Health Inequity in Sexual Health Services Among Chinese Men with Prostate Cancer in the Public Hospital Setting, 2021 PCF-Pfizer Health Equity Challenge Award - Marques Shek Nam Ng

February 22, 2023

Marques Shek Nam Ng, a recipient of the 2021 PCF-Pfizer Global Health Equity Challenge Awards, joins Charles Ryan in a discussion on research he and colleagues performed on Health Inequity in Sexual Health Services Among Chinese Men with Prostate Cancer in the Public Hospital Setting. In this research study, Ng et al. identified three determinants of health that are specific to sexual health services in Asia which form the basis for their study. Communication, culture, and finance. Marques Ng and his team hoped that by integrating both quantitative and qualitative findings, they may develop a conceptual model that explains the health inequity associated with sexual health services for managing sexual function impairments in men with prostate cancer.

PCF-Pfizer Global Health Equity Challenge Awards: A collaboration between PCF and Pfizer Global Medical Grants, the awards totaling $1.47 million are granted to teams at some of the world's leading cancer research institutions to support prostate cancer research projects that will improve the understanding of, or reduce disparities in the diagnosis, treatment, and outcomes of patients in minority and underserved communities. The 11 award winners represent eight countries, including Hong Kong, Ghana, Kenya, Malaysia, Nigeria, the United Republic of Tanzania, Uganda and the United States.


Marques Shek Nam Ng, RN, PhD, CFSWE, Assistant Professor, The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong

Charles J. Ryan, MD, the President and Chief Executive Officer of The Prostate Cancer Foundation (PCF), the world’s leading philanthropic organization dedicated to funding life-saving prostate cancer research. Charles J. Ryan is an internationally recognized genitourinary (GU) oncologist with expertise in the biology and treatment of advanced prostate cancer. Dr. Ryan joined the PCF from the University of Minnesota, Minneapolis, where he served as Director of the Hematology, Oncology, and Transplantation Division in the Department of Medicine. He also served as Associate Director for Clinical Research in the Masonic Cancer Center and held the B.J. Kennedy Chair in Clinical Medical Oncology.

Read the Full Video Transcript

Charles Ryan: Hello, I'm delighted to introduce Dr. Marques Ng, who's an assistant professor at the Chinese University in Hong Kong. Dr. Ng is a PhD nurse, and studies health inequity in sexual health practices. He's the recipient of a Prostate Cancer Foundation, Pfizer Global Health Equity Challenge Award. Dr. Ng, delighted to see you today, interested to hear about your work, and thank you for joining us.
Marques Ng: Thank you so much. Thank you for your introduction. I'm Marques, from the Nethersole School of Nursing, the Chinese University of Hong Kong. Thanks for Dr. Ryan's invitation to talk about my study here, is titled, Health Inequity in Sexual Health Services Among Chinese Men with Prostate Cancer in the Public Hospital Setting.

So as we all know, prostate cancer is the second most prevalent cancer among men, worldwide. Although the incident and mortality rates in Asia were not really the highest amount the continents, it consists of a very large population. In terms of the number, we got the highest in mortality case and the second highest in the incident cases. These patients are mostly affected by sexual function impairment, which include premature ejaculation and erectile dysfunction.

We know that it negatively impacts their relationships, mental health and quality of life. According to a review, around 25% to 60% of men with prostate cancer reported this problem after treatment. In Hong Kong, we found that up to 85% of men reported such problems. Actually, we got a wide range of good treatment options for these men, like for pharmaceutical therapy, physical therapy, sex counseling and education, as well as complimentary therapy. These treatments may be provided through sexual health services.

However, in public hospitals, it is constrained by human resources or financial resources shortages, and also excessive demand. It leads to limited service capacity and long waiting times. For example, in Hong Kong's public urology clinic, the waiting time for non-agent cases reached 50 weeks. That means patients need to wait for a year before getting consultation, and is severely affect the access to appropriate care.

Our team identified three determinants of health that are specific to sexual health services. First, communication. Patients and conditions like opportunity or time to discuss about sex. We found that culture, in the clinical settings, somehow discourages such conversations. One study found that information shared with patients and their partners may not be relevant, so actually clinicians may not really understand the need of their clients, regarding information.

Second, the culture. Sexual function is seen as an important indicator for masculinity in Asian cultures, and sexual function impairments may be regarded as a threat to one's identity. Because of the concerns about privacy and dignity, men are reluctant to discuss their sexual health, even with their partners, and so they're not to disclose this problem to their clinicians.

Third, finance. Because of the limited resources, many healthcare systems prioritize curative care, so some other services, like sexual health services, may be given a lower priority, but patients are reluctant to pay for non-subsidized surface with their out pocket expenses. In Hong Kong, we got a study that a patient with lower income actually less likely to receive some kind of quality and comprehensive healthcare.  Therefore, these free determinants form the basis for our study. 

To investigate the barriers from the perspective of different stakeholders, we proposed this study. We used a mixed methods design because we found that this phenomenon is rather complex, and actually it involved different stakeholders. It includes our cross sectional survey and some or semi-structured interviews. In the surveys, we will invite 159 patients from oncology centers and assess their sexual function, access to service and determinants of health using different instrument like EPIC, QLACS, PSQ, and INCOST. By using statistical analysis, we will identify significant determinants about access to care, and we'll use that in the qualitative interviews. So in the interviews, we will ask questions for the participants to share their views about perception and experiences about sexual health services. The participants include a selection of patients from the cohort, and also healthcare professionals involved in providing sexual care. We hope that by integrating both quantitative and qualitative findings, we may develop a conceptual model that explain our health inequity associated with sexual health services for managing sexual function impairments in men with prostate cancer. We are going to recruit our patients, and as I've mentioned, talking about sex is really difficult in clinical settings.

We are working hard with our clinical partners and IRBs to safeguard the privacy of our clients.We hope that by integrating objective factors and incorporating individual perspectives, we can create a more comprehensive picture about health inequity. We will identify culturally specific barriers to the assets to sexual health services, then we can make recommendations to improve our healthcare system and clinical service. Sometimes, it's not about money and resources, it's about how we deliver care and education in the way that our clients prefer. We hope that we will inform better allocation of healthcare resources to address the needs of our clients.

We think that this is an understudied area in Asia, and we hope that our findings will help all those men with prostate cancer in Asia, especially those with limited healthcare resources. After all, men are equal and health equity is about narrowing the gap for health of all.

So thank you very much for your invitation. I really thank PCF and Pfizer for the support for this study. Also, I would like to express my gratitude to my team members, including Dr. Ka Ming Chow, Dr. Kai Chow Choi, Miss Kath Schubach, and Professor Carmen Chan.

Charles Ryan: Thank you for that presentation. It's a very interesting project in an area of the world where the Prostate Cancer Foundation has not funded a lot of research in the past, so we are delighted to be working with you and present there. You've identified that your work seeks to identify the culturally specific barriers to care. What are your hypotheses as to what those barriers will be? What do you think you're going to find from the outset, based on your experience in the clinic already?

Marques Ng: Yeah, well hypothesize that the three health determinants will be the major factors that affect the access to sexual health service in our situation. What we actually want to see, whether there is association between both a quality of communication, while the culture, the perceived masculinity, and also their financial wellbeing with their access to sexual health service. We will use a dedicated instrument to measure all those determinants of health in our study.

Charles Ryan: I think those are likely to be universal, culturally specific barriers. However, there would be somewhat unique aspects of that in the Hong Kong population that we might not see in a California population, or a UK population, or a European population, or an African population. Do you feel that there are specific barriers to Hong Kong, whether it's the structure through which you deliver healthcare or certain communications aspects that are worth noting?

Marques Ng: Well, I think there are quite... Well, we are expecting the results, but in our experience, actually from the system and also the culture will be the most different parts in this study. The system, we are actually employing a kind of universal healthcare, but limited capacity is really big problem in our healthcare system. As you may heard in my presentation, we got a really, really long waiting time, so patients really need to wait for such a long time before they got proper care. But the point is, we have a really big imbalance between the public and private sector. Patients are really reluctant to use service out of public hospital. So that form of really or difficult situation for them, I suspect that they may give up some of their problems. Well, they will just put it aside and wait for those cheaper service. That is something that we want to investigate in our well study.The next thing is about culture. So I think in Asian cultures, actually men perceive their sexual function to be a very important part of their identity. Well, in our experience, they seldom talk about sex in public occasion, even at home. So how they can overcome these barriers and to try to seek help, I think this is something that we want to explore in our interviews. So we will talk to the man, and try to know what is their experience from perceiving a problem to seeking help, so that we will know what barriers involved and try to address that in the future.

Charles Ryan: That's a fairly consistent problem is that men in general, are reluctant to discuss their sexual health with a healthcare provider, with their families. It'll be interesting to see how your data will integrate with data being studied from other parts of the world, and how we might one day have a clearer sense of how sexual health is discussed in Hong Kong, versus sub-Saharan Africa, versus the continental United States and other areas. What percentage is the population is in the public sector healthcare versus private in Hong Kong?

Marques Ng: Yeah, I think... Well, in Hong Kong, I think more than 90% of inpatient services are provided by the public sector. So actually, there is only a small amount of patients in the private sector. But as we know, actually there are lot of services that is provided by the private sector, not only those profit making, but some non-governmental organizations may also provide some kinds of sex therapy and other kinds of sexual health services. We are going to investigate why these service exists, but the men are reluctant to reach out to find those problem to help them.
Charles Ryan: Speak to the next step. Let's imagine you identify barriers. You've created your conceptual model that you've spoken of. What resources will you need to close gaps and address some of these barriers as your next project? Let's put it that way.

Marques Ng: Yeah, well that is something very ambitious, I think. From the system, from the culture, and from practice, I think we've got a lot of things to do. So like the system, whether we can connect public service provider to the private sector so that they can refer patients to a proper service easily will be something that we can refer. For the culture, well we need to do some kind of education. I think both the patient and also the clinicians need to be educated about conversation about sex. We need to make them feel comfortable to talk about that, and sometimes we need some kind of communication skills in order for patients and conditions to communicate properly. Lastly, about practice, I'm thinking if there is some kind of communication barrier in this process, we may develop some kind of communication tool or surface model that can easily identify sexual health problem in men, and provide early intervention. These works depend on what we have identified in our study.

Charles Ryan: Could you speak to whether the patients in Hong Kong would be open to getting information online versus in person? It sounds like with a 50 week wait for services, there may be an opportunity to create some content that individuals could watch or learn from before they have their appointment, for example.

Marques Ng: Oh, sure. I think nowadays, our clients rely on online information a lot. Doing things online may be something that we can develop. Not only online stuff, we can do apps, so that they can easily assess all those information with their mobile device. But another thing is I think Chinese patients rely on expert, rely on those with professional qualification, so how we can provide this kind of professional advice will be quite important. Well, maybe we can use those multimedia or interactive strategies in order to facilitate this kind of conversation before they really get a consultation.

Charles Ryan: I think that would be a great way to address some of these barriers and to help individuals who are waiting for their expert advice, which will come. Well, I want to thank you for your time today, and congratulate you on the receipt of this award. We are very excited to have you become part of the PCF community, and look forward to your results.