Introduction
Poverty and ill-health are inter-linked. The bilateral associations between poverty and ill-health result in a vicious cycle, especially in less developed countries with inadequate healthcare and welfare support systems [
1]. The classic conceptual framework on poverty-health vicious cycle proposed by Wagstaff illustrated that ill-health affects individuals’ financial status through loss of income and increased susceptibility to catastrophic healthcare cost, whereas poverty causes ill-health as the poor suffer from different kinds of health-compromising tangible and intangible deprivations [
1]. Dahlgren further stressed on the financial and social consequences of ill-health in terms of increased debts, disposal of assets and thus exacerbated poverty [
2]. Despite the established conceptual frameworks, studies on the poverty-health vicious cycle are mainly documented in less developed countries [
3,
4], which may have limited generalizability to developed settings facing a distinct set of political, economic, cultural and social obstacles.
In addition to the mechanisms linking between poverty and ill-health, structural determinants of health inequities, in terms of socioeconomic, political and cultural contexts as illustrated in the World Health Organization (WHO) Conceptual Framework for Action on the Social Determinants of Health [
5], play a significant role in generating social stratification, thus shaping the distribution of the more down-stream intermediary determinants of health. Nonetheless, these contextual environments differ substantially between developed and less developed settings. In developed settings, poverty is not simply defined by absolute minimal physiological needs but exists in relation to the social norm of a population as a form of relative deprivation of diets, amenities, and social activities. While absolute material living standards may be critical drivers to ill-health in less developed countries, poor lifestyle choices and psychological stress, as a result of relative deprivation, are expected to link more closely to the great burden of non-communicable diseases in the developed world [
6]. Also, their investments on healthcare and social welfare are not comparable due to differential economic capacities and policy initiatives. Consistent with past studies in the developed regions, income distribution and social policy provisions appear to have strong impact on poverty cycles and health inequities [
7]. Also, a recent review paper commissioned by the King’s Fund suggested that the National Health Service, the public healthcare system in the United Kingdom, can be better designed to tackle poverty through its impact on health, income distribution, employment and service commissioning [
8]. Without strengthened healthcare and welfare systems, the “21
st century health-poverty trap”, as coined by Bor et al. [
9], is expected to emerge and subsequently widen inequalities in health [
9‐
11]. In view of these fundamental differences, understanding whether, how and why the poverty-health vicious cycle operates in developed settings may go beyond delineating the mechanisms but inform the inadequacies of existing policies or interventions and hence alternative strategic directions to further alleviate the vicious cycle. Given the complex dynamics of the influence of structural determinants and their interactions with the down-stream intermediary factors, it is necessary to adopt qualitative research methods for an in-depth understanding of the poverty-health vicious cycle.
An in-depth investigation in Asian settings is particularly warranted given that a pooled analysis on 24 cohort studies showed a greater association of socioeconomic status with premature death and risk of cardiovascular diseases in Asian populations when compared with that in the Western populations [
12]. Hong Kong, a leading Asian economy, serves as an ideal setting for understanding the dynamics of poverty-health vicious cycle and health inequities, given its all-time high Gini Index of 0.539 in 2016 with almost 20% of Hong Kong’s households living in poverty [
13,
14] as well as the greatest housing affordability issue across the globe [
15]. Furthermore, as one of the first Asian populations to have experienced rapid economic and epidemiological transitions over the recent decades [
16,
17], Hong Kong could also act as an exemplar to other emerging economies in Asia.
The present study aimed to collect views from multiple major stakeholders of the healthcare setting, in order to explore the perceived mechanisms and drivers of the poverty-health vicious cycle under the highly developed but socially unequal context of Hong Kong.