Primary Care Paediatrics in Hong Kong



Preamble



As declared in the World Declaration on the Survival,


Protection and Development of Children 1990 – “The


children of the world are innocent, vulnerable and


dependent. They are also curious, active and full of hope.


Their time should be one of joy and peace, of playing,


learning and growing. Their future should be shaped in


harmony and co-operation. Their lives should mature, as


they broaden their perspectives and gain new experiences.


The well-being of children requires political action at the


highest level”. Interest of children must be accorded high


priority in all government policies that will have effect on


children. The health of children should be promoted,


protected and maintained with our best effort.



Introduction



The neonatal and infant mortality rates have improved


significantly over the past three decades in Hong Kong


(Figure 1).


1 However, over the period, there has been

considerable change in psycho-socio-economic


environment that has tremendous adverse impact on the


health of the children of Hong Kong.


2 The health needs of

children have changed dramatically. Paediatricians, being


the best trained professional to understand those needs and


be able to provide quality health care services to infants,


children and adolescents within the context of their family,


community and environment have a mammoth task of


renovating the child health services to meet these


challenges.



Changing Psycho-socio-economic Environment


and Health Status of Children



Demography



In the 60s, Hong Kong was called the City of Children


where almost 40% of the population was under 15 years of


age and at end of 2000 the total population is 6.87 million


with 17.2% and 11.2% <15 years of age and 11.2% over


64 years of age respectively (Figure 2). The birth rate has


been on the decrease (Table 1)


3, however, every year about

thirty thousand children from mainland immigrate to Hong


Kong. They will contribute to about a third of our new


childhood population posting considerable challenges to


our education, social and health care system.



Physical Health



With urbanization, children are exposed to many


environmental hazards especially air and water pollution


that are detrimental to their well being. Asthma and allergy


rates are on the rise. With improvement in living standards,


nutritional deficiencies are a rarity but what follows are


problems of unhealthy eating habit, physical inactivity and


obesity.


4 With improvement in medical care and provision

of active immunization programme and other public health


measures, infectious diseases and many acute illnesses are


adequately treated or controlled and the challenges now


are injuries as leading cause of death and disability and


rehabilitation and care of children with chronic illnesses or


handicaps.



Psycho-social Health



The social and cultural environment has shown


remarkable changes over the past three decades (Table 2).


5

Traditional extended families have increasingly been


replaced by small nuclear families. Many young and


inexperienced couples have difficulties in coping with child


rearing problems and are not provided with sufficient help


from their elders within the family nor from the community.


There have been considerable changes in family structures


– single parent and divorce rate are increasing, more


children have both parents under employment etc. Parents


tend to spend less and less time with their children leaving


them exposed to influence of media especially the electronic


means, video games and internets. However, children are


under enormous pressure to excel in academic performance.


The modern family is increasingly under stress and have


lead to increase in physical and psychological morbidities


besides child abuse/neglect and injuries. In a recent survey,


Hong Kong children are the most unhappy group in Asia.


The societal relationships and values of older generations


are very different from the newer generations. The values


associated with post-war need for survival, shelter, stability


and the consequent need for authority and external control


have shifted towards expectations for a good quality of life


including health, decline in trust in institutions and


authorities, less compliant and more questioning and


demand for real control over one’s own life and local


circumstances. The recent economic downturn with increase


in unemployment rate together with rapidly changing


political environment has added significant sense of


uncertainties and anxiety among adults and children alike.


The rich-poor divide has widened and some 300,000


children lives in poverty. All these have generated


tremendous psycho-socio-medical child health problems


in the community that have not been properly recognized,


adequately studied nor tackled.


It is important to note that people tend to form their


values between 17 and 24 years. These are then carried


throughout life with only marginal change over the years.


Children and adolescents’ attitudes are largely shaped by


family and social environment they live through. With


globalisation, the influence of the mass media especially


television can be considerable and evidence has shown that


this may lead to increase in violence and risk behaviours.


Another way in which the child is influenced without our


overt awareness concerns peer pressure. This is an immense


influence in persuading a child or adolescent to smoke, try


drugs or experiment with sex. The survey by District Board


of Central-Western District in 1991 confirmed that 70% of


adolescents first tried drugs for fun or curiosity and the


main source was from friends. The 1999 survey by the


Council of Social Service is even more worrying.


Employers considered 85% of our youths lack sense of


responsibility and 40% was poor in interpersonal


relationship and lack communication skills. About half of


our youths would consider using illegal means to earn


money if needed. These psycho-social problems and


insidious pollution of the mind may be a far more potent


threat to the present and future generations than anything


else. The social developmental trend of children and youth


in past two decades has shown significant deterioration


compared with women and elderly as shown by a study by


The Hong Kong Council of Social Services


5 (Tables 2 & 3,

Figure 3).



Mental Health



The foundation for healthy growth and development


in later years is established to a large degree in the


first six years of life.



Towards a Healthy Future: Second Report on the


Health of Canadians.



F/P/T Advisory Committee on Population Health


(1999).


• All children are born wired for feelings and ready


to learn.


• Early environments matter and nurturing


relationships are essential.


• Society is changing and the needs of young


children are not being addressed.


• Interactions among early childhood science,


policy, and practice are problematic and demand


dramatic rethinking.


There is strong scientific evidence showing the


importance of early life experiences on the development


of the brain and the evolvement of human behaviour.


6

Research clearly demonstrates the strong links between an


adult’s health status and his or her coping skills, sense of


identity, competence and personal effectiveness. There is


strong evidence to support the fact that the development of


these important coping skills along with resistance to health


problems and overall health and well-being are profoundly


influenced by early childhood experiences.


7

With modernization and socio-economic changes, “new


morbidities” of behavioural or emotional problems, learning


disorders, decision problems (e.g. suicide, accidents and


violence), life-style problems (e.g. smoking, drug abuse,


unhealthy eating habit) and child abuse have emerged as


major health problems facing our new generation.


8-11 With

economic downturn, the rich-poor divide has widened


considerably with more and more children living in poverty.


Our children are now exposed to different sets of adverse


factors.



Value of Health to Children on Society



“Children are a quarter of our population but all of our


future”. Health and nutrition of children have long-term


effects on productivity and output because they influence


a child’s ability and motivation to learn. These effects, in


turn, influence adult productivity. The protection of health


and improvement of health status especially of the children


must therefore become fundamentals of any socioeconomic


policy.



Special Needs of Children



The health needs of children thus have changed


dramatically in the past few decades (Table 4).


To meet the basic health needs of children, they need be


provided with a safe, loving, nurturing and responsive


environment to grow and develop, to experience and learn,


to interact with people and to participate so to maximize


their full potential and become a responsible adult who can


meet the challenges of their futures. Their needs vary


considerably at different ages. The infant requires complete


care on some basic needs for survival which include feeding,


warmth, cleanliness, protection from harm and treatment


of acute or chronic illnesses. As they grow, in addition to


these basic needs, they will express their own wants to an


increasing extent and would demand respect and being


listened to although the young continue to need guidance


especially on such matters as safety and healthy life-style.


With greater independence and the start of formal education


come more opportunities for self-expression, risk-taking


attuned to experience, and social intercourse with peers and


other members of their community. They should be provided


with every opportunity to establish value for life and for


their full development in addition to advice on life-style,


social behaviour and counselling about future career and


other aspects of adult life. At all ages children need care,


affection and companionship best supplied by loving parents


and a warm accepting home. They will also need protection


from environmental hazards which may be physical,


chemical, psychological, social, moral or spiritual.


The health needs of children and their families are diverse


and ever changing. Thus, it is vital that they be taken care


of by professionals who are trained and experienced in


recognizing the needs of children and who can advocate


for them. There is a need to integrate the whole range of


health services and supports and to link this system to other


services to form a more comprehensive and coordinated


system of services and supports for expectant parents,


children and their families.



The Present Child Health Care Services



The bulk of curative primary health care is provided by


private sector and preventive care by Department of Health.


The more specialized problems are referred to specialist in


the Hospital Authority and the private sector (Tables 5 &


6). It is obvious that services for children are fragmented


and compartmentalized. A comprehensive ranges of


services are available but parents often need to shop or


approach several organizations for the services they need.


Communication not to mention collaboration that span


across all sectors: social, health care and education are


lacking. Continued emphasis has been on hospital paediatric


specialist care with little planning on preventive, protective


and promotive services. The system is non-responsive and


is unable to meet the changing trends of society and total


needs of children.



Maternal and Child Health (MCHC) Service (0-5 years)



At present, there are 50 MCHC centres providing health


and development surveillance, health education (on


breastfeeding, nutrition, childcare skills and home safety


etc.) and immunization services. A positive parenting


programme will be introduced to help parents to develop a


positive relationship, encourage desirable behaviour and


to teach new skills or behaviour to their children. Coverage


for immunization is very good however, attendance for


comprehensive observation scheme after one year of age


has not been high. Hearing screening is still mainly by


behaviour distraction test and pilot has been conducted on


the use of oto-acoustic emission (OAE) to replace


distraction test. The whole delivery system of the MCHC


needs reevaluation on its effectiveness, efficiency, training


and collaboration with other services.



Student Health Service (6-17 years)



Student Health Service with its 12 Student health service


centres and 3 special assessment centres provide voluntary


and free annual appointment for all students for assessment


and counseling to promote and maintain the physical and


psychological health of students to enable them to maximize


their potential for education. In 2000, 1445 schools with


684,510 students join the service. Participation rate is high


for primary school (98.3%) but much lower for secondary


school (74.7%). In the assessment the followings were


conducted: physical examination, screening for nutrition


& growth, blood pressure, vision, hearing, spinal curvature,


psychosocial health, sexual development, individual


counselling and health education. Abnormalities were


detected in 38% of students and the major problems were


visual abnormalities, growth problems (mainly obesity or


short stature), psychosocial problems, phimosis, scoliosis,


heart murmur and hearing defect. Those with special


problems will be further assessed at Special Assessment


Centres or referred to paediatricians for further management.


Child Assessment Services with its 7 centres provide


comprehensive physical, psychological and social


assessment for children with developmental anomalies.


They were usually referred from MCHCs or hospital for


assessment. Those with diagnostic problems will be


referred to Hospital Authority for diagnostic workup.


Developmental diagnosis followed by of formulation of


rehabilitation plan will be developed. The child will then


be referred to appropriate education facilities for


training, and education. Parental support and counselling,


talks and support groups will also be provided. Screening


is of little value in itself unless it leads to action with


adequate provision for subsequent assessment and ongoing


management. There is great needs for more integration


of hospitals and habilitation services.



Rehabilitation



The rehabilitation service is very much compartmentalized.


The Commissioner for Rehabilitation under


HWB is responsible for planning and coordination of


the services, however services at operation level are not


well coordinated. Communications and collaboration


among services providers at operation level are very


much lacking.



Clinical Genetic Service



It provides comprehensive genetic services to whole


territory through diagnosis, counselling, prevention and


overall management of genetic diseases. The Genetic


Screening Unit conducts screening programme for G6PD


deficiency and congenital hypothyroidism. The Genetic


Counselling Unit deals with over a thousand different types


of genetic diseases.



Child Protection



It is a great worry that the incidence and also complexity


of child abuses is on steady rise. It is well established that


being abused or neglected in childhood has profound effect


on the healthy development of a child. In 1998 a guideline


has been established for the multi-disciplinary handling of


child abuse cases. The emphasis is still mainly on the


investigatory side without much attention on the prevention


and management of abuse. There is little evaluation on the


effectiveness of the programmes. Coordination and


collaboration among different services providers is


improving but is still far from satisfactory.



Secondary and Tertiary Paediatric Services (Table 7)



Over 90% of hospital services and follow up of children


with chronic illnesses are provided by Hospital Authority


and over 90% of primary medical care provided by private


sectors. Communication and coordination of care between


the two sectors is still far from adequate.


Shared care programmes and referral guidelines/


protocols have been established among the services


however, the services are still fragmented with duplications


and poor coordination.



Need for Change in Delivery Model for Child


Health Services



The health of young children is affected by a wide range


of social, cultural, physical and economic determinants.


Health services, thus is part of a broader strategy for


improving health and issue of health is now much wider


than traditional health care and must include other issues


such as social (e.g. poverty, unemployment, and housing)


educational and economic concerns. To meet the needs of


children, well-child care will be an important part of child


health services. Well-child care will need to address total


needs of children and parents, as well as their time


limitations for accessing clinical visits.


Much of the ill health and injury that manifest among


children and young people is potentially preventable but


this has to be achieved through a multi-level, multicomponent


and multi-disciplinary approach following the


life-course of the child in the context of family and


community. Hence the goals of child health care services


should be:


1. Enhance the strengths and involvement of children in


creating, maintaining and improving their own health.


2. Ensure that all children have access to the necessary


conditions required for optimal health and growth.


3. Promote healthy behaviours and reduce the incidence


of preventable death, disability, injury and diseases.


4. Foster strong and supportive families, caregivers and


communities.


5. Ensure a safe, sustainable, high-quality, physical and


mental environment for all children.


6. Provide a comprehensive, cost-effective network of


policies, programmes and services for all children and


families that stresses health promotion, disease


prevention, protection and care.


To meet these goals, child health services needs to be


linked to other services to form a more comprehensive and


coordinated system of services and supports for expectant


parents, children and their families. Primary care


practitioner is usually the first point, and sometimes the


only point, of contact for a child and parent. It is essential


that primary care practitioners be connected to a network


or system of services that can support families through


pregnancy, birth and child rearing. Education and


preventive care (including screening, mental health care,


family planning and sexual health advice), and access to a


coordinated system of hospital and community services and


supports are crucial components of an integrated system to


support all expectant parents and families with young


children. It is critical that primary care providers have sound


knowledge about healthy child development, determinants


of health and the full range of available services and


supports in order that timely and appropriate referrals can


be made.



Emphasis on Integrated Preventive Services



As rightly pointed by the Hong Kong College of


Paediatricians in her submission to Government on


“Lifelong investment in Health” that Government should


concentrate on the following important issues in the delivery


of services related to child health:


1. Preventive Paediatrics:


• Primary prevention: to reduce incidence of disease.


• Secondary prevention: to reduce the prevalence of


disease by early diagnosis and treatment.


• Tertiary prevention: to reduce the complications of


established disease.


2. Acute care of sick and injured


3. Rehabilitation of disabled and chronically ill


4. Proper interface and collaboration among providers in


child health


Dual system of public and private practice.


Better coordination between health care services


and other service providers, such as education and


social services.


5. Research


6. Advocacy


The practice should also be re-designed so that they are:


i. Integrated childhealth services that is family centred.


ii. Delivered by trained & experienced specialist.


iii. More emphasis on quality of outcomes.



Needs for Primary Care Paediatricians



There is great need to train more Primary Care


Paediatricians whose role primarily involve ambulatory care


and includes co-ordination of care with other health care


professionals. The role of the primary care paediatricians


emphasizes continuity of care, comprehensiveness, and


coordination and the primary care pediatricians have an


extremely valuable and central role to play in the provision


of health care to children. The training, therefore, should


emphasize on the knowledge, skills, and attitudes necessary


for a sound foundation in general pediatrics for all possible


roles. The job included in the primary care paediatricians,


besides acute and general remedial care is extensive which


may include:


As seen from above, community child health as a whole


is an impossibly large portfolio of work. With advances in


technology and changes in service delivery model, the


distinction between hospital and community care is less


clear cut and in fact outdated – they form a continuum.


While children are best managed out of hospital, specialist


paediatric teams have a responsibility to ensure that care


of these cases be continuous either being provided by


specialists and/or a network of well informed and supported


competent community paediatricians. To be effective, we


do need an integrated child health care service model for


the delivery of services.



Community-based Integrated Child Health Care Service


Model



Thus a “Community-based Integrated Child Health Care


Model” (Appendix 1) was proposed by the Hong Kong


College of Paediatrians to set up network of health services


for children in which various child health disciplines will


be integrated and contribution by professionals in the private


and public sectors will be better coordinated.


13 A proper

interface and collaboration should be established among


various healthcare providers, namely the Department of


Health, Hospital Authority, private sectors and the Social


Welfare Department and schools. Rehabilitation services


for children with disabilities are currently compartmentalized.


The proposed “Child and Adolescent Health


Centres” could play a major role in the proper coordination


of these services. The services currently provided by the


Social Welfare Department, non-Government organizations


and Education Department for children with physical


disabilities, learning and behaviour disorders, hearing and


visual deficit could be better integrated. The role of the


centre is to ensure, through effective consultation and


referral systems, that children with illnesses or disabilities


would receive appropriate care, attention and educational


and social benefits.


These centres should be run by community paediatricians


who are trained and experienced in the care of children.


They are able to provide a continuing spectrum of care from


preventive paediatrics to providing medical treatment to


children. As specialists in the field of paediatrics, they will


effectively provide one-stop service for children and reduce


referrals to specialized care; hence significantly reduce


pressure on secondary and tertiary services in the hospitals


and thus the overall health care expenditure of the


community. These community paediatricians with their


better understanding the determinants and consequences


of child health and illness as well as the effectiveness of


services provided, are instrumental in improving the health


of children by creating, organizing and implementing


changes in communities. They will provide a far more


realistic and complete clinical picture by taking


responsibility for all children in the community, providing


preventive and curative services. The establishment of


“Child and Adolescent Health Centres” will enable a more


integrated approach in the care of children in the


community.




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