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.
Credit:ivythesis.typepad.com
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