Child Health Service in Hong Kong
The Child Health Programme for Hong Kong
This is an introduction to the Integrated Child Health and Development Programme (ICHDP), which is a population-based, health promotion and disease prevention programme for children 0 to 5 and their families, delivered through a network of 31 Maternal and Child Health Centres in Hong Kong. It comprises the three components of parenting, immunisation and health and developmental surveillance. The Comprehensive Child Development Service, a 2005 government policy initiative, augments the ICHDP with service components that address the special needs of at risk pregnant mothers, families with psychosocial needs, mothers with postnatal depression and preschool children with developmental problems. The current programme covers about 90% of infants born to local parents.
Keyword : Child health services; Health promotion; Maternal-child health centres
Development is defined as "a systematic, organised, intra-individual change that is clearly associated with age-related progression, and is carried forward in some ways that have implications for a person's pattern or level of functioning at some later time".1 Developmental tasks or issues are conceptualised as being broadly integrative, cutting across the physical, cognitive and psychosocial domains. Issues or tasks at one stage lay the groundwork for subsequent ones.2
The Bio-socio-ecological framework views a child's development as being shaped by the interaction of both nature and nurture, including the child's biogenetic makeup, his/her experiences and interactions with others in the family, and the social environment.3-5 Though most researchers nowadays agree with this view, it is also thought that the relative influence of the two may vary depending on the aspects of development considered.6 For example, physical development is strongly influenced by nature and given the minimum necessary environment, maturation will occur. Cognitive development lies in the middle of the continuum. While internal forces are clearly at work, it is well known that a host of environmental factors can influence cognitive development. Social emotional development is at the other end of the continuum where environmental forces are influential but genetic factors are still operational.
It is therefore important that all children be provided with an enabling home and social environment in order to promote their holistic development and to safeguard their health. During the early years of a child's life, the family plays a fundamental and crucial role in the upbringing of the child. To create a health promoting home environment for the child, parents and other significant caregivers need to be equipped with the necessary knowledge and skills in childcare and parenting; spend adequate time (adequate in terms of both quantity and quality) with the child; maintain their own psychological well-being and be ready to receive social support if needed.
The Integrated Child Health and Development Programme (0-5)
The Integrated Child Health and Development Programme (ICHDP) is a population-based child health programme for 0 to 5 years that focuses on health promotion and disease prevention. The service is delivered through 31 Maternal and Child Health Centres (MCHCs). Every year, over 90% of the local newborn population are covered by this programme. The current ICHDP is the result of a review and re-development of the service since 2000, based on the needs of parents and the best evidence or model of good practice.7,8 It comprises the following 3 components designed to meet the developmental needs of preschool children in the physical, cognitive and psychosocial domains in a co-ordinated way. The three components are :
Parenting Programme - this new component was introduced in 2002. Parents are equipped with the knowledge and skills to take care of the child as well as to promote all aspects of their child's health and development. The universal parenting programme is for all expectant parents and parents/caregivers of pre-school children. They receive anticipatory guidance on childcare and parenting issues which are appropriate to the ages of their children. For parents of children with early signs of behavioural problems or those who encounter difficulties with parenting, an intensive parenting programme, the Positive Parenting Programme (Triple P) is available to help them deal with child behaviour problems.
Immunisation Programme - immunisation against nine infectious diseases (tuberculosis, hepatitis B, poliomyelitis, diphtheria, pertusis, tetanus, measles, mumps and rubella) is currently provided. The Childhood Immunisation Programme is recommended by the Scientific Committee on Vaccine Preventable Diseases (SCVPD) of the Centre for Health Protection of the Department of Health (DH). The SCVPD comprises paediatricians, infectious disease specialists and public health physicians, and is tasked to provide science-based advice on vaccine use at the population level.
Health and Developmental Surveillance Programme - health care professionals at the MCHCs work in partnership with parents and/or significant others in the continual monitoring of health and development of the child through:
Children with significant health and developmental problems are referred for assessment and management by relevant specialists of the Hospital Authority (HA) and/or the Child Assessment Service of the DH, while those with significant family or social problems are referred to social services for follow-up.
The Comprehensive Child Development Service
The ICHDP has been designed as a universal child health programme. However, there are children and families with various needs that may not be adequately addressed by the core programme, for example, at risk pregnant women and families with psychosocial needs. Furthermore, postnatal depression (PND) affects about 10% of mothers. Not only the mental health of the mother, but that of the partner, the marital relationship, mother-child interaction, and the long-term emotional, physical and cognitive development of the child are affected.9,10 Besides, some child developmental problems may not manifest themselves until the child starts school. To address these issues, the Comprehensive Child Development Service (CCDS) was introduced as a government policy initiative in 2005, to augment the universal child health programme. It works through better alignment of health, education and social services and comprises additional components that aim at early identification and management of the following four target groups.
At-risk Pregnant Women
Pregnant women with substance abuse or mental illness, or pregnant teenagers are identified and referred to hospital Obstetrics Departments by various health and social service professionals during the antenatal period. Comprehensive assessments are conducted and management plans are developed to provide coordinated care and support. The mother and child are subsequently followed up by visiting paediatricians at MCHCs to facilitate convenient access to specialist and primary child health services at the same time.
Families with Psychosocial Needs
An assessment tool has been devised to facilitate MCH nurses to assess the psychosocial needs of families during their routine child health visits at MCHCs. Families in need are referred for further management by the Integrated Family Service Centres, which consist of a family resource unit, a family support unit and a family counselling unit, providing a continuum of preventive, support and remedial services.11
Mothers with Postnatal Depression
Mothers are routinely screened for postnatal depression by MCH nurses during their 2-month child health visit, using the Edinburgh Postnatal Depression Scale (EPDS). Depending on the mother's needs, counselling or treatment is provided by trained MCH nurses, visiting psychiatric nurses, or psychiatrists. Mothers with other social needs are referred to social services for further management.
Pre-school Children with Developmental Problems
Pre-school teachers are provided with ongoing training on the identification and management of children with developmental problems. A formal mechanism has been developed to enable pre-school teachers to refer these children to MCHCs for management.
Quality Management of Programmes
As a standard practice, formative and process evaluations are carried out during the development of programmes or health information/resource materials to ensure they are user-friendly and relevant for clients. Outcome evaluation is conducted where possible to evaluate the effectiveness of the programmes. For example, to evaluate the effectiveness of the breastfeeding promotion programme, regular breastfeeding surveys are conducted in MCHCs to track the rates of breastfeeding. Results of these surveys revealed that the rate for all forms of breastfeeding (including exclusive, predominant and partial) at 2 months had increased from 22% for babies born in 1997 to 37.2% for those born in 2006, while that for 6 months increased from 9% to 22.6%. The rate of exclusive breastfeeding for 4 to 6 months was 6% for the 1997 cohort, increasing to 13.3% for the 2006 cohort. Prior to the implementation of the Positive Parenting Programme, a randomised controlled trial was conducted, with results indicating that the programme was effective in improving the parenting sense of competence, parenting practices and marital relationships as well as reducing child behaviour problems.12 A process and intermediate outcome evaluation of the CCDS, carried out about 15 months after the pilot demonstrated that the new initiative had facilitated intersectoral collaboration and organisational changes, resulting in the improvement of service quality in terms of access, acceptability and equity.13 A pilot infant hearing screening programme using the AOAE test showed that it out-performed the traditional DT and the results compared favourably with recommended benchmarks.14 Furthermore, training to equip MCH staff with the necessary knowledge and skills to effectively deliver the services, performance management (setting standards, regular assessment and coaching if indicated) as well as provision of opportunities for continuous learning have been put in place to ensure a high service quality.
1. Rutter M. Continuities, transitions and turning points in development. In: Rutter M, Hay DF, editors. Development through life: A handbook for clinicians. Oxford: Blackwell Scientific, 1994:1-25.
2. Sroufe LA, Rutter M. The domain of developmental psychopathology. Child Dev 1994;55:17-29.
3. Bronfenbrenner U. The ecology of human development. Cambridge: Harvard University Press, 1979.
4. Bronfenbrenner U. Ecological systems theory. In: Vasta R, editor. Annals of Child Development: Vol. 6. Six theories of child development: Revised formulations and current issues. Greenwich: JAI Press, 1989:187-249.
5. Buchanan A. Present issues and concerns. In: Buchanan A, Hudson B, editors. Promoting children's emotional well-being. Oxford: Oxford University Press, 2000:1-27.
6. Bee H. The developing child. 9th ed. Needham Heights: Ally and Bacon, 2000.
7. Leung CM, Chan HY, Chan KY, Chung A, Lai J, Leung S. Clients' perception of Hong Kong Government child health service: A qualitative study. HK J Paediatr (new series) 2002;7:255-62.
8. Hall D, Elliman D. Health for all children. 4th ed. New York: Oxford University Press, 2002.
9. Lee DT, Yip SK, Chiu HF, et al. Detecting postnatal depression in Chinese women. Validation of the Chinese version of the Edinburgh Postnatal Depression Scale. Br J Psychiatry 1998;172:433-7.
10. Luoma I, Tamminen T, Kaukonen P, et al. Longitudinal study of maternal depressive symptoms and child well-being. J Am Acad Child Adolesc Psychiatry 2001;40:1367-74.
11. Social Welfare Department (2005). Integrated Family Service [homepage on the Internet]. c2005 [updated 2008 Jan 11; cited 2008 Mar 1]. Available from: http://www.swd.gov.hk/en/index/site_pubsvc/page_family/sub_listofserv/id_228/
12. Leung C, Sanders M, Leung S, Mak R, Lau J. An outcome evaluation of the implementation of the Triple P-Positive Parenting Program in Hong Kong. Family Process 2003;42:531-44.
13. Evaluation Report of the Comprehensive Child Development Service (CCDS). Family Health Service, Department of Health, Hong Kong; 2007. Available from: http://www.fhs.gov.hk/english/reports/reports.html
14. Chan KY, Leung SL. Infant hearing screening in Maternal & Child Health Centres using Automated Otoacoustic Emission screening machines: a one-year pilot project. HK J Paediatr (new series) 2004;9:118-25.