Primary Care Paediatrics in Hong Kong

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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