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George et al. International Journal for Equity in Health 2012, 11:44 http://www.equityhealthj.com/content/11/1/44

RESEARCH Open Access

Self-reported chronic diseases and health status and health service utilization - Results from a community health survey in Singapore Pradeep Paul George1*, Bee Hoon Heng1, Joseph Antonio De Castro Molina1, Lai Yin Wong1, Ng Charis Wei Lin1 and Jason Tian Seng Cheah2

Abstract

Objective: To report the extent of self-reported chronic diseases, self-rated health status (SRH) and healthcare utilization among residents in 1-2 room Housing Development Board (HDB) apartments in Toa Payoh.

Materials & methods: The study population included a convenience sample of residents from 931 housing development board (HDB) units residing in 1-2 room apartments in Toa Payoh. Convenience sampling was used since logistics precluded random selection. Trained research assistants carried out the survey. Results were presented as descriptive summary.

Results: Respondents were significantly older, 48.3% reported having one or more chronic diseases, 32% have hypertension, 16.8% have diabetes, and 7.6% have asthma. Median SRH score was seven. Hospital inpatient utilization rate were highest among Indian ethnic group, unemployed, no income, high self-rated health (SRH) score, and respondents with COPD, renal failure and heart disease. Outpatient utilization rate was significantly higher among older respondents, females, and those with high SRH scores (7-10).

Conclusions: The findings confirming that residents living in 1-2 room HDB apartments are significantly older, with higher rates of chronic diseases, health care utilization than national average, will aid in healthcare planning to address their needs.

Introduction Self-rated health and utilization of healthcare services are important determinants of health, and have particu- lar relevance for public health [1]. Health service utilization is a complex behavioral phenomenon, related to the availability, quality, cost and comprehensiveness of services as well as socio-cultural structure, health beliefs and personal characteristics of the users [2]. There is reason to believe that people reporting better health status are less frequent users of healthcare ser- vices [3]. Understanding how self-perceived health status influences healthcare utilization may help estimate fu- ture demand for physicians, and healthcare planning. In Singapore, the rapid ageing of the baby-boomer gen- eration poses a serious challenge to healthcare providers

* Correspondence: [email protected] 1Health Services and Outcomes Research (HSOR), National Health Group, Singapore Full list of author information is available at the end of the article

© 2012 George et al.; licensee BioMed Central Commons Attribution License (http://creativec reproduction in any medium, provided the or

and policy makers [4]. Ageing will result in an increase in chronic disease morbidity, reduced levels of function- ing, and increased disability, leading to increased med- ical care and healthcare expenditures. Studies show that the people with low income/socio-economic status (SES) have more health related problems than people with high SES [3-8]. This group exhibit greatest need for healthcare and are the most frequent users of healthcare services [2,9]. Healthcare utilization information for government out-

patient facilities and hospitals are readily available from statistics of clinic attendances and inpatient discharges. However, current information on people’s healthcare preference, health seeking behavior, functional assess- ment and perception about their health status are either not available or not up to date [5,6]. Community health assessment helps us to understand the health problems and priorities of a population.

Ltd. This is an Open Access article distributed under the terms of the Creative ommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and iginal work is properly cited.

George et al. International Journal for Equity in Health 2012, 11:44 Page 2 of 7 http://www.equityhealthj.com/content/11/1/44

The National Healthcare Group (NHG) embarked on a community health assessment, aimed to determine the prevalence of self-reported chronic diseases and risk fac- tors, functional status, lifestyle behavior, willingness to participate in health programs, and utilization of health services. It provides baseline information to support pro- gram planning for groups at greater risk of chronic dis- eases, who may potentially have limited access to healthcare, and to identify opportunities for disease pre- vention and health promotion. The aim of this study was to describe the self-reported chronic diseases, health status and health service utilization of residents living in 1–2 room Housing Development Board (HDB) apart- ments in Toa Payoh.

Methods The study population included a convenience sample of residents from 931 housing development board (HDB) units residing in 1–2 room apartments in Toa Payoh. Convenience sampling was used since logistics pre- cluded random selection. These 1–2 room HDB units are heavily subsidized by the government’s Housing and Development Board to the poor and needy citizen fam- ilies with no housing options and with a gross house- hold monthly income of below S$2,000 (~ USD 1589) for purchase, or below S$1,500 (~ USD 1191) for rent [10]. Of the 1- and 2-room resident population in Singapore, 9.4% of them reside in Toa Payoh [11,12]. The house-to-house survey was conducted between June and October 2009 in two stages: (a) a household survey enumerated all persons in the households to de- rive eligible respondents, telephone contact, language medium for quality audits and future contacts. It pro- vided an estimate of the total study population, which served as the denominator for indicators captured in the survey; and (b) an individual survey to elicit the in- formation to address the specific aims of the project. Housing units where none of the residents could be contacted after three visits on three separate days were excluded. Respondents were eligible for the individual survey if they were household members and were Singa- pore citizens or Permanent Residents. A household member was defined as one who considered the house as his/her main dwelling place, slept in the house at least 4 nights per week, and/or was in the house for most part of the day (≥8 hours) and/or shared the same eating arrangements for most part of the week (≥5 times a week) in the preceding month. Foreigners, work permit and employment pass holders staying at the selected household were excluded. Except for those with asthma, respondents should have been at least 18 years old. Patients with asthma who were at least 7 years old were interviewed. Proxy respondents who were suffi- ciently familiar with circumstances of the person he/she

was representing, e.g. parent, child, main caregiver, other close relative, were allowed for cognitively and mentally challenged household members, and children with asthma below 7 years of age. Eligible respondents who were not contactable after three attempts on three separate days were excluded. After obtaining the verbal consent, interviewers provided the respondents with a survey overview and expected duration of completion. Individual’s responses were recorded in the study ques- tionnaire (Additional File: 1). Eligible respondents were asked if they had been

diagnosed by a western doctor for eight major chronic diseases such as hypertension, diabetes, hypercholester- olemia, heart disease, stroke, renal failure, asthma, COPD and other medical conditions; their actual health service utilization and preference of provider. Respon- dents were asked to rate their health status on a likert scale from 1–10, with a score of one indicating poor health and a score of ten indicating best possible health. The developed questionnaire (Additional File: 1) was subjected to cognitive testing, field-tested, translated and back translated from English to Mandarin and Malay. Face-to-face interviews were conducted in English, Man- darin, Malay or Chinese dialects by a team of trained re- search assistants. The completed survey forms were subjected to quality audit and subsequently entered into an MS Access database with inbuilt validity checks to re- duce data entry errors. Ethics approval for the survey was obtained from the Domain Specific Review Board of the National Healthcare Group.

Statistical analysis Age, work status, income were grouped into broader categories for analysis. Continuous variables were expressed as mean ± SD or median (intra-quartile range) and categorical variables were reported as percentages. Associations of self-reported chronic diseases, health status and healthcare utilization with socio-demographic variables and other risk factors were assessed by Pear- son chi-square tests or t-test where appropriate. Multi- variate logistic regression (enter method) analysis was carried out to determine factors significantly asso- ciated with self-rated health, in-patient and out-patient utilization, variables included in the equation were age, gender, ethnicity, education, work status, monthly in- come, self-rated health and chronic diseases. To avoid over-fitting the model, only variables found significant on univariate analysis were included in the final regres- sion model. All statistical analysis were performed using Predictive Analytics SoftWare (PASW) Statistics Version 18. All tests were conducted at the 5% level of signifi- cance. The percentages and the Odds ratio (OR) were reported with their 95% Confidence Intervals (CI) where applicable.

Table 1 Response rate

Total no. of housing units in 4 blocks 931

Household survey:

- vacant (excluded) 39

No. of units visited 892

- no answer after 3 visits 168

- refused 166

No. of units agreed to participate (a) 558

Household response rate 558/(892) = 62.6%

Individual survey:

Total no. of residents in (a) 1,145

- eligible 974

- refused 109

- not contactable after 3 attempts (excluded) 87

No. of residents successfully surveyed 778

Individual response rate 778/974 = 79.9%

Overall response rate 62.6% x 79.9% = 50.0%

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Results Demographic and other characteristics The overall survey response rate was 50.0%; household and individual response rate were 62.6% and 79.9% re- spectively. Of the total 1,145 residents staying in 558 households, 991 residents were eligible for the survey, of

Table 2 Comparison of demographic characteristics of survey

Characteristics Categories Su

Age <25

25 - 44

45 - 64

≥65

Gender Male

Female

Ethnic group Chinese

Malay

Indian

Others

Highest educational level attained No formal education

Primary

Secondary and higher

Work status Employed (Full time/Part-time)

Unemployed

Personal monthly income < S$500

S$500 - S$999

≥ S$ 1000

*Sources: Yearbook of Statistics 2009 & General Household Survey 2005 accessed fr http://www.singstat.gov.sg/pubn/popn/ghsr1.html. ┼CI: Confidence Interval.

whom 778 were successfully interviewed (Table 1). Sur- vey respondents were older, had higher percentage of Malays, higher percentage with no formal education and higher percentage of unemployed persons and higher percentage with income less than $500 than the national average (Table 2). Average age of the respondents was 56.2 ± 18.4 years. 63.7% of the respondents were Chinese, 22.6% were Malays and 9.8% were Indians. 48.1% of the respondents had no formal education, 29.7% had primary education and 22.2% had tertiary education. 67% of the respondents had monthly personal income of < S$500 (Singapore dollars) and 22.9% earned between S$500 – 999 and 10.1% earned ≥ S$1000.

Self-reported chronic diseases The prevalence of self-reported eight major chronic dis- eases was 48.3% (n = 376, 95% Confidence Interval (CI): 44.8 – 51.9%). Twenty-two percent reported having one chronic disease (n = 169), 14% reported having two dis- eases (n = 109), 8% reported having three diseases (n = 64), and 4% reported having been diagnosed with four or more diseases (n = 34). Self-reported prevalence of hypertension, diabetes, heart disease and asthma were 32%, 16.8%, 21.1% and 7.6%, respectively. Other chronic diseases reported include mental problems (2.4%), mus- culoskeletal problems (2.1%), skin problems (1.2%), eye problems (0.9%), gastrointestinal problems (0.8%) and

respondents with Singapore general population

rvey respondents % 95% CI┼ Singapore population*%

53 6.8 5.3 - 8.9 31.4

132 17.1 14.5 - 19.9 32.2

300 38.8 35.4 - 42.4 27.6

288 37.3 33.9 - 40.9 8.8

390 50.1 45.1 - 55.1 49.5

388 49.9 44.9 - 54.9 50.5

496 63.8 59.8 - 67.8 74.7

176 22.6 16.6 - 28.6 13.6

76 9.8 2.8 - 16.8 8.9

30 3.9 0.0 - 10.9 2.8

374 48.1 43.1 - 53.1 16.4

231 29.7 23.7 - 35.7 22.0

173 22.2 16.2 - 28.2 61.6

335 43.1 38.1 - 48.1 96.0

157 20.2 14.2 - 26.2 4.0

521 67 63.0 - 71.0 3.7

178 22.9 16.9 - 28.9 9.5

79 10.1 3.1 - 17.1 86.8

om http://www.singstat.gov.sg/pubn/popn/population2009.pdf,

Table 3 Self-reported chronic diseases# and health service utilization by various characteristics (n = 778)

Characteristics Categories n Row%

Self-reported chronic disease

Outpatient utilization rate

Inpatient utilization rate

SRH score 1-6

Age-group* <25 53 26.4 83.0 11.3 13.2

25 - 44 132 34.8 78.0 8.3 29.5

45 - 64 300 54.8 78.7 10.0 33.2

≥65 288 80.6 91.0 11.1 41.3

Gender Males 390 53.1 79.0 10.8 32.3

Females 388 65.5 88.1 9.8 36.6

Ethnicity Chinese 496 62.7 83.5 9.5 38.1

Malay 176 51.1 85.2 9.7 24.4

Indian 76 60.5 85.5 18.4 34.2

Others 30 46.7 70.0 6.7 33.3

Highest educational level attained No formal education 374 70.6 85.0 12.8 40.1

Primary 231 55.0 80.1 6.5 32.9

Secondary education and above 173 40.5 84.9 9.8 24.3

Work status Working full-time or part-time 335 43.6 76.7 8.4 23.6

Unemployed 157 69.4 85.4 16.6 41.2

Retiree 134 82.8 91.0 9.0 39.6

Housewife 129 72.1 89.9 10.9 44.2

Student or national serviceman 23 8.3 87.5 0.0 8.7

Personal Monthly Income╣ <S$500 421 71.7 88.5 12.4 44.2

S$500 - 999 278 47.5 76.9 8.6 24.1

≥S$1,000 79 34.2 79.7 5.1 19.0

Self-rated health status Score 1-6 268 77.9 91.8 13.8 -

Score 7-10 510 49.4 79.2 8.4 -

Chronic diseases Presence of one or more chronic disease 461 - 98.0 13.2 45.3

No chronic disease 317 - 62.4 6.0 18.6 # refers to hypertension, diabetes, hypercholesterolemia, heart disease, stroke, renal failure, asthma, COPD, cancer and other mental, musculoskeletal, skin, eye, gastrointestinal problems. * Age not available for five respondents, income not available for 3 respondents. SRH: Self-reported health; score of 1 indicates poor health and a score of 10 indicates best possible health. Scores 1–6 indicate fair to poor self-rated health status. ╣Income in Singapore dollars.

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cancer (0.5%). The rate of self-reported chronic diseases increased progressively with age, and was higher among females, Chinese ethnic group, retirees, unemployed, respondents with monthly income < $500 and those whose self-rated health (SRH) score (1–6) (Table 3). Self-reported chronic diseases were classified as one or more chronic disease and no chronic disease, multivari- ate logistic regression was performed to identify the sig- nificant predictors. Presence of one or more chronic disease significantly predicted the resident’s self-rated health, inpatient and outpatient utilization. Residents with one or more chronic disease were 3 times more likely to report poor self-rated health (Odds Ratio (OR): 3.05, 95% (CI): 2.09 – 4.44), 2 times more likely to report inpatient utilization (OR: 2.25, 95% CI: 1.25 – 4.03) and 36 times more likely to have outpatient utilization (OR:

36.2, 95% CI: 17.31 – 17.55) than residents with no chronic disease (Table 4).

Healthcare utilization Inpatient utilization Overall, 10.6% of the survey respondents (n = 83, 95% CI: 8.6 – 13.1%) were hospitalized in the preceding 12 months. Respondents with eight listed chronic dis- eases had significantly higher hospital utilization (12.5%) in comparison to respondents with no known medical diseases (6%) (p = 0.003). Similarly respondents who were younger (< 25 years), belonging to Indian ethnic group, those with no formal education, those who were unemployed, those with monthly income < S$500, those who self-rated their health score 1–6, and patients with COPD, renal failure and heart disease had higher

Table 4 Determinants of Self-reported health and health service utilization by various characteristics (n = 778)

Characteristics Categories Self- rated health

(1–6), OR

95% CI for OR

Inpatient utilization,

OR

95% CI for OR

Outpatient utilization,

OR

95% CI for OR

Upper Lower Upper Lower Upper Lower

Age-group* <25 1 1 1

25 - 44 2.27 0.84 6.14 0.51 0.16 1.63 1.66 0.57 4.87

45 - 64 1.78 0.66 4.77 0.49 0.17 1.49 1.31 0.45 3.83

≥65 1.38 0.49 3.92 0.44 0.13 1.46 2.09 0.59 7.35

Gender Males 1 1 1

Females 0.94 0.65 1.35 0.68 0.39 1.17 1.55 0.92 2.61

Ethnicity Chinese 1 1 1

Indian 0.92 0.52 1.61 2.35 1.15 4.77 1.02 0.45 2.35

Others 0.98 0.42 2.29 0.70 0.16 3.19 0.42 0.15 1.17

Malay 0.57 0.37 0.88 1.23 0.64 2.35 1.49 0.84 2.64

Highest educational level attained

No formal education 1.16 0.70 1.92 1.06 0.52 2.16 0.41 0.20 0.81

Primary 1.12 0.67 1.86 0.45 0.20 1.02 0.52 0.27 1.00

≥ Secondary education 1 1 1

Work status Working full-time or part-time 1 1 1

Retiree 0.68 0.23 1.96 0.23 0.03 1.75 0.71 0.17 3.00

Housewife 0.89 0.30 2.66 0.32 0.04 2.36 0.86 0.21 3.52

Student or national serviceman 0.37 0.06 2.41 0.00 - - 4.89 0.75 31.83

Unemployed 1.05 0.37 2.97 0.39 0.06 2.78 0.84 0.24 2.99

Personal Monthly Income╣

<S$500 3.11 0.94 10.27 8.15 0.90 73.78 0.76 0.18 3.17

S$500 - 999 1.25 0.63 2.49 2.09 0.65 6.65 0.66 0.32 1.39

≥S$1,000 1 1 1

Chronic diseases Presence of one or more chronic disease 3.05 2.09 4.44 2.25 1.25 4.03 36.17 17.31 75.55

No chronic disease 1 1 1

* Age not available for five respondents, income not available for 3 respondents. OR: Odds ratio, CI: Confidence Interval, ╣Income in Singapore dollars. SRH: Self-reported health; score of 1 indicates poor health and a score of 10 indicates best possible health. Scores 1–6 indicate fair to poor self-rated health status.

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inpatient utilization (Table 3). Independent predictors of inpatient utilization were ethnic group and presence of chronic diseases. Patients from Indian ethnicity had higher odds for inpatient utilization in comparison with their Chinese counterparts (OR: 2.35, 95% CI: 1.15 – 4.77); similarly patients with chronic diseases had signifi- cantly higher inpatient utilization than those without chronic diseases (OR: 2.25, 95% CI: 1.25 – 4.03) (Table 4).

Outpatient utilization Eighty four percent of the respondents had visited an outpatient clinic in the preceding 12 months (n = 654, 95% CI: 81.3 – 86.5%), with a total of 4,225 outpatient visits made by 654 respondents, an average of 6.5 outpatient visits per person per year. Older respondents (≥ 65 years), females, Indians, respondents with no for- mal education, Retirees, respondents with monthly in- come < $500 and those with self- rated health (SRH)

scores (1–6) had high outpatient utilization (Table 3). Presence of any chronic disease was an independent pre- dictor of outpatient utilization; patients with chronic dis- ease had higher odds for outpatient utilization when compared to those with no chronic disease (OR: 36.17, 95% CI: 17.31 – 75.55) (Table 4). Among respondents with 8 chronic diseases seeking treatment at the polycli- nics, the rate of utilizing polyclinics increased progres- sively with age; and a higher proportion of younger respondents (<45 years) with 8 chronic conditions sought treatment at the general practitioner (GP) (Table 5). Polyclinic was the popular choice for the treatment of

chronic diseases for 55% of the respondents, main rea- sons being cheap and accessible. For respondents who preferred to consult at specialist outpatient clinic, rea- sons for preference were accessibility, loyalty/familiarity, doctor-related factors and their perception that their medical conditions could be better managed. Similarly,

Table 5 Age-specific utilization rate (%) of primary care services in preceding year

Age-group Utilization rate (%)

Any chronic disease No chronic disease

n* Government polyclinic General practitioner n* Government polyclinic General practitioner

≤ 25 11 27.3 36.4 39 33.3 41.0

25 - 44 32 28.1 65.6 86 32.6 33.7

45 - 64 122 53.3 23.8 136 35.3 16.2

≥ 65 208 63.5 25.9 56 26.8 21.4

Total 373 317

* Patients could have utilized more than one or more primary care service, hence the numbers would not add up to total (n = 778).

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the decisions to seek treatment at GP clinics were for ac- cessibility, doctor-related factors and service quality (Table 6).

Self-rated health status The median SRH score was seven (interquartile range, 6–8). Thirty-six percent of women and thirty two per- cent of men reported below median SRH scores. There was a discernible disparity among those with 8 chronic diseases (47%) and those with no known medical condi- tions (19%), respectively, reporting below median scores (p = 0.0001). Approximately 2 in 5 of respondents aged 65+ years, those with no formal education, either un- employed, retired or were housewives, were without in- come or belonging to Chinese ethnic group had below

Table 6 Reason for choice of outpatient healthcare provider*

Reasons for choice % respondents who cited their preference for care providers

Government polyclinics

Specialist outpatient clinics in government

hospitals

Private general practitioners

n = 342 n = 120 n = 164

Cheap 72.5 25.8 23.8

Accessible 66.1 37.5 59.8

Loyalty/familiarity 13.2 20.0 25.6

Service quality 10.8 5.8 21.3

Disease can be better managed

9.6 61.7 18.9

Doctor-related factors 8.8 30.0 23.8

Efficient 5.0 9.2 17.7

Recommended by others

3.8 10.0 5.5

More advanced technology

2.0 15.0 2.4

Good reputation 1.8 6.7 3.0

* Respondents may cite more than one reason for their choice and could have visited more than one outpatient healthcare provider.

median SRH scores (Table 3). Presence of any chronic disease was an independent predictor of poor self-rated health status (SRH score 1–6), respondents with any chronic disease had higher odds of reporting poor self- rated health when compared to those without chronic disease (OR: 3.05, 95% CI: 2.09 – 4.44) (Table 4).

Discussion This study shows the self-reported rates of hypertension, diabetes, high blood cholesterol and asthma and in- patient utilization were higher than the national rates [13]. A third of respondents reported fair to poor SRH, similar to another study among 1–2 room residents [14] but higher than another report from Singapore [15]. The proportion of respondents with fair or poor health were higher among older age groups, among respondents who were not gainfully employed and among those with mul- tiple chronic diseases, similar to that reported in other studies [13,14,16,17]. In a survey by Fong et al. [11] in the vicinity of the present survey, inpatient utilization was higher for females and those aged 60+ years. Our results showed that inpatient and outpatient utilization to be associated with presence of self-reported chronic conditions. The median age of survey respondent was 14 years older than that of the Singapore population, and not surprisingly a higher prevalence of chronic dis- eases. With ageing, this phenomenon will be further compounded. In Canada, an estimate of the impact of population ageing shows that the prevalence of chronic diseases would increase by more than 25% within the next quarter century and that this will result in health resource requirements growing more rapidly than the population, twice as rapidly in the case of hospital stays [18]. Another study found that levels of socio-economic status-based health inequality in a cohort progressively increase as the cohort ages [19]. Government polyclinics were the preferred as the pri-

mary care provider (55%), higher than 23.6% in the gen- eral population. The reverse holds true for private GPs with 75.9% of the general population preferring to seek

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treatment at GPs compared to 16% among respondents. This is expected. With the significantly lower median household income of S$1,090 among persons living in 1-2-room apartments compared to the national S $4,950, [17] makes the heavily subsidized government polyclinics a more affordable option for these resi- dents. The study also showed that a higher proportion of persons with chronic disease gravitate to the polycli- nics, similar to the 2007 National Health Surveillance Survey. The implication is with the significantly older residents in 1–2 room apartments that are associated with higher prevalence of chronic diseases; demand for government polyclinic services for this segment of population will further compound the national demand as the population ages.

Strengths and limitations The study highlights the healthcare disparities of a coun- try with rapidly aging population. The study has several limitations that need to be acknowledged. This was a cross-sectional descriptive study and hence unable to show the temporal relationship between self-reported prevalence, self-rated health and healthcare utilization. The findings of this community health assessment had limited generalizability to the population from 1- and 2- room apartments beyond the Toa Payoh district within which the data were collected. The design of the survey is subject to recall bias. These limitations notwithstand- ing, this study has uncovered or confirmed significant findings useful for health planners in countries with rap- idly aging populations.

Conclusion Residents in 1–2 room apartments are significantly older, a lower proportion being gainfully employed earn- ing a significantly lower income, a higher proportion had chronic diseases and utilizes government polyclinics, and lower self-rated health status. The disparity in health status among persons with low and high income being greatest among the older people needs to be addressed.

Additional file

Additional file 1: Survey of knowledge, self-empowerment and health-service utilization for chronic diseases.

Competing interests The authors declare that they have no competing interests.

Authors’ contributions PPG, HBH, JADM, WLY, NGCWL and CJTS assisted with the conceptualization and the actual design of the study. PPG carried out the statistical analysis and drafted the manuscript along with HBH and JADM. WLY, NGCWL and CJTS assisted with drafting the manuscript. All authors read and approved the final manuscript.

Author details 1Health Services and Outcomes Research (HSOR), National Health Group, Singapore. 2Agency for Integrated Care, Singapore.

Received: 5 January 2012 Accepted: 3 August 2012 Published: 16 August 2012

References 1. Chakraborty N, Islam MA, Chowdhury RI, Bari W, Akhter HH: Determinants

of the use of maternal health services in rural Bangladesh. Health Promot Int 2003, 18(4):327–337.

2. Solome B, Sarah W, Sandro G, Stefan P, George P: Community perceptions and factors influencing utilization of health services in Uganda; 2009.

3. Syed HR, Dalgard OS, Hussain A, Dalen I, Claussen B, Ahlberg NL: Inequalities in health: a comparative study between ethnic Norwegians and Pakistanis in Oslo, Norway. Int J Equity Health 2006, 5(1):7.

4. Smith GD, Blane D, Bartley M: Explanations for socio-economic differentials in mortality. Eur J Publ Health 1994, 4(2):131–144.

5. Dalstra JAA, Kunst AE, Borrell C, Breeze E, Cambois E, Costa G, Geurts JJM, Lahelma E, Van Oyen H, Rasmussen NK: Socioeconomic differences in the prevalence of common chronic diseases: an overview of eight European countries. Int J Epidemiol 2005, 34(2):316–326.

6. Demakakos P, Nazroo J, Breeze E, Marmot M: Socioeconomic status and health: the role of subjective social status. Soc Sci Med 2008, 67(2):330–340.

7. Siegrist J, Marmot M: Health inequalities and the psychosocial environment–two scientific challenges. Soc Sci Med 2004, 58(8):1463–1473.

8. Mackenbach JP, Kunst AE, Cavelaars AEJM, Groenhof F, Geurts JJM: Socioeconomic inequalities in morbidity and mortality in western Europe*. Lancet 1997, 349(9066):1655–1659.

9. Wong M, Chau PH, Goggins W, Woo J: A geographical study of health services utilization among the elderly in Hong Kong: from spatial variations to health care implications. Health Serv Insights 2009, 2:1–12.

10. Housing & Development Board. HDB InfoWEB; www.hdb.gov.sg. 11. Fong NP, Phua KH: Utilization and expenditure on medical services in a

local community. Singapore Med J 1985, 26(2):131–138. 12. Ministry of Trade & Industry Singapore: Census of Population 2000:

Geographic distribution and travel: Singapore Department of Statistics; 2001. http://www.singstat.gov.sg/pubn/popn/cop2000admin.pdf

13. National Health Surveillance Survey; 2007. http://www.moh.gov.sg/mohcorp/ publicationsreports.aspx?id=22520

14. Ramkumar A, Quah JLS, Yeo TWLSH, Nieh CC, Shankar A, Wong TY: Self- rated health, associated factors and diseases: a community-based cross- sectional study of Singaporean adults aged 40 years and above. Ann Acad Med Singapore 2009, 38(7):606.

15. Lim WY, Ma S, Heng D, Bhalla V, Chew S: Gender, ethnicity, health behaviour & self-rated health in Singapore. BMC Publ Health 2007, 7(1):184.

16. Leslie K: International comparison of key healthcare utilization trends, MoH Information Paper; 2004/04. www.moh.gov.sg/mohcorp/. . ./Information. . ./ International_Comparison_of_Key_Healthcare

17. Department of Statistics, Singapore. Press release. http://www.singstat.gov.sg/ news/news/op19022010.pdf

18. Denton FT, Spencer BG: Chronic health diseases: changing prevalence in an aging population and some implications for the delivery of healthcare services; http://socserv.mcmaster.ca/sedap/p/sedap259.pdf

19. Prus S: Age, SES, and health: a population level analysis of health inequalities over the life course. http://socserv2.socsci.mcmaster.ca/~sedap/p/sedap181.pdf

doi:10.1186/1475-9276-11-44 Cite this article as: George et al.: Self-reported chronic diseases and health status and health service utilization - Results from a community health survey in Singapore. International Journal for Equity in Health 2012 11:44.