Barriers to preventive care utilization among Hong Kong community‐dwelling older people and their views on using financial incentives to improve preventive care utilization

Abstract Background Financial incentive is increasingly used as a mean to promote preventive care utilization (PCU), but the current Elderly Health Care Voucher Scheme (EHCVS) in Hong Kong is ineffective for encouraging PCU. Objective To explore the older people's barriers to PCU and their views on financial incentive, including EHCVS, for improving private PCU. Design and setting Focus‐group discussions were conducted in community elderly centres located in five districts of Hong Kong. Participants Community‐dwelling older people aged 60 years or above. Results Lack of understanding about preventive care and low awareness of the need for preventive care were key factors for the low motivation for PCU. Uncertainty over the level of service fee charged and concerns over service quality hindered the choice of using the private service providers under the current EHCVS. Financial incentives specific for preventive care services were thought to be cues to actions and guides for service promotion. However, some flexibility in service coverage and a set time limit of the financial incentives were preferred to accommodate individual needs. Conclusions Apart from promoting knowledge of preventive care, official monitoring for service fee and quality is important for empowering older people to choose private service providers for preventive care. Financial incentives for preventive care services should be more specific to cue service promotion and uptake of preventive care while maintaining flexibility to accommodate individual needs. Patient or public contribution Participants were recruited using purposive sampling with the coordination of community elderly centres. Data were analysed using thematic coding.


| INTRODUC TI ON
The global population is ageing rapidly with increases in life expectancy and declining fertility. 1 As in many jurisdictions, the Hong Kong (HK) population aged 65 years or older is projected to increase from 17% in 2015 to 33% in 2064. 2 Population ageing is associated with increasing health care demand, in particular among older people with non-communicable chronic diseases (NCDs), putting pressure on the health-care system and increasing family caregiver burden. 3 Appropriate preventive care utilization (PCU) could enhance early detection and treatment of disease complications and therefore improve quality of life and reduce long-term health care costs. 4,5 However, PCU rates among older people remain low in HK. Older adults are recommended to have regular health checks to identify risk factors or complications in their early stages, enhance active ageing and reduce future costs to the health-care system. 6 However, only about 40% of older people in HK have regular check-ups. 7 A similar uptake was found in the National Health Service (NHS) Health Check in the United Kingdom, much lower than the original aspiration of 75% uptake rate. 8,9 It was estimated through modelling that the NHS Health Check Programme could prevent 300 premature deaths and 1000 cases of cardiovascular disease, dementia and lung cancer each year in England. 10 HK has a mixed medical economy with inpatient services largely provided by public hospitals (90%) and primary care largely from the private sector (70%), paid out-of-pocket. 11 Public primary care charges around HK$50 (~US$6/ ~£5) per public general outpatient visit, 12 while a visit to one of more than 3700 Western medical practitioners' clinics can cost five times as much. 13,14 Other health-care professionals such as Chinese medicine practitioners, dentists, nurses, physiotherapists, occupational therapists and optometrists also provide private services, and while private services are available to anyone, users bear the full cost since most are not subsidized by government. 14 In 2009, the HK Government launched an Elderly Health Care Voucher Scheme (EHCVS) to encourage older people to purchase private preventive care and chronic disease management services and to reduce the burden on the public sector. 15,16 The voucher is worth HK$2,000 (~US$258 / ~£202) annually, can be used to pay for services offered by enrolled practitioners, and unspent vouchers can be accumulated up to HK$8,000 (~US$1,032/ ~£809). 15 However, a recent study found that the voucher scheme did encourage use of private services for acute illness but not for preventive care or chronic disease management. 17 We therefore sought to understand how financial incentives might encourage PCU by obtaining information from the users' perspectives. With a current lack of any information from that perspective, we designed a qualitative study to explore factors contributing to the underuse, by older people, of private preventive care services and their opinions on financial incentives. The specific research questions were as follows: 1. What are some of the barriers for older people in using private preventive care services? 2. What are older people's views on financial incentives for PCU through private care providers?
The results from this study can provide useful information from users' perspectives for developing financial incentives to encourage PCU in older people.

| Participants and subject recruitment
Between May and June 2019, five focus-group discussions (FGDs) were conducted in elderly centres located in five out of 18 administrative districts in HK, namely Kwai Tsing, Northern, Sha Tin, Tseung Kwan O and Yau Tsim Mong, with all having sufficient availability of private primary care providers within the district. 18 These were the first five centres who agreed to participate when we sent out the invitation to all 18 districts and were the only centres included since we used data saturation (see later) as our guide to sample size.
Community-dwelling people aged 60 years or older were invited, by the centre staff of the selected elderly centres, to participate in the study. The centre provided the list of potential participants to the project principal investigator who selected six to ten people from each centre for the FGD, using purposive sampling to ensure a spread of sex, age, educational attainment and family income across the five FGD. Exclusion criteria were not being a Hong Kongresident, unable to give consent to participate in the study or unable to communicate adequately due to linguistic or cognitive difficulties.
Each FGD was held in a quiet room in the centre.

| Topic guide and data collection
After giving written consent, participants completed a brief questionnaire about their demographics and were assured about anonymity and confidentiality of data. The topic guide was modified after the first FGD. This modified version (Appendix 1) was used for the four following discussions. The interview comprised three parts. The number of FGD conducted was determined by data saturation, defined as no new data emerging from the last two FGD. 19 In our study, we identified no new data at the fourth FGD and confirmed data saturation by conducting the fifth FGD.
The study received ethical approval from the Human Subjects Ethics Sub-Committee (HSESC) of the Hong Kong Polytechnic University (HSESC Reference Number: HSEARS20180629002).

| Data analysis
All interviews were transcribed verbatim for data analysis. Accuracy of transcription was checked before data analysis by re-listening to the recordings. Data were analysed using thematic coding. 20 A thematic coding scheme was first developed by two experienced researchers by reading through the five transcripts, and then, it was refined by discussion with the research team. One experienced researcher and one research assistant both coded all the data, independently, following the coding scheme but allowing new codes to emerge from the data. Codes with Cohen's kappa coefficient of lower than 0.6 indicate low inter-rater reliability 21 and were solved by joint discussions among three researchers to reach a consent in coding. During the coding process, constant comparison methods were followed to compare the similarities and differences of existing codes and newly emerged codes. 22 Theoretical categories were developed by clustering similar codes, and related categories were linked to develop themes relevant to the research questions. QRS NVivo 12.0 was used for data analysis.

| RE SULTS
There were 37 participants across the five focus groups with a group size of 6 to 10. More participants were female, had a monthly family income of less than HK$10,000 (~US$1,282) and had at least one NCD; age and educational attainment were more heterogeneous (

| Views on financial incentives for preventive care
Participants were encouraged to discuss their views on important characteristics of financial incentives derived from the literature [23][24][25][26][27] and in what ways these attributes could influence their decision for PCU. The research themes and categories are organized and presented based on characteristics of financial incentives for PCU that were specifically explored during the interview ( Figure 2).

| Recipient
Two main themes emerged when participants were asked about who should be eligible for financial incentives for preventive care services.

Recipient determined by age
There was a general consensus that age was important to determine eligibility for receiving financial incentives for preventive care.
Various reasons were given when discussing why age should be an

| Setting a time limit
Participants were also encouraged to discuss whether a time limit should be set for using the financial incentive for preventive care.
This generated three main themes: During the interviews, participants were also asked their opinions on whether a subsidized ceiling for the cost of specific services and an accumulation ceiling for the financial incentives should be set. Participants generally supported setting subsidized ceilings for specific services to manage the charges in the private sector but disagreed with accumulation ceilings.

| D ISCUSS I ON
This study identified barriers to PCU that are consistent with Anderson and Newman's framework of health-care service utilization, 28 which classifies factors that influence health-care service utilization into predisposing factors, enabling factors and illness levels. For PCU among older people, lacking understanding about and perceiving no need for preventive care may predispose a low motivation for PCU. When seeking service providers, cost uncertainty and concerns over service quality (lack of enabling factors) impede choosing private health service providers. If people perceive goodquality treatment at public hospitals, they will not be encouraged to use private care, particularly with the possibility of additional out-ofpocket expenditure. 29,30 There is also no immediate gratification (eg relieving symptoms) associated with PCU use (lack of illness-related factors).
Adding to existing literature, our study identified contributors to perceiving no need for preventive care and financial barriers.
Participants may determine need for preventive care based on somatic symptoms. This reflects a common misunderstanding about the goals of preventive care. In addition, since older HK residents commonly have routine chronic disease follow-up in the public sector, 31 this was perceived to be a way to obtain preventive care services, and therefore, there was no need for additional preventive care, especially when a visit to a private practitioner would cost around five times the cost of a visit to a public clinic. 12,13 There was a widespread feeling of uncertainty about charges in the private sector, in particular, perception of a tendency to charge more when vouchers were used. This led to a request for better governance of the voucher system. Compared to curative care, preventive care was a lower priority for using health-care vouchers 17 with no immediate gratification. Negative perceptions of ageing 32 appeared to influence behaviour, and some would save unspent vouchers towards future curative care. In addition, some participants expressed concern over service quality of the private sector, which contributed to a low willingness to pay for private preventive services. 33 Measures to increase trust in the service quality of the private sector are important in reducing barriers to PCU. With 70% primary care services provided in the private sector, 11 private providers are widely distributed across HK providing easy access. 18 We identified a common pattern of views on financial incentives There might also be government-sanctioned oversight of quality and fees.
More specific financial incentives for preventive care could be considered to prompt service-seeking while some flexibility in terms of service coverage and time limit should be maintained to allow users room to decide how and when to use the subsidy. The amount of the incentive might be service-specific, covering at least 50% of the total fee. The financial incentives should be provided before or at the time of service to avoid cash flow barriers. Finally, more positive perceptions of ageing could be promoted, consistent with wellness supported by regular PCU. 32

| CON CLUS ION
Lack of understanding of preventive care and its importance, financial barriers and concerns over service quality all hinder use of the private sector for PCU in HK. Future financial incentives for PCU should be more specific for preventive care. Flexibility in when and how to spend incentives would maintain autonomy of people to act according to perceived need.

E TH I C S A PPROVA L
The study received ethical approval from the Human Subjects Ethics

CO N FLI C T O F I NTE R E S T
The authors declare they have no conflict of interest.

AUTH O R CO NTR I B UTI O N S
QL developed the topic guide, conducted the focus-group discus- 2. To explore factors that affect use of financial incentives for preventive care among elderly.

Topic guides
Opinion and experience of using preventive care voucher for preventive services similar to the current health-care voucher; or it could be in cash handout. What do you think of these different forms of financial incentive? (type) 8. Who do you think the government should provide these financial incentives for preventive care? (recipient) Why?
9. If the government was to provide financial incentives for preventive care, would this encourage you to uptake preventive care?
If yes, what is the minimum subsidy amount that will make you consider using these preventive services? [If the elder cannot give a specific amount, please ask them the maximum price they are willing to co-pay] in response to the following three services: