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 Hong Kong Bull Rheum Dis 2013;13:xx-xx Original

The Socioeconomic Impacts on Household Income, Employment

Status, Need for Public Assistance, and Marriage Opportunities in
Patients with Spondyloarthritis: A Comparison with the Hong Kong
Population

Ho-Yin Chung, Cynthia Yan-Yan Chan, Hoi-Lun Tsang, Yuen-Ling Au, Chak-Sing Lau

Abstract: Objectives: Our goal is to assess the impacts of spondyloarthritis (SpA) on household income, employment status,
need for public assistance, and marriage opportunities by comparing the disease group with the Hong Kong
population. We also aim to identify the potential predictors for lowered monthly household income in SpA patients.
Methods: One hundred and sixty patients were involved in the study. Age and sex categorized household income,
employment status, need for public assistance, and marriage opportunities were compared between SpA patients
and the Hong Kong population. Baseline characteristics were compared between SpA patients with a monthly
household income above or below the median Hong Kong Island population monthly household income. Univariate
regression analyses were performed using a natural log (ln) of monthly household income as the dependent
variable and baseline characteristics with a significant difference (p<0.1) as independent variables. A multivariate
regression model was built up using ln (monthly household income as the dependent variable) and factors with a
significant difference (p<0.1) in univariate analyses as independent variables. Results: SpA patients in the older
group were found to have lowered household income, decreased marriage opportunities, a greater percentage of
unemployment, and a need for public assistance. Monthly household income is positively associated with tertiary
education (B=0.19; p=0.03) and negatively associated with mSASSS (B=-0.26; p=0.02), living alone (B=-0.18;
p=0.03), and the presence of medical problems (B=-0.19; p=0.03). Conclusion: Having SpA has a significant
impact on various socio-economic factors. The impacts appeared to increase in the older age group. Disease
severity is one of the major factors that predict a lowered household income..

1 Keywords: xxx, xxx, xxxx, xxxx, xxxx

DIVISION OF RHEUMATOLOGY AND CLINICAL IMMUNOLOGY, QUEEN Introduction

2 MARY HOSPITAL, 102 POKFULAM ROAD, POKFULAM, HONG KONG
Ho-Yin Chung xxx
Spondyloarthritis (SpA) is a chronic rheumatic disease that
Hoi-Lun Tsang xxx
affects the younger age group. It leads to functional disability
Yuen-Ling Au xxx
and causes a number of socio-economic impacts. SpA patients
Chak-Sing Lau xxx
have increased work disability1,2 and difficulties engaging in
DEPARTMENT OF PSYCHIATRY, PAMELA YOUDE NETHERSOLE EASTERN marital relationships. 3 Children with juvenile onset
HOSPITAL, 3 LOK MAN ROAD, CHAI WAN, HONG KONG Ankylosing Spondylitis (AS) and polyarticular juvenile
Cynthia Yan-Yan Chan xxx chronic arthritis are reported to have poorer school
performance.4,5 AS disease costs are high,6,7 reportedly 3 times
D IVISION OF R HEUMATOLOGY AND C LINICAL I MMUNOLOGY , T HE that of the general population,8 imposing burdens on both
UNIVERSITY OF HONG KONG, 102 POKFULAM ROAD, POKFULAM, individuals and society.
HONG KONG
Chak-Sing Lau xxx
The government of Hong Kong conducts a population census
every 10 years, and a by-census every 5 years. The 2011
Correspondence to: Chak-Sing Lau
2 xxxx 3
Population Census covered various data topics including
demographic, educational, economic, household, housing, and
home moving characteristics in Hong Kong. Details of the
census have been published on the Hong Kong government
homepage.9 The results allowed us to assess and compare SpA
patients with the general population regarding various socio-
economic aspects including monthly household income,
unemployment rate, percentage of population on public
assistance, marital status, and educational opportunities.
Through the analyses, we also aimed to identify potential
predictors of lower monthly household income in SpA
patients.
Method
This is a cross-sectional analysis involving Chinese SpA
patients managed in the rheumatology clinic of Queen Mary
Hospital, Hong Kong. The cohort was initially decided for
assessment of the psychiatric impact on 160 consecutive SpA
patients. Patients were interviewed to collect socio-economic
and demographic data. The recruitment period was from May
2011 to October 2011. Included subjects were ethnic Chinese,
fluent in Cantonese and with the ability to give written
informed consent (which included study objective and details).
Pregnancy, illiteracy, and those with severe co-morbidities
likely to invalidate informed consent or limit the ability of the
subject to comply with the protocol requirements were excluded
from the study. All included patients fulfilled at least one of the
SpA criteria: modified New York (MNY) criteria,10 European
Spondyloarthropathy Study Group (ESSG) criteria,11 Amor
criteria,12 or ASAS classification criteria for axial SpA.13,14
Baseline Socio-economic and Demographic Data
Data collected during the interview included age, sex, marital
status, age of symptom onset, year of onset of inflammatory
back pain (IBP), year of onset of peripheral arthritis, the
presence of other medical and psychiatric problem(s), marital
status, living arrangement (alone or with family), education
level, monthly household income (rounded up to the nearest
Hong Kong dollar 500), and employment status. The studied
patients were also asked if they were on the government
economic assistance scheme: the Comprehensive Social
Security Assistance (CSSA). The data were cross checked with
the hospital's computer database (Computer Management
System [CMS]). Whenever there was discrepancy, the patient
was interviewed again for confirmation. Educational level was
categorized into (1) no education; (2) pre-primary education;
(3) primary education; (4) secondary education; (5) post-
secondary education. Monthly household income was
expressed in Hong Kong dollars. Duration of IBP and
peripheral arthritis were defined as the differences between
year of interview and year of onset of IBP/year of onset of
peripheral arthritis respectively. The amount and duration of
non-steroid anti-inflammatory drug (NSAID) used was
checked from the CMS to calculate the NSAID score.15
Disease Activities and Functional Status
Patients were invited to perform self-rating assessment scales
to determine their disease activities and functional status.
These included the Bath Ankylosing Spondylitis Disease
Activity Index (BASDAI),16 Bath Ankylosing Spondylitis
Functional Index (BASFI),17 and Bath Ankylosing Spondylitis
Global score (BAS-G). 18 C-reactive protein (CRP) and
erythrocyte sedimentation rate (ESR) were checked to
determine the CRP or ESR-based Ankylosing Spondylitis
Disease Activity Score (ASDAS-CRP or ASDAS-ESR).19
SpA disease activity was determined by BASDAI and
ASDAS-CRP/ ASDAS-ESR while BASFI was used for the
assessment of functional status.
Radiology Assessment
The modified Stoke Ankylosing Spondylitis Spine Score
(mSASSS)20 was determined by performing radiographs of
the cervical spine and lumbar-sacral spine. Sacroiliac (SI)
joints radiographs were also performed and graded according
to Modified New York (MNY) criteria:10 grade 0 is normal,
grade 1 is suspicious, grade 2 is sclerosis or mild erosions,
grade 3 is severe erosions with joint space changes or partial
ankylosis, and grade 4 is complete ankylosis. Radiological
AS was defined when SI joints radiographs showed bilateral
grade 2 or unilateral grade 3 or 4 sacroiliitis. All radiographs
were reviewed and scored by two independent rheumatologists
to determine the inter-observer correlation. The mean
mSASSSs of the two scores were used for analyses.
Statistical Analyses
The study data were compared with those in the 2011
Population Census. The median household income in Hong
Kong Island in 2011 was Hong Kong dollar (HKD) 28,040,
equivalent to United States dollar (USD) 3,618.06 (exchange
rate HKD 7.75 to USD 1).9 Student t-tests and chi-square tests
were used to compare the continuous and categorical variables
respectively between SpA patients with a household income
above and below HKD 28,040 (or USD 3618.06). The
percentage of the never-married SpA patients was also
Chung et al. 3

compared to the population using a chi-square test. Linear corticosteroid (prednisolone 10 mg per day) on the day of the
variables with a difference (p<0.1) between the two groups interview.
were used as independent variables in a univariate linear
regression model, and median household income was used as The mean monthly household income of the study population
the dependent variable. The monthly household income of was HKD 29,958 (or USD 3865.54). Sixteen (10%) patients
SpA patients had a skewed distribution and was transformed were unemployed, and 11 (6.9%) were on CSSA. Sixty three
using natural logarithms (ln) in regression analyses. (39.4%) SpA patients had co-existing medical problem(s),
Independent variables with significant association (p<0.1) and 21 (13.1%) had co-existing psychiatric problem(s). In
were re-tested in a multivariate linear regression analysis using the below 30 age group, the highest percentage of living alone
median household income as the dependent variable (enter (14.3%) was observed. The result reflected a lower percentage
mode). Results were expressed as regression coefficients (RC). of married patients in the SpA population.
Associations between age and significant linear/bivariate
variables were retested in univariate linear/ logistic regression Figure 1 shows the educational levels of our study population.
models. Unless specified, p-value <0.05 was defined as
statistically significant. Statistical analysis was performed Monthly Household Income
using the Statistical Product and Service Solutions (SPSS) The mean and median of the monthly household income
package 18.0. according to different age categories was charted in Figure 2.
The median Hong Kong Island population monthly household
Ethics Approval income (HKD 28,040 or USD 3,618.06) was used as a cut off
The study was approved by the Institutional Review Board point and a reference for comparison. When compared to that
of the University of Hong Kong. It was conducted in of the Hong Kong Island population, SpA patients' median
accordance with the Declaration of Helsinki and the guidance monthly household income was 1.9% lower in the below 30
for good clinical practice, 30 November 2006. age group; 28.7% in the 40-49 age group; and 46.5% in the
50-59 age group and the above 60 age group. A 42.7% increase
in median household income was noted in the 30-39 age group.
Results Table 1 shows the details of baseline comparisons between 4
SpA patients with a monthly household income above or
The cohort comprised 160 patients; 113 patients were male below the median of the Hong Kong population.
and 47 were female, giving a male to female ratio of 2.4 to 1.
The mean age of the studied population was 46.2±12.7 years
old. The average age of SpA onset was 30.2±13.1 years old.
The study population was characterized by the long duration
of inflammatory back pain (IBP) (mean duration of IBP
14.8±11.2 years), moderate disease activity (mean BASDAI
3.9±1.9, mean ASDAS-CRP 1.6±0.8, mean ASDAS-ESR
2.7±1.0), and mild functional impairment (mean BASFI
2.5±2.5). Most of the studied population fulfilled the MNY
criteria for sacroiliitis (122 patients, 84.1%) and were
considered to have radiological AS. The mean NSAID score
was 3,945.2 reflecting a long duration of NSAID usage in
our SpA population. Seventy-eight patients (48.8%) had used
DMARDs, and 138 patients (86.3%) had used NSAIDs. Six
patients (3.8%) were currently on a subcutaneous form of
anti-TNF agent (patients on infliximab were not included in
our study as they were followed up in the rheumatology day
center instead of the rheumatology clinic). Sixteen patients
(10%) were prescribed corticosteroids (either intramuscularly
or orally) while only one patient was treated with oral Figure 1. Education levels of the studied SpA patients.
 4 xxxx 3
Univariate and Multivariate Regression Models Using
ln (Monthly Household Income) as Dependent Variable
Baseline data with a significant difference (p<0.1) were tested
as independent variables in univariate regression models using
ln (monthly household income) as the dependent variable.
The independent variables tested included age, age of disease
onset, duration of IBP, SpA patients received tertiary
education, presence of other medical problem(s), ASDAS-
ESR, BASFI, mSASSS, and patients with radiological AS.
Age (B=-0.04; p=0.001), age of disease onset (B=-0.03;
p=0.03), tertiary education (B=1.18; p<0.001), presence of
other medical problem(s) (B=-1.17; p<0.001), living alone
(B=-1.40; p<0.001), ASDAS-ESR (B=-0.33; p=0.03), BASFI
(B=-0.21; p=0.001), and mSASSS (B=-0.03; p<0.001) were
found to be significantly associated with ln (monthly
household income) and were retested as independent variables
in multivariate regression models.
4 Table 2 shows the multivariate regression model using ln
(monthly household income) as the dependent variable. The
monthly household income was found to be positively
associated with the tertiary education level and negatively
with the presence of other medical problems, mSASSS, and
living alone.
SpA: xxxx; HKD: Hong Kong Dollars; HK: Hong Kong
Figure 2. Comparison of monthly household income between SpA patients and Hong Kong Island
population according to different age categories.
Univariate Analyses Using Tertiary Educational Level,
mSASSS, Presence of Medical Problem, and Living
Arrangement (Living Alone) as the Dependent Variable
and Age as the Independent Variable
Univariate logistic/linear regression showed age was
associated with tertiary educational level (OR0.95; p<0.001),
mSASSS (B=0.85; p<0.001), and presence of medical
problem(s) (OR1.07; p<0.001). It was not associated with
living alone (OR1.01; p=0.58).
Unemployment and Social Aassistance
Table 3 shows the percentage of unemployment and the 4
percentage of patients on CSSA with reference to different
age categories. The unemployment rate of Hong Kong in 2011
varied from 3.2% to 3.6%.9 The pre-retirement group (50-59
years old) in our study population was noted to have the
highest unemployment rate as well as the highest percentage
of patients on CSSA.
Marital Status
Table 4 shows the percentage of male and female patients
who had never been married and the divorce rate according
to the different age categories. The data were compared to
 Chung et al. 5

the Hong Kong population (no analysis was performed Discussion

between SpA population divorce rate and Hong Kong
population divorce rate). The possibility of getting married
was similar in the younger age group but significantly lower
in the older age group (>40 in female group and >45 in male
group).
Socio-economic impacts on patients are important in the
management of chronic diseases. Indirect costs in Chinese
AS patients had been reported in a previous study.21 We used
monthly household income for comparison because age and

4 Table 1. Baseline comparisons between SpA patients with monthly household income above and below the median of Hong Kong Island
population
Income >HKD 28040 Income <HKD 28040 p-value

Age (n=158) (years) 41.2±10.5 49.9±13.0 <0.001

Male sex (n=158) 47 (72.3%) 65 (69.9%) 0.74
Married (n=158) 43 (66.2%) 47 (50.5%) 0.051
Lives alone (n=158) 1 (1.5%) 14 (15.1%) 0.004
Received tertiary education (n=160) 41 (63.1%) 16 (17.2%) <0.001
Age of disease onset (n=157) (years) 27.0±10.9 32.7±14.2 0.01
Presence of back pain (n=158) 63 (96.9%) 90 (96.8%) 0.96
Duration of IBP (n=151) (years) 13.6±10.3 16.2±11.5 0.047
Presence of peripheral arthritis (n=158) 50 (76.9%) 72 (77.4%) 0.94
Duration of peripheral arthritis (n=107) (years) 12.6±9.3 12.3±11.8 0.85
Presence of other medical problem(s) (n=158) 16 (24.6%) 46 (49.5%) 0.002
Presence of other psychiatric problem(s) (n=158) 6 (9.2%) 13 (14.0%) 0.37
BASDAI (n=154) 3.8±1.7 4.1±2.0 0.33
ASDAS-CRP (n=150) 1.5±0.8 1.6±0.8 0.32
ASDAS-ESR (n=149) 2.6±1.0 2.9±1.0 0.09
BASFI (n=158) 1.8±1.9 3.1±2.7 0.001
mSASSS (n=131) 17.4±15.8 32.4±24.0 <0.001
Fulfilled MNY SI joints criteria (n=143) 41 (63.1%) 16 (17.2%) <0.001

4 Table 2. Multivariate regression model using ln (monthly household income) as dependent variable
5 Multivariate regression (n=131) Standardized Regression 95% confidence p-value
co-efficient (Beta) co-efficient (B) interval
Age 0.05 0.01 -0.03; 0.05 0.39
Age of disease onset -0.10 -0.01 -0.04; 0.02 0.35
Received tertiary education 0.19 0.74 -0.08; 1.40 0.03
Presence of other medical problem -0.19 -0.72 -1.36; -0.07 0.03
ASDAS-ESR -0.05 -0.09 -0.45; 0.28 0.65
BASFI -0.06 -0.05 -0.21; 0.12 0.58
mSASSS -0.26 -0.02 -0.04; -0.004 0.02
Living alone -0.18 -1.29 -2.46; -0.12 0.03
 6 xxxx 3

sex categorized data were available in the Hong Kong 2011
Population Census. Unlike in western populations, the
assessment of monthly household income, as opposed to
personal income, could be important as it would not be
uncommon to share an individual's income amongst the entire
family in Chinese cultures. In addition, the successful
application for government-subsidized anti-TNF agents in
Hong Kong requires an assessment of monthly household
income instead of personal income. These indicate the need
to examine the effect of monthly household income in our
SpA population.
The 2011 Population Census divided Hong Kong into three
different regions: Hong Kong Island, Kowloon, and the New
Territories. Data were reported independently in each region,
and Hong Kong Island had the highest monthly household
income among the three. As one of the two major
rheumatology centers is in Hong Kong Island, we used the
median monthly household income in Hong Kong Island for
comparison. A lower monthly income could be observed in
the below 30 age group because it included students, who
would have no monthly income. Overall, our data (as shown
in univariate analysis) showed that SpA patients in the older
age group have a significantly lower monthly household
income. Older SpA patients also had higher unemployment
rate and increased applications for CSSA. The findings are in
concordance with those of western centers, in that older age
is associated with higher work disability in SpA.22 Although
multivariate analysis showed the rationale behind a lowered
household income in the older age group is likely to be related
to the advance in disease severity in the aging population, the
financial impact could be more problematic as the aged
patients would find it more difficult to mobilize social
resources and are prone to be neglected.
A previous study has found that higher disease cost is
associated with higher BASDAI and Bath Ankylosing
Spondylitis Radiology Index (BASRI).23 Our study yielded
similar findings. A decrease in monthly household income
was associated with higher ASDAS-ESR, BASFI, and

4 Table 4. The percentage of unemployment and on CSSA in SpA patients according to different age categories
Number of SpA patients Number of SpA patients On CSSA Not on CSSA
with unemployment with employment
Age <30 0 (0.0%) 14 (100.0%) 1 (7.1%) 13 (92.9%)
Age 30-39 0 (0.0%) 40 (100.0%) 1 (2.6%) 38 (97.4%)
Age 40-49 7 (17.5%) 33 (82.5%) 2 (5.1%) 37 (94.9%)
Age 50-59 7 (18.4%) 31 (81.6%) 5 (13.2%) 33 (86.8%)
Age ≥ 60 2 (7.1%) 26 (92.9%) 2 (7.1%) 26 (92.9%)

4 Table 5. The percentage of male and female patients who had never been married according to the different age categories: comparing
between SpA patients and Hong Kong population
Never married Never married Never married Never married Divorced
(male SpA patients) (percentage of Hong Kong (female SpA (percentage of Hong Kong (percentage of
male population) patients) female population) SpA patients)
(p-value) (p-value)
<20 year-old 1 (100.0%) 99.8% N/A 99.7% 0
20-24 year-old 2 (100.0%) 97.0% (p=0.94) N/A 94.0% 0
25-29 year-old 6 (100.0%) 82.6% (p=0.32) 5 (100.0%) 69.3% (p=0.16) 1 (9.1%)
30-34 year-old 13 (65.0%) 50.0% (p=0.26) 2 (66.7%) 37.7% (p=0.32) 0
35-39 year-old 4 (30.8%) 28.8% (p=0.54) 2 (66.7%) 22.0% (p=0.12) 0
40-44 year-old 3 (30.0%) 20.9% (p=0.35) 4 (50.0%) 17.1% (p=0.005) 1 (5.6%)
45-49 year-old 5 (33.3%) 14.2% (p=0.01) 1 (12.5%) 14.0% (p=0.69) 0
≥50 year-old 6 (13.0%) 5.8% (p<0.001) 1 (5.0%) 5.8% (p<0.001) 7 (10.6%)
 Chung et al.
mSASSS. Upon adjustment for other potential confounding
factors, including age, disease duration, education level,
presence of other medical problems and living alone by
multivariate linear regression, monthly household income was
still negatively associated with mSASSS although the
associations with ASDAS-ESR and BASFI were lost. One of
the important reasons for this observation is that individual
income decreased as a result of loss of productivity due to
advanced disease. A study in 2010 showed loss of productivity
in SpA is highly correlated with BASFI and BASDAI.22
Another study also showed that limitations in physical
functioning are strongly associated with work restriction.24
Some physical impairment (e.g. hip involvement) may also
preclude AS patients from leading a productive work life.25
Unlike other studies, we failed to demonstrate associations
with ASDAS-ESR and BASFI in multivariate regression
analysis. This suggested disease severity may have a greater
impact on monthly household income when compared to
disease activity.
From our data, monthly household income was negatively
associated with living alone and the presence of other medical
problems. The reason seems clear. SpA patients living alone
had the fewest number of household workforces and therefore,
less household income. On the other hand, a previous study
showed that better social support in AS predicts better physical
function improvement over time.26 Living alone could be a
negative predictive factor for poor physical function leading
to increased indirect disease cost. Further limitations in work
capability would be expected in SpA patients with multiple
medical co-morbidities27 as a result of a worsened functional
status, leading to lower monthly household income.
The impact of SpA on marriage has seldom been studied.
Our result showed SpA patients could find it more difficult to
engage in long-term marriage. The phenomenon is observed
only in the older age groups, which could be explained by the
fact that the majority of the Hong Kong population enter
4 marriage after the age of 30 (Table 4), and the older age groups
were empowered to observe for the difference. A recent study
also reported AS patients as having decreased opportunities
for marriage.28 The importance of marital relationship in SpA
patients was reflected in two large surveys.29,30 In these studies,
up to 14% of SpA patients reported problems in spousal
relationships which they rated as very important. There could
be a variety of explanations for the marital problems. SpA
patients could have decreased social interaction as a result of
pain and impaired functional activities. This was reported in
7
a previous study that assessed the functional status of AS
patients by the Medical Outcome Study Short-Form 36 (SF-
36).31 Moreover, increased anxiety and depression and low
self-esteem as a result of body image concerns could further
limit their social interaction, making marriage in SpA patients
more difficult. The divorce and separation rate was higher in
SpA patients although no formal analysis was performed in
view of the low incidence.
We have not compared the education level between SpA
patients and the Hong Kong population. The 2011 Population
Census released information about the education level in Hong
Kong but not Hong Kong Island. The combination of higher
education levels, and thus higher income levels, and the low
income levels of poorly-educated immigrants in Hong Kong
Island,9 rendered direct comparison with that of the entire
Hong Kong population inappropriate. As a late adolescence
onset disease, SpA patients are expected to be minimally
affected in terms of educational attainment. From our analyses,
higher education level is a negative predictive variable for
lower monthly household income. Similar observations were
reported in previous studies which found high education level
to be a protective factor against unemployment in AS
patients.32,33
In conclusion, SpA has significant impacts on monthly
household income, employment status, and marriage
opportunities. SpA patients also have a greater need for public
assistance. The problems appeared to be more prominent in
the elderly patients. Our study, however, is limited by the
small sample size and cross sectional design. Data collected
by physician directed interview allowed patients to round up
their monthly household income, thus making the data
potentially prone to recall bias. Further larger scale, follow-
up studies would provide more detailed assessments of the
socio-economic impacts in SpA patients. Despite these
limitations, it is hoped that this information will help
rheumatologists and policy makers to decide on the kinds of
support they could provide to SpA patients. The long-term
goal would be to integrate them into the community.
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