for improvement? ____________________________________________________________________________________ ____________________________________________________________________________________

12. Are there any other comments? ____________________________________________________________________________________ ____________________________________________________________________________________

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Thank you for your valuable comments!

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In: Health Issues in Chinese Contexts, Volume 1 Editor: Zenobia C. Y. Chan

ISBN: 978-1-61209-385-7 © 2009 Nova Science Publishers, Inc.

Chapter 18

PRIMARY HEALTH CARE PROGRAM: OCCUPATIONAL SAFETY AND HEALTH FOR PEOPLE WITH INTELLECTUAL DISABILITIES Gary Wong and Zenobia C. Y. Chan

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ABSTRACT A two-year primary health care program, called “Work Safety Begins with Your Participation” has been planned. The program aims at empowering participants with occupational safety and health (OSH) knowledge and skills, and in helping their employers, colleagues, and families by providing them with a supportive environment. To meet the needs of the individuals, peers, family members, and the community, various intervention strategies can be implemented. This program includes an OSH educational group, a peer support group, individual job site visits and home visits, a participants’ daily log, and building a network of community resources for the participants. The program is also believed to help the communities manage issues of OSH for people with intellectual disabilities at work. With active participation, intersectoral collaboration, and addressing the equity of the participants, the program could facilitate the development of self-management skills for people with intellectual disabilities in OSH over the long run.

INTRODUCTION People with intellectual disabilities should be respected by their families, communities, and society. They have the right to enjoy the best holistic health care and the same rights afforded to all citizens, despite their intellectual differences. There are many studies that have proved the positive correlation between employment, quality of life, mental health, and family relationships. Full-time employment is considered the ultimate goal of vocational rehabilitation for people with intellectual disabilities. However, their occupational safety and health (OSH) issues are seldom addressed in the context of open employment. Workplace injuries and illnesses remain at high levels, and involve an unnecessary health burden worldwide. According to statistics from the World Health Organization and the International Labour Office, there were two million work-related deaths per year, causing 4–

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5% loss of gross domestic product. However, it has been established that only 10–15% of the workers are able to access the basic standard of occupational health services worldwide (World Health Organization, 2000). In Hong Kong, more than 44,000 incidences of occupational injury were recorded in 2005. The top three highest incidences of occupational injury and illness were observed among employees in the personal, retail, and manufacturing service industries (Occupational Safety and Health Council, 2005). These industries usually employ people with intellectual disabilities (Luftig and Muthert, 2005). Thus, people with intellectual disabilities are exposed to a high risk of occupational injury or illness. In the Chinese culture, employees with intellectual disabilities are a minority in the mainstream employment market, and their OSH needs are usually ignored. This makes them hesitant to express their concerns, even if they work in an unsafe working environment. In addition, being assertive is often misunderstood as challenging the supervisor, and this hinders them in expressing their OSH needs. Special concerns regarding occupational safety are essential for people with intellectual disabilities. They usually have difficulties in identifying, avoiding, or correcting hazards in the workplace (Agran and Madison, 1995). Unfortunately, many of them are not adequately prepared to respond appropriately to risks, and enter the workforce with little or no instruction in work safety (Holzberg, 2002). People with intellectual disabilities require special strategies in learning (Brown and Ganzglass, 1998). Mainstream OSH resources, such as OSH workshops, may not meet their learning characteristics. Therefore, a tailored-made OSH program for people with intellectual disabilities at work is essential. However, currently, this type of program is not common in Hong Kong.

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PROGRAM OBJECTIVES AND CONCEPTUAL FRAMEWORK A program called “Work Safety Begins with Your Participation” has been planned for employees with intellectual disabilities at work. The program aims to achieve the following: • • •

Empower participants’ OSH knowledge and skills Facilitate development of a supportive working environment by peers, families, and employers Develop support among participants

To have a comprehensive primary health care program, three basic components are essential, which include participation, equity, and intersectoral collaboration (Macdonald, 1993; Bryar, 2000; Pan American Health Organization, 2004). Active engagement of the participants is expected in four levels: implementation, benefits, program evaluation, and decision-making. Through active participation, the participants can have a sense of program ownership (McKenzie and Smeltzer, 2001). They can also have the power to decide their work habits in order to guarantee their occupational safety. Moreover, for people with intellectual disabilities, active participation from their families and employers is also expected. Through participation in various levels of programs, the

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employers would be able to understand the needs of their employees, and offer a safe working environment (Isernhagen, 2000; Price and Gerber, 2001). From the family perspective, people with intellectual disabilities often have difficulties in communicating with their families. They may not share their difficulties regarding their work, including the issues of OSH. When the families participate actively in the program, they can understand the needs of people with intellectual disabilities. For intersectoral collaboration, joint work with various health care and other sectors can be carried out to contribute to well-being (Macdonald, 1993; Isernhagen, 2000). The rationales for collaborating with other sectors owing to various factors influence the health of the individuals. From the equity perspective, the issues concerned include resource allocation, equal opportunities, and social justice (Macdonald, 1993). In resource allocation, 70% of the social welfare expenditure is spent on central social security assistance (Social Welfare Department, 2004). However, resources for sustaining people with intellectual disabilities in open employment and their OSH issues are limited. With respect to equal opportunities, currently there is no government policy in Hong Kong that requires employers to hire people with disabilities. Therefore, the majority of employers do not tend to employ people with disabilities. An unemployment rate of about 50% was observed among people with disabilities (Hong Kong Council of Social Service, 2005), and those who are employed usually work in unfavorable working conditions, such as prolonged working hours, low salary, and unsafe work environment. These working conditions cause a high risk of occupational injury or illness for people with intellectual disabilities. Thus, the focus of the program is on empowerment. One of the functions of the primary health care practitioner is to support individuals in making decisions about their health (Brassett-Harknett et al., 2006). This program is aimed at empowering the participants’ OSH knowledge and skills, communication skills with employers and colleagues, and the methods of finding support. These would help them to identify their own concerns, and to gain skills and confidence (Raeburn and Rootman; 1998). Furthermore, once they have been empowered, they will be able to manage their health and environment. They can also be initiated to take on the role of being their own manager (Bodenheimer, 2005), which could raise their self-efficacy and commitment to behavioral changes (Jaber et al., 2006). Teamwork in the planning, decision-making, implementation, evaluation, and monitoring stages of a primary health care program is essential (Macdonald, 1993; Mu and Royeen, 2004). In this program, a team with multiple professionals and representatives from participant’s side—their families and employers—can be set up. Team members with various types and degrees of skills and knowledge could thus be able to carry out their responsibilities more effectively. Hence, as a whole, the team could have greater impact on the individuals (Munro et al., 2002; Raymond, 2005).

NEEDS ASSESSMENT Prior to program implementation, a program team must be established. The team may include professionals such as nurses, social workers, and occupational therapists. Representatives from the participants’ families and employers can also be included, giving

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the participants power in decision-making and realizing their full potential. The participants act as the principal actor in the process, rather than recipients of the program (Macdonald, 1993). After forming the team, the needs assessment can be carried out, covering individual, environmental, and economic perspectives (Raymond, 2005). In the individual perspective, perceptions of occupational safety of the participants and their OSH knowledge as well as skills can be identified. Moreover, the risk factors in one’s lifestyle pattern, e.g., work habits of the participants, can also be identified (SPM Board of Directors, 1999). This facilitates the team in deciding on a program to meet the expectations and needs of each participant (Raymond, 2005). In the environmental perspective, the physical work environment, i.e., workstation design and physical work demands, can be identified (Isernhagen, 2000). The information could be useful in planning the program, as environmental hazards may cause occupational injury (Holzberg, 2002). The sociocultural context in the workplace and family can also be assessed. This includes the social support of the participants from their families, peers, colleagues, and supervisors. In the economic perspective, the economic situations of the participants are assessed. This is important in primary health care (Macdonald, 1993). It helps in identifying poverty, which is a key element related to ill health, in the context of social justice (Raymond, 2005). Several assessment strategies can be adopted in this program. Participants can be interviewed to identify their OSH skills, attitudes towards OSH, and their perception of jobs, employers, colleagues, and families. Moreover, a standardized assessment tool such as the OSHC assessment checklist can be adopted (Occupational Safety and Health Council, 2007). Interviews with the participants’ carers can be conducted by the social worker to understand the family and economic support of the participants. Job sites of the participants are visited to understand the physical, social, and cultural environment.

TARGET PARTICIPANTS A comprehensive primary health care program should be free, open, and accessible to all who need it (Macdonald, 1993). However, owing to limited resources, the target population can be limited to 15 participants with intellectual disabilities who are engaged in open employment. Before joining the program, all of the candidates should undergo screening. Participants with the highest risk or having history of occupational injury can be invited to join the program. The screening aims at maintaining equity in the program by identifying participants who have the highest need for empowerment with OSH knowledge and skills.

PROGRAM SITE In the equity dimension, participants who are in need of the program can access the service (Taket, 2005). Since the income of the participants would be limited, they may have difficulty paying travel fares needed to join the program. Hence, the program activities can

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take place in locations close to the participants. Space in non-government organizations (NGOs) facilities, such as the youth centers, can be booked for the program. Thus, the participants will be required to spend only limited travel fees (less than US$2) to attend the program. Individual needs assessment and follow-up can take place at the job site, and home visits can be conducted for discussion with participants’ families regarding economic issues.

SELF-MANAGEMENT STRATEGIES To manage the condition of the participants in an effective way, they can assume responsibility in taking an active role in managing their condition and directing others to assist them in the management (Rantz and Scott, 1999). The professionals can act as teachers, partners, and advisors aiding the participants to develop skilled health practices (Linnell, 2005). To reduce inequality among the participants with respect to economic, social, and environmental factors, together with health education and support (Lockyer and South, 2006), individuals, family, peers, and the community should be involved in the program (Taket, 2005).

INDIVIDUAL PERSPECTIVE

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OSH Educational Group The OSH educational group, particularly designed to suit the capacities of people with learning disabilities, can be conducted by the occupational therapists and nurses. Common topics such as basic ergonomics and safe body mechanics at work can be covered (Isernhagen, 2000). In addition, the safety officer of the Occupational Safety and Health Council (OSHC) and the labour officer of the Selective Placement Division of the Labour Department can be invited to share their ideas on common occupational diseases and labor legislation related to OSH, respectively, with the participants. Thus, the group aims at empowering OSH knowledge and skills of the participants.

Resource Networking To empower individuals, it is necessary to provide information on services and other available resources (Brassett-Harknett et al., 2006). Therefore, various community resources can be introduced, including the OSH promotion service of the Labour Department and Occupational Safety and Health Council. A self-learning package, such as a VCD and computer games provided by the Labour Department and the OSHC can be introduced (Occupational Safety and Health Council, 2006). Through these channels, the participants would have the right to decide their learning priorities and strategies to meet their own needs (Macdonald, 1993).

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Generalization of OSH Skills in the Workplace People with intellectual disabilities often face difficulties in the development of adaptive skills from the school-to-work environment (Stephensa et al., 2005). Hence, a job site visit can be conducted after the education group. During the visit, the team member can educate the participants on applying the OSH skills learned from the educational group to their workplace. Moreover, participants and their employers would be able to raise their concerns during the job site visit and solve the problems in the workplace.

Developing Individual Goal in OSH A daily logbook can be given to the participants, requiring them to develop concrete, achievable, and specific behavioral goals at the beginning of the program. Once the goals are established, the participants are required to monitor their actions by writing down their OSH performance daily. In the OSH educational or support group, participants can be allowed to share their progress in achieving the OSH goals. They can also be given feedback. This method could motivate them to change or sustain behavioral skills while they are actively involved and when prompt feedback is received (Nokes and Nwakeze, 2005). If the participants are unsuccessful in achieving the goals, barriers can be identified, and the groups can brainstorm for possible solutions to modify the goals (Holzberg, 2002; Linnell, 2005).

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Daily Monitoring of Personal Conditions Participants can be instructed to record their level of fatigue in the back and hands after work. Their records can be reviewed during program evaluation and group meetings. Participants must be made responsible for daily management of their condition and reporting their changes (Chodosh et al., 2005; Linnell, 2005).

FAMILY PERSPECTIVE Family plays an important role in providing primary health care to people with intellectual disabilities. Behavioral interventions and teaching carer skills could address carers’ attributes, beliefs, and emotions (Allen, 1999; Lloyd and Dallos, 2006). In addition, there is a consensus from government, families, and practitioners that a collaborative approach could empower people with intellectual disabilities (Cunningham and Davis, 1985; Lloyd and Dallos, 2006). Interventions must be culturally valid, relevant to the family’s circumstances, and timely. Families also need adequate social and physical resources (Lloyd and Dallos, 2006). To address the above criteria, the resources of the participants’ families are addressed in this program. A social worker can conduct home visits to explore the relationships between participants and their families. In addition, this aims to assess the quantity as well as quality

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of contact and the mode of communication among family members. A recent study found that the quality of life among people with intellectual disabilities, especially men, is related to the quality of contact with their mother (Rimmerman et al., 2005). If they have financial difficulties, social workers can assist them in applying for financial assistance from various funding bodies. These ensure that the participants have a supportive family environment in the program.

Family Support Group It has been found that families face emotional distress in caring for people with disabilities, and there is a need to support familial carers (Hare et al., 2004). Family distress is also associated with the level of social support (Dunn et al., 2001). To overcome this difficulty, a family support group has been planned. In the family support group, strategies for communicating with people with intellectual disabilities and detection of early signs and symptoms of occupational injury can be introduced. The families, therefore, could assist in early identification of occupational injury or illness. In addition, this facilitates families in supporting the participants throughout the program.

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PEER PERSPECTIVE A recent study found that people with intellectual disabilities are associated with poor peer relationships, social skill deficits, and communication problems (Heiman, 2000; Rimmerman et al., 2005; Weiss et al., 1999). Furthermore, they also show a lower level of self-esteem (Shaw-Zin et al., 2005). Therefore, providing peer supports could facilitate people with intellectual disabilities to overcome their difficulties in work. It is known that peer groups for people with intellectual disabilities could facilitate and provide them with support, and could give them confidence in social skills (Broderick et al., 2002). A regular peer support group can be conducted to facilitate the participants in sharing their difficulties at work. It is also a valuable chance for the participants to gain peer support and develop their self-management strategies. Group facilitators could raise the participants’ concerns in the group. The group provides opportunities for the participants to share information and ask questions (Jaber et al., 2006). Social connections among peers provide emotional support, a means of relaxation, and chances to voice various frustrations (Heiman, 2000).

COMMUNITY PERSPECTIVE Through community perspective, partnership with the participants’ employment can be developed. Employers can be invited to participate in the planning and decision-making of the program. Throughout the program, a close liaison with the employers can be developed to facilitate them in providing a safe working environment for the participants.

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Intersectoral collaboration with various health care and other sectors in the community can also be developed. Various sectors are included, because all of the sectors of society are required to take action to successfully achieve health promotion, health protection, and handling health inequalities (Taket, 2005). Collaboration with health care sectors, such as the hospital authority, could facilitate referral of participants for medical treatment when they show signs and symptoms of occupational injury or illness. For the non-health care sector, the social welfare department can be enlisted to facilitate referral of participants for financial assistance or other types of social services, such as family counseling, if necessary. Collaboration with the Labor Department and OSHC can provide updated OSH information to the participants, families, and employers. The NGOs can also be contacted to assist in program promotion and recruitment of participants. Mass media, such as District News, can be enlisted to promote the program as well as to report the outcome of the program.

DISCUSSION Since there is a marginalization among people with intellectual disabilities in full-time employment, this program could fill the knowledge gap by addressing the OSH needs among people with intellectual disabilities. Unlike traditional OSH promotion programs, this program focuses on partnerships among participants, their peers, families, and employers. This could provide a respectful, negotiated way of working together, which enables choices, participation, and equity (Bidmead and Cowley, 2005).

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Implications of the Program Implications of this program can be viewed on several levels. At the level of policy change, the results could facilitate the policymaker in considering putting resources into the empowerment of OSH skills for people with intellectual disabilities. This could improve the productivity of the company and reduce the costs of medical claims and absenteeism in the long run. At the level of clinical service, since no OSH program is tailored-made for people with intellectual disabilities, this program could facilitate them in learning the techniques. They could be empowered with OSH knowledge and skills by adopting techniques that facilitate their learning, such as involving co-workers and the use of VCD. It has been found that people with cognitive disabilities could benefit from intensive training, the involvement of co-workers, and information presented in the form of pictures or CD-ROM (Loy and Batiste, 2004). There are limited studies on the effectiveness of a health promotion program in the workplace (McLeroy et al., 1984). Evidence, especially for people with intellectual disabilities, is uncommon, and a sound evidence base is required. Further research to demonstrate the long-term benefits of the program could guide primary health care practitioners to implement the program. In addition, modifications of the program after implementation can be constructed to meet the concerns of the participants. Furthermore,

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primary health care practitioners could also periodically survey employees with intellectual disabilities to find out whether they require assistance in OSH, such as emergency handling techniques at work (Loy and Batiste, 2004).

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Limitations of the Program To implement this program, several limitations must be faced. Since collaboration among several sectors in this program are required, each having their own mode of operations and policies, it is not easy to develop common working modes and communication strategies within various sectors in a program (Isernhagen, 2000; Linnell, 2005). Close communication with various sectors can be initiated at the beginning of the program to understand the roles and expectations of one another, and develop a common time frame for the program. Since the program would last for two years, the drop-out rate may increase as the length of the program increases (Jaber et al., 2006). To reduce the drop-out rate, a meeting with participants prior to the beginning of the program, to explain the commitment and involvement needed among participants, may be helpful (Linnell, 2005). Regular group meetings, such as every three two six months over two years, may have the highest attrition rate (Jaber et al., 2006). Moreover, a deposit policy could be set up, which could increase the participants’ commitment and ownership on the program (McKenzie and Smeltzer, 2001). Active participation of the employers is essential in an effective OSH program (Isernhagen, 2000). However, it is difficult to guarantee that the employers would assume social responsibility in providing a supportive environment for people with intellectual disabilities. Representatives of the Labor Department could be invited to provide consultation on OSH ordinance (Labour Legislation, 2007) to the participants’ employers. In addition, information about the OSH Enhancement Scheme for Small and Medium Enterprises, launched by the OSHC, could be introduced to the employers to facilitate them in developing a safe working culture for the participants (Occupational Safety and Health Council, 2004). On the whole, it is necessary to deliver the message to the employers that reasonable adjustments should be made to allow employees with disabilities to work in a safe environment (Jones, 2007). To guarantee the long-term effectiveness of the program, it is necessary to identify evaluation tools to measure the long-term behavioral effects on the participants, problems in generalizing the program contents to other settings, strategies to maintain program benefits, and the need to combine physiological, psychological, and behavioral measures in evaluations (McLeroy et al., 1984).

CONCLUSION Based on the principles of primary health care, the OSH program for people with intellectual disabilities emphasizes active participation of the participants, collaboration with various sectors, and addressing equities. Through various interventions, the program is expected to empower the participants and to encourage them to adopt self-management strategies in their work. Furthermore, a supportive environment provided by the employers,

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colleagues, and families would also facilitate people with intellectual disabilities to be safe at their workplace.

AUTHOR’S BACKGROUND Gary Wong is an occupational therapist in Caritas Joyous Link, Caritas Rehabilitation Service, Caritas–Hong Kong. He can be reached by email at [email protected]

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Hong Kong Council of Social Service. (2005). Rehabilitation Service. Retrieved 10 May 2007 from, http://www.hkcss.org.hk/rh/employ_manual.htm. Isernhagen, D. D. (2000). A model system: Integrated work injury prevention and disability management. Work, 15, 87–94. Jaber, R., Braksmajer, A., and Trilling, J. (2006). Group visits for chronic illness care: Models, benefits and challenges. Family Practice Management, 13(1), 37-42. Jones, S. (2007). Weekly dilemma…Disability discrimination and health and safety. Personnel Today, 10 April 2007, 22. Labour Legislation. (2007). Occupational safety and health ordinance, chapter 509. Labour Department, The Government of the Hong Kong Special Administrative Region. Retrieved 5 May 2007 from, http://www.labour.gov.hk/eng/legislat/content4.htm. Linnell, K. (2005). Chronic disease self-management: One successful program. Nursing Economics, 23(4), 189-198. Lloyd, H., and Dallos, R. (2006). Solution-focuesd brief therapy with families who have a child with intellectual disabilities: A description of the content of intital sessions and the processes. Clinical child psychology and psychiatry, 11(3), 367-386. Lockyer, S., and South, J. (2006). Tackling inequalities through partnership working: the development of a neighbourhood project. Primary Health Care Research and Development,7, 50-59. Loy, B., and Batiste, L. C. (2004). Evacuation preparedness: Managing the safety of employees with disabilities. Occupational Health and Safety, 73(9), 112-117. Luftig, R. L., and Muthert, D. (2005). Patterns of employment and independent living of adult graduates with learning disabilities and mental retardation of an inclusionary high school vocational program. Research in Developmental Disabilities, 26, 317–325. Macdonald, J. J. (1993). Primary health care: Medicine in its place. Connecticut: Kumarian Press, Inc. McKenzie, J. F., and Smeltzer, J. L. (2001). Planning, implementing, and evaluating health promotion programs: a primer (third edition). Boston: Allyn and Bacon. McLeroy, K. R., Green, L. W., Mullen, K. D., and Foshee, V. (1984). Assessing the eeffects of health promotion in worksites: A review of the stress program evaluation. Health Education Quarterly, 11(4), 379-401. Mu, K., and Royeen, C. B. (2004). Interprofessional vs. interdisciplinary services in schoolbased occupational therapy practice. Occupational Therapy International, 11(4), 244247. Munro, N., Felton, A., and Mcintosh, C. (2002). Is multidisciplinary learning effective among those caring for people with diabetes? Diabetic Medicine, 19, 799-803. Nokes, K. M., and Nwakeze, P. C. (2005). Assessing self-management information needs of persons living with HIV/AIDS. Aids Patient Care and STDs, 19(9), 607-613. Occupational Safety and Health Council. (2004). OSH Enhancement Scheme for SME’s. Retrieved 12 May 2007 from, http://www.oshc.org.hk/eng/company/company04.asp. Occupational Safety and Health Council. (2005). Occupational Safety and Health Statistics. Retrieved 13 May 2007 from, http://www.oshc.org.hk/eng/resource/health.asp. Occupational Safety and Health Council. (2006). Manual Handling Operations Self-Learning Kit. Retrieved 20 May 2007 from, http://www.oshc.org.hk/others/moh/index.html.

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Occupational Safety and Health Council. (2007). Risk Assessment for Manual Handling Operations. Retrieved 6 May 2007 from, http://online.oshc.org.hk/assessment/MH/ user/en/index.asp. Pan American Health Organization. (2004). 45th Directing Council: Pan Health Care Remains Key. Retrieved 10 May 2007 from, http://www.paho.org/English/DD/PIN/ ptoday12_nov04.htm Price, L. A., and Gerber, P. J. (2001). At second glance: Employers and employees with learning disabilities in the Americans with disabilities act era. Journal of Learning Disabilities, 34(3), 202-210. Raeburn, J., and Rootman, I. (1998). People-centred health promotion. Chichester: John Wiley and Sons Ltd. Rantz, M. .J., and Scott, J. (1999). Promoting self-management of chronic illness: Possibilities for outcome evaluation of case management. In Cohen, E. L. Editor, and Back, V. D. Editor (Eds.), The outcome mandate: Case management in health care today (pp. 215-225).. St Louis: Mosby, Inc. Raymond, B. (2005). Health needs assessment, risk assessment and public health. In Sines, D. Editor, Appleby, F. Editor, and Frost, M. Editor (Eds.), Community health care nursing, (third edition, pp. 70-88). Oxford: Blackwell Publishing. Rimmerman, A., Yurkevich, O., Birger, M., and Araten-Bergman, T. (2005). Quality of life of men and women with borderline intelligence and attention deficit disorders living in community residences: A comparative study. Journal of Attention Disorder, 9(2), 435443. Shaw-Zin, B., Popali-Lehane, L., Chaplin, W., and Bergman, A. (2005). Adjustment, social skills and self-esteem in college students with symptoms of ADHD. Journal of Attention Disorders, 8(3), 109-120. Social Welfare Department. (2004). Social welfare department annual report. 2004. Retrieved 5 May 2007 from, http://www.swd.gov.hk/doc/annreport/0304annrepe.pdf. SPM Board of Directors. (1999). Ethics guidelines for the development and use of health assessments. In Hyner, G. C. Editor, Peterson, K. W. Editor, Travis, J. W. Editor, Dewey, J. E. Editor, Foerster, J. J. Editor, and Framer, E. M. Editor (Eds.), SPM handbook of health assessment tools (pp. xxiii). Pittsburgh, PA: The Society of Prospective Medicine. Stephensa, D. L.., Collinsa, M. D., and Dodderb, R. A. (2005). A longitudinal study of employment and skill acquisition among individuals with developmental disabilities. Research in Developmental Disabilities, 26, 469–486. Taket, A. (2005). Primary health care in the community. In Sines, D. Editor, Appleby, F. Editor, and Frost, M. Editor (Eds.), Community health care nursing, (third edition, pp. 26-40). Oxford: Blackwell Publishing. Weiss, M., Hechtman, L.T., and Weiss, G. (1999). ADHD in adulthood: A guide to current theory, diagnosis, and treatment. Baltimore: Johns Hopkins University Press. World Health Organization. (2000). Occupational Health. Retrieved 13 May 2007 from, http://www.who.int/occupational_health/en/.

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INDEX # 9/11, 93

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A AAT, 198 ABC, 213 abnormalities, 3 Aboriginal, 135 absorption, 28 academic, vii, 31, 32, 121 academic performance, 31 accessibility, 130, 141, 228 accidents, ix, 46 accommodation, 7, 14, 215 accreditation, 206 accuracy, 31, 61, 63, 189 achievement, 52, 208, 210 acid, 156 acquisition of knowledge, 207 activation, 84 acute, 7, 25, 69, 93, 97, 107, 168, 169, 174 acute stress, 69 Adams, 154 adaptability, 212 adaptation, 51, 116 additives, 34 ADHD, 230 adipose, 28 adipose tissue, 28 adjustment, 24, 58 administration, 210 administrative, 47, 93, 99, 109, 110, 163 administrators, 99 adolescent behavior, 29 adolescent patients, 192

adolescents, x, 27, 28, 29, 30, 31, 32, 33, 34, 35, 37, 38, 39, 40, 41, 42, 228 adult, 23, 56, 60, 88, 126, 135, 152, 229 adult education, 126 adult learning, 135 adult population, 60, 152 adulthood, 230 adults, 37, 39, 116, 128, 145, 146, 147, 149, 150, 152, 178, 212, 228 adverse event, 96 advertisement, 36 advertisements, 35, 36 advertising, 42, 142, 143 advocacy, 184 aerobic, 29 Africa, 189 afternoon, 55, 57, 177, 194 age, ix, x, 1, 2, 3, 7, 8, 11, 13, 15, 17, 21, 30, 34, 49, 72, 75, 76, 79, 82, 113, 139, 140, 142, 146, 150, 184, 191 ageing population, xi agent, 193, 196 agents, 96 aging, xi, 14, 17, 18, 25, 139, 145, 146, 162 aging population, 17, 139, 145 aid, 59, 173, 176 aiding, 223 air, 146 Albert Einstein, 207 alcohol, 42, 150 alcohol consumption, 150 alertness, 29 allergy, 57 aloe, 36 alternative, 15, 116, 119, 121, 126, 212 alternatives, 130, 155, 206, 212 alters, 96 ambassadors, 196 amendments, 144

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Index

American Cancer Society, 150, 153 amino, 28 amino acid, 28 amino acids, 28 anaerobic, 29 anaesthesia, 69, 81, 102 anaesthetists, 102 analgesia, 69, 88 analgesic, 81 anger, 5, 192 anorexia, 124 anorexia nervosa, 124 antecedents, 94 anthropology, 71 antibiotic, xiii, 187 antibiotic resistance, xiii, 187 antibiotics, xiii, 187 antisocial behavior, 29, 41 anxiety, xi, 4, 12, 57, 67, 68, 69, 70, 75, 77, 78, 79, 82, 83, 84, 85, 87, 88, 89, 163, 165, 168, 186 apathy, 111 appetite, 62, 160 application, 11, 13, 90, 105, 131, 169, 170, 183, 194, 210, 211 Arabia, 174 argument, 170 arousal, 68 arrest, 189 artery, 68 Asia, x, 27, 134, 146, 168 Asian, xii, 19, 28, 70, 104, 149 Asian countries, 104 assessment, xii, 16, 18, 22, 40, 63, 64, 70, 80, 83, 84, 86, 99, 100, 113, 114, 129, 130, 131, 132, 138, 141, 142, 143, 144, 149, 151, 152, 153, 177, 179, 180, 185, 210, 222, 223, 230 assessment tools, xii, 142, 143, 149, 230 assets, 104 assumptions, 47, 73, 121, 124, 170 atherosclerosis, 68 athletes, 29 atmosphere, 50, 51, 95, 161, 211 attachment, 42 attacks, 189 attitudes, x, xiii, 27, 28, 30, 31, 32, 33, 35, 39, 42, 48, 119, 191, 198, 222 attractiveness, 34 Australia, 64, 89, 122, 146 authority, 184, 205, 226 autism, 228 autistic spectrum disorders, 228 autonomy, 103, 106, 111, 113, 115, 140, 205 availability, 10, 23, 129, 130, 141, 177

avian flu, 168, 171 avian influenza, 97, 171 awareness, xi, 46, 55, 60, 62, 68, 94, 97, 101, 112, 114, 120, 127, 128, 130, 132, 140, 141, 142, 143, 145, 188, 194, 195, 198, 209, 228

B babies, xii, 173, 174, 175, 176, 178, 179, 180, 181, 182, 195 back pain, 160 background information, 177 bargaining, 192 barrier, 174 barriers, 30, 33, 38, 106, 112, 129, 135, 153, 177, 224 beef, 136, 150, 155 behavior, x, xii, 6, 13, 14, 27, 29, 31, 33, 35, 37, 39, 40, 41, 42, 63, 64, 89, 139, 140, 142, 145, 151, 152, 181, 198 behavioral change, 144, 145, 149, 150, 153, 221 behavioral effects, 227 behavioral modification, 63 behaviorism, xiii, 173, 178, 179, 180, 182, 183 behaviours, 45, 210 Beijing, 190 beliefs, xi, 33, 35, 38, 109, 110, 111, 114, 120, 188, 189, 194, 195, 224 benefits, 32, 33, 35, 62, 69, 86, 182, 183, 220, 226, 227, 229 benign, 75, 77 bereavement, xiii, 191, 192, 193, 194, 196, 197, 198, 199, 200, 202 beverages, x, 27, 29, 30, 32, 33, 34, 35, 36, 37, 39, 40, 41 bias, 15, 16, 123, 125, 145 bioterrorism, xiii, 187 bird flu, 169 birds, 168 birth, 14, 45, 140, 185 birth rate, 14 births, 186 bladder, 3 bleeding, 95 blood, 68, 131, 156, 189 blood glucose, 131 blood pressure, 68, 131 body fat, 156 body image, 41 body language, 177, 178, 180 body weight, 28, 53 bonding, 15, 38, 86 bonds, 115

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Index bonus, 115, 209 borderline, 230 borrowing, 34 Boston, 105, 167, 170, 185, 213, 229 bottom-up, 141 bowel, 3, 151, 156 boys, 29, 30, 34, 35, 39 brain, 22 brain injury, 22 brainstorming, 114, 152, 184, 209 Brazil, 174 breakfast, 54, 57, 156, 210, 215 breathing, 78, 102 Britain, 14 Buddhism, 79 Buddhist, 200 buffer, 110 buildings, 94 bun, 156, 178 burn, 15, 99 burnout, 52, 161, 163, 165 buses, 127

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C cables, 101 calcium, 28, 36 calorie, 155 cancer, xii, 19, 23, 55, 75, 77, 79, 90, 145, 149, 150, 151, 153, 154, 156 cancer cells, 150 candidates, 222 capacity, 7, 101, 119, 122, 214 carbohydrates, 54, 55 carcinoma, 72, 75, 76 cardiac catheterization, 88, 90 cardiovascular disease, 25, 46, 128, 129 caregiver, 4, 18, 19, 21, 71, 84 caregivers, 2, 4, 5, 7, 11, 13, 16, 17, 18, 19, 20, 21, 22, 23, 24 caregiving, 10, 11, 15, 18, 20, 21, 22, 23, 24 carrier, 189 case study, x, 47, 61, 63, 67, 71, 72, 74, 90, 110, 125 catalyst, 112 catecholamine, 68 Catecholamines, 90 category b, 73 catheterization, 88, 90 Catholic, 185, 200 Caucasians, 2 causal relationship, 47 CDC, 168 cell, 28, 76

233

Census, 21, 44, 65, 142, 146 Centers for Disease Control, 170 cereals, 136, 151, 156 cerebrovascular, ix cerebrovascular accident, ix certificate, 194, 208, 211, 214 channels, 223 charitable organizations, 209 cheese, 54, 136, 155 chemical reactions, 28 chemotherapy, 75 chicken, 150, 155 child abuse, 173, 175 childcare, 174 child-centered, 194 childhood, 36, 41, 42 children, xii, xiii, 5, 8, 9, 10, 28, 29, 33, 40, 41, 55, 62, 75, 84, 85, 163, 173, 174, 175, 179, 191, 194, 195, 199, 228 China, 5, 17, 19, 25, 34, 35, 38, 42, 70, 102, 167, 171, 185, 186, 197 China Daily, 186 Chinese medicine, 30, 41 Chinese women, 42 chocolate, 155 cholesterol, 68, 156 chopping, 78 CHP, 128, 129, 140 chronic disease, 24, 55, 128, 156, 162 chronic diseases, 55, 128, 156, 162 chronic illness, 11, 19, 25, 39, 229, 230 chronic stress, 159 chronically ill, 10, 19 chrysanthemum, 35 CINAHL, 68 citizens, 102, 103, 120, 219 citrus, 28 classes, 85, 141, 144, 162 classroom, ix, 121 classrooms, 31 clients, xiii, 16, 51, 82, 84, 85, 86, 87, 95, 103, 112, 191, 192, 193, 194, 195, 196, 200, 228 clinical judgment, 213 clinical psychology, 25 clinical trial, 151 clinician, 178 clusters, 97, 114 CNS, 116 Co, v, 1, 58, 111, 214 Cochrane, 20, 164 codes, 75 coding, x, 32, 43, 49, 73 coercion, 111, 113

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Index

coffee, 55 cognition, 89 cognitive, xii, 3, 63, 64, 139, 140, 144, 145, 152, 207, 226 cognitive function, 3 cognitive process, 207 cohesion, 30, 38, 115, 175 cohesiveness, 114, 169 cohort, 25 Coke, 36, 37 collaboration, 113, 114, 128, 130, 133, 134, 140, 141, 142, 219, 220, 221, 226, 227, 228 college students, 230 colon, 150, 153, 154 colon cancer, 150, 153, 154 colorectal cancer, xii, 149, 150, 151, 153, 154 Columbia, 126 Columbia University, 126 communication, xiii, 48, 51, 52, 96, 100, 102, 103, 111, 112, 120, 143, 160, 161, 163, 169, 170, 173, 175, 176, 177, 182, 183, 184, 185, 188, 194, 197, 209, 221, 225, 227 communication skills, 100, 103, 169, 175, 221 communication strategies, 227 communities, xiv, 24, 55, 60, 102, 135, 146, 219 community, xi, xiv, 5, 11, 14, 17, 21, 24, 25, 53, 55, 56, 61, 63, 77, 97, 102, 109, 110, 113, 114, 116, 117, 121, 129, 130, 132, 133, 134, 136, 140, 141, 142, 143, 144, 145, 146, 147, 149, 151, 153, 160, 163, 165, 219, 223, 225, 226, 230 community service, 5, 11, 141 compensation, 45, 100 competence, 211 competency, 193, 198 competition, xiii, 112, 191, 192, 197 competitiveness, 206 complexity, 8 compliance, 86 complications, 67, 69, 78, 81, 83, 84, 86, 87, 95 components, 35, 101, 120, 129, 130, 131, 150, 196, 220 composition, 153 concentration, 9, 11, 29, 96 conception, 6, 159 conceptualization, 120, 124, 168, 170, 175 concrete, 177, 179, 180, 224 confidence, 78, 80, 98, 112, 113, 150, 194, 195, 206, 221, 225 confidence interval, 150 confidentiality, 31, 73, 142, 177 confinement, 3, 4, 11, 12 conflict, 4 confrontation, 180

Confucianism, 5, 13 Congress, iv congruence, 178 Connecticut, 229 consciousness, 5, 6, 35, 39, 60, 153 consensus, 224 consent, 31, 73, 74, 87, 91, 175, 176, 177 consolidation, 98 constraints, 34, 48, 61, 62, 67 construction, 126 consumption, x, 27, 28, 30, 32, 33, 35, 36, 40, 41, 42, 43, 44, 46, 54, 55, 57, 59, 61, 84, 150, 151, 152, 154, 168 consumption habits, x, 27, 28, 30 consumption patterns, x, 27, 30 contaminated food, 168 content analysis, ix, x, xi, 1, 31, 43, 48, 64, 67, 73 contingency, 97, 102 continuity, 2, 16 contractors, 101 contracts, 174 control, xii, 8, 12, 37, 78, 79, 95, 96, 97, 100, 102, 111, 120, 141, 149, 163, 168 conversion, 103 cooking, 9, 38, 58, 126, 134, 155, 163 Coping, 165 coping strategies, 5, 23, 86, 159, 164 corn, 136 corona, 168 coronary artery disease, 68 correlation, 150 correlations, 39 cortisol, 68 cost saving, 88 costs, 34, 79, 120, 140, 183, 226 cough, 168 counseling, vii, xii, xiii, 162, 173, 175, 176, 177, 180, 183, 184, 185, 186, 191, 195, 197, 199, 226 covering, 222 creativity, ix, 111 credibility, 8, 47, 63, 168 credit, 113 crisis intervention, 94, 95, 106, 168 crisis management, ix, xi, xii, 93, 94, 95, 97, 98, 99, 100, 101, 102, 103, 104, 106, 167, 168, 169, 170, 171, 188, 189 critical thinking, xiii, 103, 121, 124, 205, 206, 209, 213, 214, 216 critical thinking skills, 209, 213, 214 cross-cultural, 165 cross-sectional, 142 crying, 39 CT, xiii, 205, 206, 207, 208, 209, 210, 211, 212

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Index cues, 73 cultural beliefs, 194, 195 cultural factors, 56 Cultural Revolution, 70 culture, ix, 1, 2, 5, 6, 13, 14, 17, 19, 20, 23, 38, 51, 52, 53, 64, 77, 84, 94, 95, 104, 106, 110, 111, 112, 114, 134, 141, 181, 185, 189, 220, 227 curriculum, 104, 105, 110 customers, 51, 52, 55, 196 cycles, 8 cycling, 163

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D daily living, 3, 23, 78, 140, 143, 145 dairy, 136 dairy products, 136 dances, 126 danger, 94, 102 data analysis, xi, 7, 18, 48, 50, 67, 73, 87, 125 data collection, ix, 1, 7, 15, 30, 31, 32, 47, 61, 123 database, 131, 198 death, xiii, 2, 4, 15, 21, 78, 84, 191, 192, 193, 194, 195, 196, 197, 198, 201 deaths, 2, 128, 198, 219 decay, 36 decision making, 14, 111, 112, 114, 207, 209 decision-making process, 109 decisions, 102, 111, 113, 180, 205, 207, 221 Decoding, 41 defense, 151 deficit, 2, 72, 230 deficits, 84, 225 definition, x, 35, 43, 50, 53, 54, 106, 121, 130, 179, 184, 228 delivery, 58, 59, 70, 75, 82, 86, 195 dementia, 19 democracy, 206 denial, 192 Denmark, 29, 33, 41, 122, 136, 147 density, 142 dental caries, 36 depressed, 4, 13, 57, 162 depression, 3, 4, 12, 21, 23, 24, 52, 56, 57, 78, 144, 192 depressive symptoms, 174 deprivation, 45 destruction, 102 detection, 2, 120, 225 developmental disabilities, 230 developmental process, 207 developmental psychology, 18 diabetes, 36, 55, 68, 128, 209, 229

235

dialysis, 22, 89 diet, x, xi, xii, 29, 37, 43, 44, 46, 48, 50, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 65, 77, 84, 87, 127, 128, 129, 131, 132, 133, 134, 137, 138, 143, 149, 154 dietary, xii, 28, 46, 53, 56, 129, 143, 149, 150, 151, 153, 154 dietary behaviour, 151 dietary fat, 150 dietary habits, 143 dietary intake, 28, 53 dieting, 127, 128, 130, 131, 132, 133 diets, 28, 42, 128, 129, 151 digestion, 28, 57 dignity, 197 disability, 2, 4, 12, 25, 78, 84, 120, 228, 229 disabled, 24, 78 disaster, 106 discipline, 31, 70, 199 disclosure, 180 discomfort, 45, 77, 201 discrimination, 229 diseases, 25, 35, 57, 81, 95, 128, 129, 187, 189, 223 disorder, 63, 88 displacement, 28 disputes, 106, 174 disseminate, 109, 112 distraction, 177 distress, 68, 102, 201, 225 distribution, 32 diversification, 62 diversity, 111, 123, 165 division, 5, 125 division of labor, 5 divorce, 15 doctors, 23, 79, 100, 102, 113, 115, 120 drinking, 3, 33, 34, 35, 36, 37, 38, 40, 41, 42 drugs, 81 duration, 31, 163, 177, 203, 216 duties, 73, 179

E early warning, 167 ears, 28 earthquake, 167 eating, x, xi, 3, 43, 44, 46, 48, 50, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 64, 65, 126, 128, 129, 131, 132, 133, 135, 137, 150, 151, 155, 156, 163 Ebola, 189, 190 economic status, 2 Education, v, 24, 41, 49, 50, 63, 64, 67, 69, 81, 82, 85, 86, 87, 88, 89, 90, 105, 117, 126, 135, 145,

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236

Index

153, 154, 163, 165, 187, 190, 197, 212, 213, 214, 229 education reform, 163 educational process, 211 educators, ix, 121, 165 egg, 55 ego, 95 elderly, xi, xii, 2, 6, 13, 14, 15, 17, 18, 19, 22, 23, 116, 128, 139, 140, 142, 143, 144, 145, 146, 173, 174, 175, 176, 178, 180 elderly population, 2, 17, 140, 142, 146 elders, 22, 82, 139, 140, 141, 142, 143, 144, 145 electrocardiogram, 97 email, 197, 211, 215, 228 emigration, 14 emotion, 9 emotional, 9, 10, 19, 21, 39, 42, 52, 84, 123, 124, 159, 177, 194, 225 emotional distress, 225 emotional exhaustion, 159 emotional reactions, 84 emotions, 42, 78, 99, 100, 102, 114, 123, 124, 188, 224 empathy, 178, 179, 180 employees, x, 43, 44, 45, 46, 47, 48, 52, 59, 60, 65, 99, 101, 220, 221, 227, 228, 229, 230 employers, xiv, 45, 52, 59, 60, 79, 173, 219, 220, 221, 222, 224, 225, 226, 227 employment, xii, 65, 173, 174, 219, 220, 221, 222, 225, 226, 229, 230 employment relationship, 173 empowered, 128, 141, 153, 182, 196, 207, 221, 226 empowerment, 55, 112, 115, 117, 120, 140, 141, 151, 153, 159, 193, 198, 206, 221, 222, 226 encouragement, 33, 112, 114, 132, 133, 211 end-of-life care, 193, 198 endoscopic retrograde cholangiopancreatography, 90 endurance, 13, 29, 144 energy, 28, 29, 35, 54, 128, 152 energy consumption, 54 engagement, 3, 50, 220 England, 63 enslavement, 116, 198 enthusiasm, 113 environment, xi, xiv, 4, 12, 32, 50, 52, 80, 81, 84, 85, 93, 95, 96, 97, 99, 101, 103, 104, 105, 140, 141, 143, 168, 177, 193, 203, 211, 213, 219, 220, 221, 222, 225, 227, 228 environmental factors, 6, 223 environmental influences, 41 epidemic, xii, xiii, 149, 187, 188 epidemics, 189 epistemological, 19

epistemology, 24 equality, 38 equilibrium, 152 equities, 227 equity, 31, 141, 144, 145, 196, 219, 220, 221, 222, 226 ergonomics, 223 essay question, 48 estimating, 152 ethics, 31, 74, 106 ethnic diversity, 165 ethnicity, 7, 174 etiquette, 177 Europe, 168 evacuation, 101 evening, xii, 57, 167 examinations, 29, 163 excuse, 62 exercise, 11, 52, 58, 59, 64, 103, 135, 137, 143, 144, 146, 152, 171, 208, 209 expenditures, 210 expert, iv, 142, 212 expertise, 120, 159 exploitation, 189 exposure, 151 external validity, 47 eye contact, 100, 177, 178, 179 eyes, 80, 178

F facial expression, 74, 100, 177, 178 facilitators, 225 factorial, 6 faecal, 150 failure, 78, 207 faith, 188 familial, 168, 225 family, vii, ix, xii, xiii, xiv, 1, 3, 5, 6, 7, 9, 10, 12, 14, 16, 17, 19, 20, 21, 22, 23, 24, 29, 30, 33, 38, 39, 41, 45, 52, 53, 58, 63, 72, 77, 78, 79, 80, 83, 84, 87, 91, 121, 124, 134, 143, 159, 161, 162, 163, 168, 173, 174, 175, 176, 177, 178, 179, 180, 181, 182, 183, 184, 185, 191, 192, 194, 195, 197, 219, 221, 222, 223, 224, 225, 226, 228 family conflict, 45 family environment, 225 family functioning, 174 family income, 12 family life, 52, 184 family medicine, 87

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Index family members, xiii, xiv, 24, 38, 39, 77, 80, 83, 84, 121, 124, 162, 174, 175, 184, 191, 192, 194, 219, 225 family physician, 41 family relationships, 45, 63, 219 family structure, ix, 1, 14, 17 family studies, vii family support, 5, 14, 143, 225 family system, 124 family therapy, 124 fast food, 55, 58, 59, 128, 129, 130 fat, 28, 53, 54, 58, 129, 136, 150, 151, 152, 154, 155, 156, 157 fatigue, 9, 11, 46, 77, 160, 162, 224 fear, 4, 5, 82, 99, 189 fears, 13, 99, 185 February, xii, 146, 167, 168, 185 fee, 211 feedback, 51, 111, 114, 120, 121, 144, 163, 164, 170, 211, 224 feeding, 9, 186 feelings, xii, 5, 15, 39, 53, 56, 57, 59, 75, 99, 111, 139, 144, 159, 170, 181, 194, 201 fees, 185, 210, 223 feet, 146, 175, 177 females, ix, 1, 4, 72, 84, 85, 124, 129, 134, 140, 150 feminism, 6 feminist, ix, 1, 5, 6, 8, 20, 21, 22, 23, 24, 124, 126 fever, 168 fiber, 54 fiber content, 54 filial piety, 6, 14 film, 188, 189 films, xiii, 187, 188, 189 financial loss, 93 financial problems, 4 financial resources, 141 financial support, 79, 95, 96, 174 financing, 140 fire, xi, 93, 94, 96, 98, 100, 101, 102, 103, 104, 105 fire event, 103 fires, 96, 98, 101, 103 firms, 51 fish, 136, 150, 155 fitness, 59, 143 flavor, 37, 157 flexibility, 113, 144 flight, 174 flow, 31 fluid, 28, 30, 77 focus group, x, 27, 30, 31, 32, 35, 41, 61 focus groups, 30, 41, 61 focusing, xii, 55, 95, 149, 177, 180, 211

237

folate, 28, 154 food, x, xi, xii, 12, 34, 35, 43, 44, 54, 55, 56, 57, 58, 59, 61, 62, 63, 78, 81, 83, 87, 121, 127, 128, 129, 130, 132, 133, 136, 149, 151, 152, 154, 155, 156, 157, 168, 169, 170, 175, 184 food intake, xii, 54, 128, 149, 151 food poisoning, 168, 169, 170 food safety, 121 football, 163 footwear, 143 Ford, 119, 122 forgiveness, 125 formal education, 9 foul language, 189 fragmentation, 121 framing, 111 freedom, 8, 37, 113, 211 Freud, 95 friendship, 228 fruit juice, 29, 35 fruits, 55, 60, 128, 129, 136, 151, 155, 156 frustration, xiii, 11, 57, 111, 191, 194, 201 frying, 155 fulfillment, 196 funding, xi, 67, 87, 140, 225

G gait, 145 games, 209, 211, 223 gender, 5, 6, 7, 20, 32, 39, 125, 126, 174 gender differences, 39 generalizability, 154 generation, 70, 85, 170 genetics, xiii, 187 Geneva, 136, 147 geography, 130 geriatric, 109, 110, 113 Germany, 165 gestalt, 173, 182, 183 Gestalt, xiii gift, 195 gifts, 209, 210 ginseng, 87 girls, 29, 30, 34, 39 glucose, 28, 131 goal setting, 179, 180, 182, 183, 184 goals, xi, xiii, 74, 86, 109, 110, 113, 115, 119, 142, 173, 180, 183, 184, 206, 209, 210, 224 God, 79 government, x, xi, 5, 12, 17, 43, 52, 55, 56, 60, 62, 94, 120, 127, 128, 129, 131, 132, 134, 140, 141, 142, 144, 184, 189, 221, 223, 224

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government policy, 221 grain, 156 grains, 136, 156 grandparents, 38, 179 grassroots, 188 Great Leap Forward, 70 grief, xiii, 168, 191, 192, 194, 199 gross domestic product, 220 groups, xi, 16, 30, 31, 32, 61, 62, 87, 94, 97, 102, 109, 111, 114, 141, 142, 144, 152, 161, 169, 170, 208, 209, 210, 224, 225 growth, 2, 35, 111, 140, 197 Guangdong, 197 guardian, 64 guidance, 61, 103, 104, 111, 165 guidelines, 31, 46, 48, 53, 56, 84, 94, 95, 96, 98, 100, 113, 159, 197, 230 guilty, 5, 11, 162

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H handling, 9, 51, 95, 98, 101, 103, 159, 169, 195, 209, 226, 227 hands, 100, 178, 181, 224 hanging, 18, 53 happiness, 37 harassment, 174 harm, xi, 5, 39, 93, 96, 97, 103, 106, 113, 184 harmful effects, 55 harmony, 5, 39, 113, 184 Harvard, 93, 94, 99, 100, 101, 105 hazards, 96, 101, 104, 220, 222 headache, 10, 11, 56, 57, 160 healing, 110 health care, vii, ix, x, xi, xii, xiii, 1, 2, 6, 10, 11, 14, 16, 17, 24, 46, 64, 68, 69, 71, 72, 89, 93, 94, 95, 96, 97, 102, 103, 104, 105, 109, 110, 116, 119, 120, 122, 123, 134, 136, 139, 140, 141, 142, 147, 151, 153, 159, 167, 168, 169, 170, 171, 196, 197, 205, 206, 208, 212, 214, 216, 219, 220, 221, 222, 224, 226, 227, 228, 229, 230 health care professionals, x, xi, 1, 6, 10, 16, 17, 71, 93, 95, 102, 103, 104, 153 health care sector, 2, 95, 226 health care system, 2, 69, 97, 110, 212 health care workers, 102, 168 health education, xii, 40, 41, 68, 86, 104, 120, 122, 149, 151, 160, 161, 163, 164, 167, 184, 223 health effects, 29, 33 health information, 60, 132 health problems, 3, 44, 56, 57, 59, 62, 69, 84, 96, 143 health psychology, 63

health services, 42, 114, 115, 121, 144, 220 health status, 28, 39, 46, 86 healthfulness, 35, 36, 37, 39 Healthy eating, 64 Heart, vi, xiii, 55, 68, 72, 88, 90, 95, 97, 135, 154, 191, 193, 196, 197, 213 heart disease, 55, 68 heart rate, 68, 97 height, 36, 131 helplessness, 188 Hendra, 4, 21 herbal, 30 high risk, 4, 39, 95, 114, 220, 221 high school, 163, 229 high tech, 192 high-fat, 128, 150, 155, 156, 157 high-level, 152 hip, 15, 20, 89, 90, 111, 113 hip replacement, 89, 90 histologic type, 72 HIV, xiii, 122, 187, 229 HIV/AIDS, 122, 229 HK, 21, 34, 56, 127, 128, 129, 131, 132, 140, 142, 143, 144, 145, 198, 199, 210, 214, 215 holistic, 68, 120, 167, 197, 219 holistic care, 68 Holland, 194, 198 homebound, 12, 14 homeless, 126 homesickness, 174, 175 homework, 162 homogenous, 15, 174 honesty, 199, 207 hopelessness, 77, 188 hospice, 191 hospital, xi, 7, 8, 14, 15, 17, 18, 20, 21, 23, 67, 75, 77, 78, 81, 83, 87, 88, 90, 93, 94, 95, 99, 100, 102, 103, 104, 110, 114, 134, 194, 195, 199, 210, 211, 226 hospitalization, 2, 67, 90 hospitalized, 95 hospitals, xiii, 17, 67, 97, 102, 110, 113, 114, 193, 194, 196, 197, 202, 205, 206, 210, 211, 214 host, 175 House, 20, 116, 197, 199 household, 7, 14, 38, 151, 152, 174 housing, 14 HPA, 68 HPA axis, 68 human, xi, 3, 5, 6, 13, 15, 22, 23, 40, 46, 51, 79, 93, 94, 95, 102, 103, 111, 112, 113, 119, 127, 168, 184, 185, 190 human activity, xi

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Index human experience, 6, 46 human resources, 51, 112 human rights, 119 human values, 15 humanitarian, 168 humanity, 13 humans, 28, 79, 168 humorous, 188 Hurricane Katrina, 102 husband, xii, 5, 9, 10, 11, 12, 13, 24, 45, 75, 77, 79, 80, 84, 85, 134, 162, 173, 174, 176, 180, 181, 182, 183, 184 hydration, 28 hygiene, 34 hypertension, 55, 68, 128 hypothesis, 150

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I ice, 85, 87, 136, 155 id, 17, 21, 39, 68, 72, 102, 106, 153, 170 identification, 88, 102, 195, 225 identity, 125, 126, 165 ideology, 53 illness care, 229 imagery, 69 images, 112 immunological, 87 implementation, xi, 65, 87, 99, 101, 109, 112, 132, 140, 149, 169, 220, 221, 226 inactive, 209 incidence, xiii, 2, 96, 134, 140, 150, 187 inclusion, 7, 15 income, 12, 122, 174, 222 income inequality, 122 independence, 62 Indiana, 20 indication, 39 indicators, 68 Indigenous, 135 Indonesia, 174, 176, 179 industrial, 44, 186 industry, 94 inequality, 223 infants, 193 infection, 95, 97, 100, 102, 168 infectious, 97, 102, 167, 169, 170, 187, 189 infectious disease, 97, 102, 167, 169, 170, 187, 189 infectious diseases, 97, 102, 167, 169, 170, 187, 189 inferences, 31 inflammatory, 150 inflammatory bowel disease, 150 influenza, 97, 105, 168

239

information seeking, xi, 14, 67 information systems, 112 Information Technology, 116, 198 informed consent, 91 ingestion, 150 inherited, 77 initiation, 8, 36 injuries, 45, 46, 62, 63, 95, 139, 140, 219, 228 injury, iv, 4, 220, 221, 222, 225, 226, 229 Innovation, 106 insight, x, 14, 43, 119, 164, 194, 195 insomnia, 160 inspection, 101 inspiration, 87, 124 instability, 52, 168 instinct, 13 institutions, 140 instruction, xi, 67, 70, 83, 84, 89, 90, 213, 220 instruments, 95, 96, 97 integration, xii, 104, 119, 173, 228 integrity, 141 intellectual disabilities, xiv, 219, 220, 221, 222, 224, 225, 226, 227, 229 intelligence, 230 intensity, 68, 72, 151, 163 intentions, 65, 200 interaction, ix, 1, 13, 30, 77, 82, 84, 87 interactions, 88, 124, 184, 208, 210 interdisciplinary, 165, 229 intergenerational, 21, 185 internal validity, 47 International Labour Office, 219 International Trade, 64 Internet, 82, 131, 183 interpersonal relations, 3, 15, 207 interpersonal relationships, 3, 207 interpretation, 6, 15, 46, 73, 124, 183, 188, 207 interrelationships, 121 intervention, xiv, 89, 90, 103, 106, 129, 135, 146, 151, 153, 168, 219 intervention strategies, xiv, 219 interview, xii, 7, 8, 30, 31, 32, 34, 48, 61, 67, 72, 73, 74, 75, 87, 90, 91, 138, 143, 144, 173, 174, 175, 176, 177, 178, 183, 184 interviews, ix, xi, 1, 2, 7, 15, 30, 31, 32, 35, 41, 61, 73, 124, 130, 133, 142, 143, 184 intimacy, 190 invasive, 97 ischemic, 68 ischemic heart disease, 68 isolation, 2, 11, 12, 16, 174 Italy, 129

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Index

240

J Japan, 75, 150, 154, 186 Japanese, 186 job performance, 52 job satisfaction, 112, 114, 196, 213 jobs, 51, 113, 114, 222 joint pain, 11, 12 joints, 143 judgment, 184, 207 justice, 125, 144, 221, 222 justification, 194

K Katrina, 102 Keynes, 228 kidney, 72 killing, 64 King, 6, 21 Korea, 75 Kuwait, 154, 174, 185

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L labo(u)r, xii, 13, 20, 173, 174, 185, 197, 223, 229 labor force, xii, 173 labour force, 174 lack of confidence, 83 language, 24, 143, 177, 178, 180, 189 law, 53, 73, 76, 77, 120, 174, 176, 179, 180, 181, 184 leadership, ix, xi, xiii, 105, 106, 109, 110, 111, 112, 113, 115, 116, 117, 192, 196, 198, 205, 206, 208, 209, 210, 212, 213, 214, 216 leadership style, xi, 109, 110, 111, 112, 113, 115, 213 learners, 161, 208, 209, 211 learning, ix, xii, xiii, 59, 60, 63, 102, 104, 105, 121, 131, 159, 160, 163, 164, 167, 170, 182, 191, 193, 194, 196, 197, 198, 199, 203, 205, 207, 208, 209, 210, 211, 212, 213, 216, 220, 223, 226, 228, 229, 230 learning culture, 121 learning disabilities, 223, 228, 229, 230 learning environment, xiii, 205, 211, 212, 216 learning outcomes, 194 learning process, 164, 196 legislation, 53, 62, 223 leisure, 4, 12, 53, 82 leisure time, 4, 12, 82 Levant, 65

liberalism, 206 liberation, 38, 213 life expectancy, 140 lifespan, 146 lifestyle, 4, 14, 45, 46, 52, 57, 59, 60, 61, 120, 143, 149, 151, 181, 222 lifestyle changes, 120 lifestyles, 44, 59 life-threatening, 95, 103 likelihood, 28, 125, 141 limitation, 77 limitations, x, xi, 1, 2, 17, 39, 43, 61, 67, 68, 85, 87, 103, 133, 145, 163, 168, 170, 175, 227 Lincoln, 2, 3, 4, 5, 15, 18, 19, 22, 47, 63, 72, 88 linguistic, 174 linkage, 73 liquids, 28 listening, 100, 121, 179, 180, 181, 194, 195 liver, 72 living arrangements, 15 living conditions, 19 living environment, 14, 143 lobectomy, 76 location, 31, 97, 101, 142 London, 20, 21, 23, 24, 25, 42, 44, 88, 90, 106, 116, 117, 122, 126, 146, 154, 185, 198, 199, 212, 213 long work, 45, 57, 58, 60, 63, 129, 175 longevity, 14 longitudinal study, 24, 150, 230 love, 13, 20, 30, 35, 38, 188, 189, 190, 199 low back pain, 160 low-intensity, 151 lung, xi, 67, 72, 75, 85, 87, 89 lung cancer, xi, 67, 72, 85, 87, 89 lung disease, 72 lying, 187

M Macau, 187, 190, 210, 214, 215 Madison, 220, 228 magazines, 41, 179 magnesium, 28 magnetic, iv Mainland China, 6, 34 mainstream, 220 maintenance, 48, 95, 105, 112, 139 male bias, 6 males, 39, 128, 129, 134, 140, 150 malignant, 75 malpractice, 106 management, ix, x, xi, xii, 3, 51, 60, 61, 67, 69, 79, 80, 93, 94, 95, 97, 98, 99, 100, 101, 102, 103,

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Index 104, 105, 106, 109, 110, 116, 159, 160, 161, 163, 164, 167, 168, 169, 170, 171, 188, 189, 194, 196, 197, 198, 212, 213, 219, 223, 224, 225, 227, 228, 229, 230 mango, 125 man-made, xii, 105, 167 manpower, 79, 86 manufacturing, 220 margarine, 155 marginalization, 226 market, 29, 34, 36, 37, 51, 78, 112, 220 marriage, 8, 9, 13, 85, 184 married women, xii, 173 Maslach Burnout Inventory, 165 mass media, 100, 143 maternal, 174 meals, 36, 37, 46, 54, 55, 57, 58, 62, 156, 214 measurement, 3, 24, 42, 131 measures, xi, xii, 31, 120, 139, 151, 184, 227 meat, 54, 55, 136, 150, 154, 155, 156 media, 35, 70, 82, 100, 107, 143, 209, 226 mediators, 42 medication, 30 medications, 9, 12, 100, 102 medicine, 22, 30, 81, 87, 186, 189, 213 meditation, 69, 80, 83 MEDLINE, 68 memory, xi, 29, 67, 83, 86, 87, 145 men, 5, 25, 38, 63, 72, 128, 150, 225, 230 mental health, vii, 2, 24, 57, 67, 219 mental illness, 7 mental retardation, 229 mentor, 197, 212 mentoring, 210 messages, 60, 100, 132, 134, 181 meta-analysis, 69, 86, 88, 89 metabolic, 88 metabolic syndrome, 88 metaphor, 189 Mexico, 147 middle-aged, 180, 183 milk, 28, 34, 35, 36, 54, 136, 155, 161 minerals, 28 minority, 32, 45, 57, 59, 220 misunderstanding, 79, 182 mobility, 3, 9, 13, 144, 162 model system, 229 models, 39, 40, 48, 120, 152, 169, 177, 180, 183, 185, 196, 207 modern society, 149 modernism, 19 modernization, ix, 1 molecules, 28

241

money, 12, 34, 52, 64, 79, 102, 128, 130, 179, 180 mood, 4, 5, 13, 21, 40, 57, 160, 162, 179, 189 mood swings, 160, 162 Moon, 188 morale, 112, 113, 188 morbidity, 14, 78, 140, 185 morning, xiii, 160, 167, 191, 192, 193 mortality, 2, 14, 25, 78, 140, 150 mortality rate, 150 mothers, xii, 38, 126, 162, 174, 186, 197 motivation, xii, 44, 111, 114, 120, 139, 146, 163, 193, 196 movement, 124, 144, 152, 156, 178 multidisciplinary, ix, 102, 113, 229 multimedia, 90 multiple sclerosis, 18, 19, 20, 22, 23 muscle, 9, 57, 143, 168 muscle weakness, 143 muscles, 144 musculoskeletal, 11, 45 musculoskeletal pain, 11 music, 163 mutuality, 112 myocardial infarction, 134

N natural, xii, 38, 93, 94, 101, 102, 106, 167, 169, 170, 195 natural disasters, 94, 167, 169, 170 natural environment, 93 needles, 96 negative influences, ix, 1 negative peer influences, 29 neglect, 58, 60, 153 negotiating, 11 negotiation, 112 neonatal, 191, 195, 197 network, xiv, 14, 16, 47, 77, 94, 143, 174, 195, 219 neuroendocrine, 88 neuroticism, 20 New Jersey, 105, 106, 165 New York, iii, iv, 18, 19, 20, 22, 23, 24, 25, 42, 44, 116, 117, 126, 154, 165, 185, 197, 198, 199, 212, 213 New Zealand, 129 newspapers, 175 Newton, 207 next generation, 39 NGOs, 113, 115, 140, 141, 142, 143, 223, 226 NIC, 195 NICU, 193, 195, 197 Nigeria, 159, 164

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Index

242

non-profit, 106 normal, x, xiii, 16, 46, 54, 77, 177, 179, 191, 192, 193 normalization, 53 norms, 181 North America, 168 North Carolina, 106 nuclear, ix, 1, 5, 10, 14, 17 nuclear family, ix, 1, 5, 14, 17 nurse, xi, xii, 9, 18, 68, 69, 78, 80, 81, 82, 83, 86, 87, 94, 97, 99, 104, 106, 115, 124, 127, 128, 130, 134, 145, 167, 207, 212 nurses, xi, xiii, 19, 21, 22, 23, 68, 80, 81, 85, 86, 90, 93, 94, 95, 96, 97, 98, 99, 102, 103, 104, 106, 109, 113, 114, 115, 116, 119, 142, 143, 193, 196, 197, 198, 205, 206, 208, 210, 212, 213, 214, 216, 221, 223 nursing, vii, xi, xiii, 16, 18, 19, 20, 24, 25, 63, 67, 68, 69, 70, 78, 80, 81, 84, 86, 87, 89, 90, 93, 94, 95, 97, 99, 100, 103, 104, 105, 106, 107, 109, 110, 113, 114, 115, 116, 120, 123, 125, 134, 135, 136, 141, 145, 146, 193, 195, 196, 197, 205, 206, 207, 208, 210, 212, 213, 214, 215, 230 nursing care, 69, 81, 193 nursing home, 20 nutrient, 28, 40, 129, 151 nutrients, 28, 35, 37, 46, 54 nutrition, 28, 30, 41, 143

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O obedience, 119 obesity, 28, 29, 36, 41, 42, 55, 56, 64, 68, 128, 150, 154 obesity prevention, 64 obligation, 45, 125 observations, ix, 46, 48, 170 occupational, xiv, 45, 46, 62, 63, 64, 142, 174, 219, 220, 221, 222, 223, 225, 226, 228, 229, 230 occupational background, 174 occupational health, 220 occupational therapists, 221, 223 occupational therapy, 229 oil, 54, 55, 58, 129, 136, 155 oils, 58 old age, ix, 1, 7, 11, 13, 15, 17, 82 older adults, 145, 146, 147, 228 older people, 146 oncology, 19, 145, 191 online, 230 open-mindedness, 207 openness, 112 optimal health, 55, 115

optimism, 188 oral, 209 orange juice, 34, 36 organ, 101, 195, 202 organization, 52, 170, 196, 206, 209 organizational culture, 213 organizational development, 106 organizations, 62, 94, 102, 128, 133, 140, 141, 144, 164, 168, 198, 199, 209, 213, 223 osteoarthritis, 20, 88 outpatient, 63 overeating, 160 overload, 19, 44, 52, 63 overtime, x, 43, 44, 45, 46, 48, 50, 51, 52, 53, 54, 56, 57, 58, 59, 60, 61, 62, 63, 65, 164 overweight, 29, 128 ownership, 120, 220, 227 ozone, 93

P Pacific, 126 packaging, 34, 35, 40 pain, 11, 12, 13, 57, 70, 77, 78, 80, 81, 84, 89, 167, 168, 192, 201 palliative, 19, 23, 122, 191 palliative care, 23, 122, 191 pandemic, 105, 171 paper, 11, 21, 68, 75, 82, 164, 170, 177, 210 parent-adolescent relationships, 186 parent-child, 45 parenting, 174 parents, x, 5, 13, 18, 27, 29, 33, 34, 35, 40, 49, 50, 56, 59, 62, 84, 146, 162, 174, 175, 176, 180, 181, 182, 183, 184, 193, 195, 197, 198, 228 participant observation, 23 participatory research, 126 partnership, 2, 113, 121, 153, 225, 228, 229 partnerships, 226 passive, 115, 121, 180 pasta, 136, 156 patella, 12 patient care, ix, xiii, 1, 4, 5, 90, 94, 95, 103, 205, 206 patients, ix, x, xi, 2, 3, 4, 7, 9, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 67, 68, 69, 70, 71, 72, 82, 83, 85, 86, 88, 89, 90, 91, 93, 95, 96, 97, 99, 100, 102, 103, 104, 106, 112, 114, 124, 145, 150, 188, 194, 196, 197, 200, 201, 208, 209, 210, 228 pedagogical, 24 pedagogy, 22, 213 pediatric, 191, 193, 194, 196, 197, 200 pediatric patients, 192, 196 peer, xiv, 8, 18, 29, 33, 34, 35, 40, 51, 219, 225

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Index peer group, 29, 33, 225 peer influence, 33, 34, 40 peer relationship, 225 peer support, xiv, 219, 225 peers, xiv, 29, 33, 35, 219, 220, 222, 223, 225, 226 perception, ix, 1, 2, 6, 17, 29, 33, 35, 42, 141, 222 perceptions, 5, 22, 23, 24, 64, 67, 222, 228 performance, 29, 31, 40, 44, 45, 46, 52, 110, 114, 163, 205, 224 permeability, 120 perseverance, 188 personal, x, xii, 8, 15, 43, 46, 47, 48, 54, 61, 102, 112, 120, 121, 123, 124, 125, 129, 140, 141, 159, 165, 177, 178, 197, 207, 208, 210, 212 personal relations, 212 personal relationship, 212 personality, 124, 162, 165 personality traits, 162 persuasion, 112 petroleum, 93, 94 phenomenology, ix, 1, 6 Philadelphia, 19, 23, 24, 90, 116, 135, 145, 198, 199 Philippines, 174 philosophical, 5 philosophy, 13, 19, 22, 110, 112 phone, 131, 132, 142, 144 phosphorus, 29 physical activity, 41, 150 physical environment, 33 physical exercise, 69, 163 physical health, 4, 58, 68, 143, 162, 168 physical well-being, 120 physicians, 21, 94, 99, 110 physiological, 68, 77, 103, 227 physiotherapy, 40 pilot study, 41 plague, 188 planning, 2, 12, 40, 72, 83, 90, 100, 114, 142, 179, 182, 183, 184, 221, 222, 225 plants, 30, 54 play, 5, 73, 121, 149, 162, 168, 169, 192, 196, 212 pleasure, 29 pluralistic, 125 poisoning, 168, 169, 170 police, 189 policy makers, x, 1 political leaders, 111, 113 politicians, 121 politics, 20 polyp, 77 polyps, 150 poor, 2, 4, 13, 29, 33, 35, 45, 46, 52, 61, 79, 95, 145, 160, 175, 225

243

poor health, 4, 29, 33 population, ix, xii, 1, 2, 3, 14, 15, 17, 18, 25, 44, 47, 60, 61, 63, 68, 70, 71, 85, 127, 129, 130, 131, 134, 139, 140, 141, 142, 145, 146, 149, 150, 151, 152, 153, 222 population group, 152 pork, 136, 150, 155 positive correlation, 4, 10, 219 positive feedback, 51, 121 positive peer influences, 29 positive reinforcement, 113 positive relation, 62 positive relationship, 62 postgraduate study, 63 postoperative, 81, 83, 86, 87, 91, 95 postoperative outcome, 86, 91 poststroke, 3, 7, 23 posture, 143 potato, 155 potatoes, 136 poultry, 136, 155 poverty, 222 power, 23, 97, 102, 112, 120, 121, 125, 169, 177, 220, 222 power relations, 23 pragmatic, 11 predictability, 111 prediction, 8 predictors, 64, 153 pregnancy, 176, 180, 183 pregnant, xii, 162, 173, 174, 176, 179, 180 premature delivery, 195 preparedness, 97, 98, 100, 105, 229 preschool, 174 preschool children, 174 president, 99 pressure, x, 27, 29, 33, 35, 51, 52, 53, 68, 96, 103, 113, 131, 145, 163, 174, 177 prestige, 14 prevention, xi, 9, 64, 94, 98, 104, 105, 106, 113, 120, 121, 139, 140, 141, 142, 143, 144, 145, 146, 153, 229 preventive, 22, 139, 140, 145, 146 primacy, 18, 20 primary care, 146, 151 primary school, 32 primate, 153 privacy, 73, 100 private, x, 38, 40, 43, 44, 47, 48, 53, 60, 81, 97, 104, 126, 193, 195, 196, 197 private sector, 53, 97 proactive, 120, 140, 167 probe, 181

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Index

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244

problem solving, xiii, 114, 205, 207, 209 problem-solving skills, xiii, 205 production, 34, 188 productivity, 45, 46, 52, 65, 96, 111, 226 professional development, xiii, 205, 206, 212 professionalism, 105, 168 professions, ix, 23, 64, 68, 84, 99, 126, 165, 169 profit, 106 program, x, xi, xiii, 24, 27, 44, 52, 55, 56, 60, 61, 68, 69, 70, 71, 82, 83, 84, 85, 86, 87, 90, 91, 103, 119, 127, 128, 129, 130, 131, 132, 133, 134, 139, 140, 141, 142, 143, 144, 145, 146, 147, 192, 193, 196, 197, 219, 220, 221, 222, 223, 224, 225, 226, 227, 229 promote, xi, xiii, 55, 71, 82, 86, 100, 120, 127, 128, 131, 133, 134, 136, 141, 150, 165, 168, 191, 192, 195, 196, 205, 210, 212, 214, 226 property, iv prostatectomy, 23 protection, 102, 105, 120, 174, 185, 226 protective factors, 209 protein, 34, 54, 129 proteins, 54, 55 protocol, 31, 74, 102 psychoeducational intervention, 88 psychological distress, 42, 164 psychological functions, 98 psychological stress, 11, 12, 68 psychological well-being, 45, 68 psychologist, 99 psychology, 71, 88, 95, 126, 229 psychosocial stress, 78 public, xi, 7, 14, 29, 36, 50, 53, 60, 62, 69, 77, 78, 83, 95, 97, 99, 100, 103, 105, 121, 122, 127, 128, 129, 135, 141, 142, 143, 145, 151, 159, 163, 185, 187, 188, 189, 196, 197, 230 public health, 29, 97, 105, 122, 141, 145, 151, 230 public housing, 14 public opinion, 189 public policy, 121 public relations, 99, 100 public sector, 53, 60 punitive, 111

Q QOL, 140, 145 qualifications, 115 Qualitative evaluation, xii, 139 qualitative research, vii, x, xi, 20, 24, 25, 43, 44, 46, 64, 65, 71, 74, 89, 123, 124, 125, 126 quality control, 34 quality improvement, 193, 196

quality of life, 3, 4, 11, 18, 20, 24, 89, 140, 219, 225, 230 query, 13 questionnaire, 44, 47, 48, 49, 61, 63, 131, 132, 143, 144, 151, 152, 154, 199 questionnaires, 47, 61, 130, 131, 132, 151, 152, 209, 211

R radiotherapy, 75 random, 142, 161, 169 random assignment, 161, 169 range, vii, 113, 169, 191, 197 rash, 48 rats, 188 reaction time, 29 reading, 163 reality, 8, 47, 102, 103, 110, 188, 192 reasoning, 207 recall, 29, 54, 188 recalling, 188 recognition, 123, 152, 197, 200 reconstruction, 98 recovery, 2, 3, 4, 23, 69, 75, 78, 79, 81, 84, 86, 90, 102, 106 recruiting, 85, 174 rectum, 150 red meat, 150, 155 reduction, 69, 79, 84, 120, 147 reflection, 6, 119, 125, 164, 192, 212 reflexivity, 22 registered nurses, xiii, 103, 205, 206, 210 regular, 54, 58, 61, 86, 93, 94, 100, 101, 144, 150, 155, 156, 175, 225 regulation, 5, 120, 207 rehabilitation, 2, 3, 4, 11, 21, 59, 162 reinforcement, 40, 113 relationship, x, xiii, 5, 13, 14, 15, 23, 28, 42, 43, 45, 46, 48, 50, 52, 56, 58, 59, 61, 62, 64, 68, 73, 77, 86, 93, 100, 110, 112, 119, 124, 125, 130, 173, 175, 177, 178, 180, 181, 184, 185, 187, 198, 210 relationships, xii, 3, 4, 5, 25, 41, 45, 47, 63, 71, 86, 121, 124, 125, 139, 145, 186, 190, 192, 207, 212, 219, 224, 225 relatives, xii, 3, 5, 10, 12, 13, 14, 16, 17, 20, 22, 71, 77, 82, 83, 86, 100, 173, 174, 175, 195 relaxation, 69, 82, 195, 225 relevance, 24, 125 reliability, 64, 74 religion, 200 reputation, 78, 168

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Index research, vii, ix, x, 1, 2, 5, 6, 7, 8, 9, 17, 20, 21, 22, 23, 24, 25, 27, 28, 30, 31, 34, 39, 40, 41, 43, 44, 46, 47, 50, 56, 60, 61, 62, 63, 64, 65, 68, 71, 72, 73, 74, 85, 88, 89, 90, 94, 103, 104, 110, 112, 121, 123, 124, 125, 126, 131, 135, 141, 163, 185, 226, 228 Research and Development, 34, 89, 228, 229 research design, 88, 121, 124, 126 researchers, xi, 4, 6, 15, 62, 69, 81, 104, 121, 123, 124, 125 resection, 72 residential, 22 resistance, xiii, 57, 112, 152, 187 resolution, 102 resource allocation, 221 resource management, 105 resources, x, xiv, 5, 11, 39, 43, 51, 61, 69, 84, 85, 87, 96, 102, 111, 112, 113, 134, 137, 138, 140, 141, 142, 143, 144, 194, 203, 219, 220, 221, 222, 223, 224, 226 respiratory, 69, 87, 93, 107, 168 responsibilities, 5, 22, 110, 188, 221 responsiveness, 101 restaurant, 55, 57, 58, 60, 64, 189 restaurants, 56, 163 resuscitation, 195 retail, 34, 220 retirement, 184 retirement age, 184 rewards, 111 riboflavin, 29 rice, 34, 40, 54, 55, 135, 136, 156 risk, xi, 4, 41, 69, 72, 77, 78, 84, 93, 94, 95, 97, 101, 105, 106, 111, 113, 114, 141, 143, 144, 146, 147, 150, 153, 154, 209, 220, 221, 222, 230 risk assessment, 94, 230 risk factors, 41, 101, 143, 150, 153, 209, 222 risk management, 97, 106 risks, xi, 62, 93, 94, 96, 100, 101, 143, 151, 220 rivers, 128 role playing, 119 Royal Society, 63, 64 rural, 38, 42, 147

S sacrifice, 189 safeguard, 102 safety, xi, xiv, 47, 51, 63, 93, 94, 95, 96, 97, 98, 99, 100, 101, 103, 104, 105, 106, 107, 114, 143, 168, 219, 220, 222, 223, 228, 229 salary, 174, 179, 180, 221 salt, 54, 55, 58

245

salts, 136 sample, 15, 39, 46, 47, 142 sampling, 7, 30, 47, 72 SAR, 19 SARS, 102, 107, 167, 169, 188, 189 satisfaction, 13, 37, 52, 89, 112, 114, 132, 133, 196, 211, 213 saturation, x, 43, 61, 74 Saturday, 177, 178 Saudi Arabia, 174 sauna, 163 scepticism, 207 scholarship, 20 school, x, xii, 27, 29, 30, 31, 32, 33, 40, 41, 55, 159, 160, 161, 162, 163, 164, 165, 176, 178, 181, 224, 229 school performance, 163 sclerosis, 23 search, 68, 70, 154 searching, 183 seasonings, 136 secondary school students, x, 27 secondary schools, 27, 30 secondary students, 32 secret, 38, 77 secretion, 68 secrets, 126, 185 security, 96, 111, 163, 199, 221 Self, 41, 90, 111, 126, 130, 195, 211, 223, 229 self-awareness, 114, 140, 141, 142, 145 self-care, 3, 84, 143 self-confidence, 115, 141, 142, 207 self-efficacy, 90, 159, 164, 221 self-empowerment, 210 self-esteem, 4, 23, 75, 174, 225, 230 self-help, 16, 25, 141, 144 self-management, 61, 219, 225, 227, 228, 229, 230 self-reflection, 160, 196, 209 self-regulation, 207 self-report, 5, 143 sensitivity, 96, 112 series, xiii, 73, 124, 142, 173, 178, 191, 192, 193, 196, 200, 202, 203, 209 service provider, 168 service quality, 97 services, iv, ix, xiii, 2, 11, 14, 16, 17, 42, 94, 95, 97, 100, 105, 113, 114, 115, 121, 130, 139, 140, 141, 142, 144, 191, 192, 196, 199, 200, 202, 208, 220, 223, 226, 229 servitude, 175 severe acute respiratory syndrome, 93 severity, 94, 163 sex, 3, 21, 41, 146

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246

Index

sexual health, 41 shape, 34, 212 shaping, 207 shares, 125 sharing, xiii, 38, 104, 114, 119, 121, 191, 192, 196, 208, 209, 211, 225 Shell, 207 shellfish, 136 short period, 152 shortage, 50, 86 shortness of breath, 168 short-term, xiii, 173, 183 shoulder, 13, 100 shoulders, 179 siblings, 75 side effects, 75 sign, 30, 38 signs, 160, 161, 225, 226 simulations, 105 Singapore, 149, 150, 154, 174 sites, 179, 222 skill acquisition, 230 skills, ix, xii, xiii, xiv, 10, 14, 15, 23, 40, 47, 60, 69, 86, 98, 100, 103, 105, 109, 110, 113, 114, 120, 121, 128, 129, 134, 141, 159, 160, 164, 165, 167, 168, 169, 170, 173, 175, 176, 177, 179, 180, 181, 183, 185, 191, 192, 193, 194, 195, 196, 200, 205, 206, 207, 208, 209, 210, 211, 212, 213, 214, 216, 219, 220, 221, 222, 223, 224, 225, 226, 230 skin, 57, 97, 155, 156 sleep, 4, 9, 10, 45, 57, 78, 99 sleep deprivation, 45 SME, 229 smoke, 121 smoking, 41, 150 social acceptance, 33 social activities, 160 social care, 198, 228 social change, 6, 135 social class, 85 social context, 125 social fabric, 125 social factors, 6 social group, 62 social influence, 41, 42 social influences, 41 social integration, 228 social isolation, 2, 11, 12, 16 social justice, 125, 144, 221, 222 social life, 4, 5, 12, 52, 58, 77 social network, 29, 33, 47, 77, 174 social order, 5, 6 social phenomena, 46, 62

social relations, 41, 71 social relationships, 41, 71 social responsibility, 227 social roles, 141, 142, 192 social sciences, 31, 95 social security, 221 Social Services, 24, 226 social skills, 23, 225, 230 social status, 174 social support, xi, 10, 11, 14, 16, 17, 20, 23, 24, 67, 68, 80, 83, 87, 159, 164, 165, 222, 225 social support network, 16 social welfare, 11, 13, 221, 226 social work, vii, 119, 126, 142, 143, 221, 222, 224 social workers, 142, 143, 221, 225 socialization, 186 sociocultural, 119, 222 socioeconomic, 15, 29, 33, 174 socioeconomic background, 15 sociological, 135, 185 sociology, 24, 71, 165 soft drinks, 28, 36, 39, 42, 136 solvent, 28 somatic complaints, 11 sounds, 181 South Africa, 22, 189 South America, 168 South Asia, 167 soy, 41 soybeans, 136 spectrum, 228 speculation, 39 speech, 181 speed, 84, 109 spills, 45 spiritual, 195 spleen, 72 sponsor, 134 sports, 36, 53, 162, 163 spouse, 15, 19, 22, 49, 50, 57 sprain, 9 St. Louis, 106, 116, 136, 146 stability, 144 stabilization, 99 staff development, 101, 197 stages, 8, 50, 175, 176, 178, 180, 182, 183, 184, 192, 221 stakeholders, 112, 116 standard deviation, 8 standardization, 8 standards, 95, 114 starch, 53 starvation, 126

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Index State Council, 34 statistics, 143, 219 statutory, 97, 179 stereotype, 121 stomach, 127, 128, 129, 130 strain, ix, 4, 9, 11, 17, 18, 19, 21, 64 strains, 5, 10, 152 strategies, xii, xiv, 5, 23, 59, 86, 115, 121, 122, 139, 140, 141, 142, 144, 145, 149, 150, 153, 159, 160, 161, 163, 164, 165, 169, 213, 219, 220, 222, 223, 225, 227 strength, 11, 17, 36, 120 stress, ix, x, 1, 2, 3, 4, 5, 7, 10, 11, 12, 13, 14, 16, 17, 20, 22, 23, 45, 46, 52, 57, 59, 64, 67, 68, 69, 70, 71, 72, 75, 77, 78, 79, 80, 83, 84, 86, 87, 89, 90, 91, 120, 159, 160, 161, 162, 163, 164, 165, 174, 184, 228, 229 stress level, x, 5, 67, 68, 71, 72, 86, 91, 163 stressors, x, 44, 67, 68, 70, 71, 72, 75, 77, 78, 79, 83, 84, 87, 89, 91, 160, 161, 162, 163, 164 stress-related, 174 stroke, ix, 1, 2, 3, 4, 5, 7, 8, 9, 13, 15, 18, 19, 20, 21, 22, 24, 25, 55, 128 students, x, xi, xii, 27, 30, 32, 36, 39, 62, 103, 119, 120, 121, 128, 160, 163, 164, 167, 169, 170, 176, 209, 214, 230 subjective, 5, 29, 144 subsidies, 143 suffering, ix, 12, 124, 168 sugar, 36, 39, 41, 42, 55, 136 sugars, 41 suicidal, 160 suicide, 64, 144 Sumatra, 167 summer, 55, 164, 179 Sun, 188 Sunday, 50 supervisor, 18, 32, 103, 220 supervisors, 115, 222 supply, 97, 102 support staff, 210 suppression, 15 surgeons, 80, 81, 154 surgeries, 70, 95 surgery, v, x, 67, 68, 69, 70, 71, 72, 75, 76, 78, 79, 80, 81, 83, 84, 86, 87, 88, 89, 90, 91, 95, 97, 99, 100, 102, 103, 106, 107 surgical, 73, 78, 85, 87, 88, 90, 95, 96, 97, 98, 99, 100, 102, 104, 192 surprise, 167 survival, 15, 69, 75, 78, 84 survivors, 3, 18, 19, 20, 22, 24 sustainability, 119, 122

247

symbolic, 31, 111, 112, 114, 196 sympathetic, 178 symptoms, 11, 160, 161, 162, 168, 174, 186, 225, 226, 230 syndrome, 107, 228 Synergy, 209 systems, 83, 84, 94, 112

T Taiwan, 70, 77, 198 talent, 112 tangible, 10 target population, 61, 129, 130, 131, 222 targets, 128, 130, 133 taste, 29, 34, 35, 37, 40 taxonomy, 63 tea, x, 27, 34, 35, 57, 58, 131, 132, 138, 177, 182 teachers, xii, 40, 159, 160, 162, 163, 164, 165, 168, 223, 228 teaching, ix, xii, xiii, 10, 70, 81, 83, 86, 110, 114, 119, 120, 121, 135, 159, 160, 162, 163, 164, 165, 167, 196, 203, 205, 208, 209, 213, 224 teaching experience, xii, 121, 159 teaching quality, 163 teaching strategies, 160, 165, 213 team leaders, 99, 209 team members, xi, 96, 97, 99, 100, 109, 111, 113, 114, 115, 131, 142, 144 technician, 101 technicians, 47 technology, 2, 44, 70, 71, 82, 96, 109, 112, 192 teenagers, 36, 38, 42 teeth, 36 telephone, 79, 131, 150, 176 television, xiii, 55, 62, 97, 187 television advertisements, 55 temperature, 211 tennis elbow, 11 tension, 192 terminally ill, 23 territory, 129, 188 Thailand, 75, 174 theory, 22, 24, 64, 85, 87, 94, 149, 151, 154, 169, 183, 185, 186, 192, 198, 211, 213, 230 Theory of Planned Behavior, 42 therapists, 221, 223 therapy, xiii, 124, 173, 182, 183, 229 think critically, 116, 205, 206, 207 thinking, xiii, 111, 114, 116, 140, 205, 207, 209, 212, 213, 216 Thomson, 106, 122, 198, 199, 212, 213 thoracic, x, 71, 72, 85, 91

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248

Index

thoracotomy, 76 threat, xiii, 64, 96, 101, 102, 168, 187, 189 threatened, 188 threatening, 168 threats, 96 throat, 168 time, xi, xii, 4, 7, 8, 9, 10, 11, 12, 34, 37, 38, 39, 44, 45, 48, 50, 51, 52, 53, 54, 57, 58, 61, 62, 65, 67, 74, 75, 81, 82, 85, 86, 87, 102, 103, 111, 120, 121, 127, 128, 129, 130, 131, 133, 134, 149, 150, 152, 153, 157, 159, 160, 163, 164, 173, 175, 176, 177, 178, 179, 181, 183, 184, 188, 189, 199, 207, 219, 226, 227 time bomb, 149 time constraints, 61, 62 time consuming, 81, 164 time frame, 227 time pressure, 103, 177 timing, 83, 86 tissue, 28, 177 Tokyo, 44 tolerance, 143, 144 tomato, 35 tradition, 5 traditionalism, 19 traffic, 128, 130 trainees, 78, 83 training, ix, xiii, 51, 87, 93, 96, 97, 101, 103, 110, 115, 116, 120, 142, 160, 163, 164, 168, 191, 196, 197, 198, 205, 206, 207, 212, 226 transcript, 73, 74 transcription, 73 transcripts, 7 transfer, 9, 11, 102, 182, 209 transformation, 14, 107 transformations, 198 transition, 14, 17, 25 translation, 50, 73 transmission, 16 transport, 79, 102, 135, 214, 215 transportation, 9, 12, 28, 94, 130 traps, 93 trauma, 168, 188 travel, 31, 75, 210, 222 trend, 17, 21, 51, 85, 128, 141, 149, 150 trial, 19, 24, 90, 135, 151 triggers, 168 triglycerides, 131 trust, 77, 141, 146, 152, 178, 181, 188, 190, 211 trustworthiness, 8, 74 tsunami, 167, 169, 170 tumour, 75 turnover, 45

two-way, 99, 163 type 2 diabetes, 128 type II diabetes, 68

U UCH, xiii, 192, 193, 195, 196, 197 uncertainty, 46, 75, 77, 78, 83, 163 unconditional positive regard, 181 undergraduate, 63, 103, 104, 105, 110, 119, 170 unemployment, 51, 221 unemployment rate, 51, 221 United Arab Emirates, 154 United Kingdom (UK), 70, 73, 77, 95, 129, 198 95 United States, 18, 28, 42, 63, 70, 94, 95, 102, 150, 198 universities, 133 university education, 32 urbanization, 152 uric acid, 156 USSR, 136, 147

V vacation, 176, 179 vaccination, 97 validation, 152, 165 validity, 47, 61, 64, 152 values, xi, 15, 38, 109, 111, 180, 181, 189, 205 variables, xii, 47, 139, 145, 207 variation, 31 VAT, 76 vegetables, 53, 54, 55, 58, 128, 129, 134, 135, 136, 137, 151, 154, 155, 156 ventilation, 211 victims, ix, 1, 3, 4, 7, 8, 15, 19, 99, 100, 102, 168, 169 violence, 173, 175, 189 virus, 168, 187, 189, 190 viruses, xiii, 189 visible, 112, 155 vision, 109, 111, 112, 113, 114, 115, 177, 188, 192, 193 visualization, 97 vitamin A, 28 vitamin B1, 28 vitamin B12, 28 vitamin C, 28 vitamins, 28, 156 vocational, 219, 229 vocational rehabilitation, 219

Health Issues in Chinese Contexts, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook Central,

Index voice, 16, 80, 99, 225 volunteer work, 114 vomiting, 162 voting, 196

W

work environment, 192, 221, 222, 224 workers, 44, 45, 52, 53, 62, 102, 127, 128, 168, 173, 220, 226 workforce, 220 working conditions, 45, 64, 221 working groups, xi, 109 working hours, 44, 45, 46, 50, 53, 55, 56, 58, 59, 60, 62, 63, 129, 134, 174, 175, 184, 221 working population, 44, 63 working women, xiii, 173, 174, 176, 177, 184, 186 workload, 44, 46, 50, 51, 52, 56, 57, 59, 60, 68, 86, 87, 163, 174, 175, 179, 180 workplace, xi, 33, 44, 46, 59, 64, 109, 110, 114, 129, 135, 161, 163, 164, 168, 170, 206, 207, 210, 212, 216, 220, 222, 224, 226, 228 work-related stress, 46, 52 workstation, 222 World Health Organization, 46, 95, 102, 107, 122, 127, 128, 129, 130, 136, 141, 142, 146, 147, 184, 186, 219, 230 worry, ix, 1, 5, 7, 11, 17, 34, 75, 77, 78, 83, 96, 180, 186 writing, vii, xi, 7, 47, 123, 124, 125, 126, 170, 175, 177, 224 writing process, 124

Y yes/no, 61 yield, 91 yogurt, 54, 55, 155

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waking, xii, 99, 159 walking, 143 war, 88 water, x, 27, 28, 34, 35 weakness, 77, 101, 143 wear, 69, 84 weight control, 129 weight gain, 29 welfare, 228, 230 well-being, 3, 5, 39, 45, 68, 89, 115, 120, 140, 142, 145, 168, 184, 221 wellness, 135 Western countries, 70, 207 Western culture, ix, 1 wheat, 55, 156, 161 whole grain, 55 whole grain bread, 55 wisdom, ix withdrawal, 39 wives, 5, 7, 9, 12, 13, 174 women, 2, 5, 6, 13, 15, 16, 20, 23, 38, 39, 41, 42, 72, 89, 90, 124, 126, 150, 154, 162, 184, 186, 197, 230 wood, 156

249

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