Hong Kong Med J 2015 Jun;21(3):261–8 | Epub 22 May 2015
DOI: 10.12809/hkmj144307
Translating evidence into practice: Hong Kong Reference Framework for Preventive Care for Children in Primary Care Settings
Natalie PY Siu, MB, BS, FHKAM (Family Medicine)1; LC Too, MB, BS, FHKAM (Family Medicine)1; Caroline SH Tsang, MB, ChB, FHKAM (Community Medicine)1; Betty WY Young, MB, BS, FHKAM (Paediatrics)2;
1 Primary Care Office, Department of Health, Hong Kong
2 Clinical Advisory Group on Hong Kong Reference Framework for Preventive Care for Children in Primary Care Settings, Hong Kong
Corresponding author: Dr Caroline SH Tsang (caroline_tsang@dh.gov.hk)
 Full paper in PDF
There is increasing evidence that supports the close relationship between childhood and adult health. Fostering healthy growth and development of children deserves attention and effort. The Reference Framework for Preventive Care for Children in Primary Care Settings has been published by the Task Force on Conceptual Model and Preventive Protocols under the direction of the Working Group on Primary Care. It aims to promote health and prevent disease in children and is based on the latest research, and contributions of the Clinical Advisory Group that comprises primary care physicians, paediatricians, allied health professionals, and patient groups. This article highlights the comprehensive, continuing, and patient-centred preventive care for children and discusses how primary care physicians can incorporate the evidence-based recommendations into clinical practice. It is anticipated that the adoption of this framework will contribute to improved health and wellbeing of children.
Advances in socio-economic conditions and health care delivery have contributed to improvement in child health indices in Hong Kong. For example, the infant mortality rate in Hong Kong is low by world standards, decreasing from 9.7 per 1000 live births in 1981 to 1.5 in 2012. Various problems, however, continue to affect the health of Hong Kong children. For instance, the increasing trend of obesity among primary and secondary school children has become a major public health concern.1 Injury is also a significant cause of mortality and morbidity in children. Many of these problems can be prevented.
In order to adopt the life-course approach to chronic disease prevention and health promotion, the Task Force on Conceptual Model and Preventive Protocols under the Working Group on Primary Care has identified two age-group–specific preventive reference frameworks, one of which is the Reference Framework for Preventive Care for Children in Primary Care Settings.2 It was developed according to the latest research evidence and with the support of the Clinical Advisory Group that comprises primary care physicians, specialists such as paediatricians, allied health professionals, and patient groups.
Many medical professionals have difficulty assimilating rapidly evolving scientific evidence into their practice. The reference framework provides an interface between research and practice, and aims to support health care professionals to promote health and provide continuing and comprehensive care for children in the community. It consists of a core document supplemented by a series of modules that elaborate on the various domains relevant to child health. This article highlights a practical use of this reference framework to improve the delivery of preventive care to children in the primary care setting.
Evidence-based preventive care for children
The core document of the reference framework provides evidence-based recommendations for comprehensive preventive care for children and can be categorised into various health domains, ranging from prenatal care to care for children with special needs. Preventive care activities for children applicable to the primary care setting are summarised in Table 1.

Table 1. Recommended preventive care for children in primary care settings
Continuing and patient-centred preventive care for children
The commitment of primary care physicians to preventive care of children is vital in the prevention of disease as well as early detection of problems and appropriate intervention. Every encounter with a child and/or the parents/caregivers should be an opportunity to promote healthy practices. Some forms of prevention should be delivered regularly, for example, vaccinations that should adhere to the locally recommended schedule. Other preventive care may be offered opportunistically, such as advice on dental care and physical activity. It is neither possible nor appropriate to initiate all preventive care at a single clinic visit. Nevertheless the long-term relationship between primary care physicians and patients allows provision of comprehensive and continuing care.
Practising preventive care for children in primary care
Primary care physicians may not have adequate time to go through the reference framework, especially in a busy clinic setting. It is nonetheless necessary to establish how recommendations of the reference framework can be applied to patient care. Four practical tips on application of the reference framework will be discussed below.
Make use of the two-page summary
The Primary Care Office has developed a two-page summary that can be downloaded from its website (Fig 1). Tabulating the various preventive activities according to age-group will enable primary care physicians to provide suitable age-specific preventive measures for their patients. The relevant chapter of the core document is identified for each aspect of preventive care, informing the primary care physician of where to find further information and supporting evidence. A summary can be posted on walls or on the desk in primary care consultation rooms to allow quick reference.

Figure 1. Two-page summary of the Hong Kong Reference Framework for Preventive Care for Children in Primary Care Settings
Make use of patient-education materials
Patient-based education interventions, especially those that involve patient-education material, have been reported to be effective in the implementation of clinical practice guidelines.3 Patient-education materials can also help more effectively deliver preventive advice. Resources related to the health care of children, such as transitional feeding (Table 2) and oral health (Table 3), are listed in annex 3 of the core document. A link to these resources can be accessed from the electronic version of the core document. These can be introduced to children and parents and enhance patient education.

Table 2. Resources on transitional feeding for children aged 6-24 months

Table 3. Resources on oral health
Record preventive care activities using checklists
Embedding guideline evidence into the processes and documents of patient care can help promote established evidence-based recommendations.4 Checklists of opportunistic preventive care can also be incorporated in patient medical records to allow clear documentation and facilitate any follow-up care. Primary care physicians can prepare their own checklists or utilise the ready-made checklists available in chapter 8 of the Module on Immunisation (Fig 2).

Figure 2. One of the checklists of immunisation and opportunistic preventive care from the Module on Immunisation
Deliver preventive care according to life stage
Childhood can be considered a sequence of life stages, namely prenatal, infancy, preschool, school age, and adolescence. Among the recommendations in Table 1, some items have particular relevance to particular life stages. For the care of an individual child in the primary care setting, preventive activities should be appropriate for age, risk status, and individual needs and values. Chapter 6 of the core document contains tables of preventive care for different life stages, and specifies the timing and action of various activities. Such a tailored approach to recommendations may ensure that the research-based message is more easily translated.5 The practice of preventive care for different life stages in daily practice can be illustrated as follows.
Prenatal care
Prenatal care is essential for a healthy outcome of pregnancy and should commence prior to conception. All women planning pregnancy should take daily folic acid supplement at a dose of 400 µg/day for at least 1 month before conception, and continue through the first trimester to reduce the risk of having a baby with neural tube defect.6 7 If the history of vaccination or infection is uncertain, the woman should be screened for rubella susceptibility and, if indicated, rubella vaccine administered 3 months before conception. Influenza vaccination should also be offered.8 In addition, screening for hepatitis B virus, human immunodeficiency virus, and syphilis infections should be offered if it has not been performed.9 10 11
Due to their harmful effect on fetal growth and development, women should be questioned about tobacco and alcohol use, and appropriate counselling offered.12 13 Breastfeeding should be promoted with relevant education and support commencing prenatally.14 15
Infancy (0-24 months of age)
Children and families experience rapid changes during the period of infancy. Immunisation for various infectious diseases is vital at this stage. Each visit of a child to their primary care physician provides an opportunity to confirm that immunisations are up to date. Other advice on preventive care can also be given at the same time, such as promotion of breastfeeding. Primary care providers can refer to the core document for strategies to promote breastfeeding and the principles of transitional feeding.
The long-term relationship between primary care physicians and families allows for surveillance of a child’s growth and development. Serial measurements of the weight and length of an infant should be recorded on a population-specific growth chart. Routine screening for hearing loss should also be arranged.
Visits to the primary care physician’s clinic provide an opportunity to observe relationships between parents and their children. Secure parent-child attachment in early childhood can be protective and provide a foundation for exploration and normal development.16 Parents can be helped to understand the concept of attachment and develop appropriate responses to the attachment behaviours of their young children. Parents’ psychosocial wellbeing and parenting capacity should be monitored and assistance given when indicated.
Preschool (2-5 years of age)
Young children should be provided with a balanced diet that comprises grains and cereals, vegetables and meat (including its alternatives, eg fish, poultry, eggs, beans, etc) in a ratio of 3:2:1 by volume.17
Ongoing surveillance of growth, and physical and psychosocial development should be undertaken in partnership with parents. Screening for vision problems should be offered for all children aged between 3 and 5 years to detect amblyopia or the presence of any risk for its development. Any parental concerns about a child’s development such as hearing, language, gross and fine motor development, and social behaviours should be elicited systematically. Updating a child’s developmental history by direct questioning of a parent or carer can assist in the identification of any abnormalities that warrant further investigation. Parents should also be asked if they have any concerns about their child’s behaviour. Testing for attention-deficit/hyperactivity disorder should be initiated if academic or behavioural problems and symptoms of inattention, hyperactivity, or impulsivity are present.
Parenting programmes have been shown to improve both child behaviour and parenting.18 19 20 21 22 As such, they should be promoted to parents.
Toddlers are prone to injury as they are active and love to explore their environment. Parents can be given advice on how to maintain a safe environment and prevent accidental injury.23
School age (6-12 years of age)
As children grow up, they can be expected to take on additional responsibility for their health. Healthy lifestyle advice, such as eating a healthy balanced diet and taking adequate physical activity, can be discussed during clinical consultations for episodic illnesses. It is recommended that children aged 5 years and above be involved in at least 60 minutes of moderate-to-vigorous–intensity physical activity each day.24 25 26 Children should minimise sedentary activity and avoid screen time of more than 2 hours per day.27 28 29 Differences can be observed in physical growth among children in this life stage. Screening for obesity can be offered for children aged 6 years and older, and appropriate weight maintained by counselling and behavioural intervention where indicated.30
School age is the time when learning difficulties or behavioural problems start to manifest. Primary care physicians can ask parents about progress at school and academic performance. Poor school performance may indicate an underlying learning or attention disorder. Children should be referred for detailed assessment if specific learning disabilities are suspected.
Adolescence (13-18 years of age)
Adolescence is the key transition stage between childhood and adulthood, a stage of attaining physical and sexual maturity. Adolescents are curious about new things and can be subject to peer pressure with consequent engagement in risk behaviour. When primary care physicians encounter adolescents, they have an opportunity to explore their psychosocial wellbeing. Information can be obtained about social life and extracurricular activities. Healthy activities such as sports and outdoor activities and healthy use of the mass media can be promoted as appropriate. If adolescents express boredom and loss of interest in their usual activities, depression should be suspected. Screening for a major depressive disorder can be conducted when systems are in place to ensure accurate diagnosis, psychotherapy, and follow-up.31
Smoking status for all teenagers should be established whenever the opportunity arises. Use of alcohol and illicit drugs should also be assessed using a non-judgemental approach. Adolescents who abuse either should be assisted to quit and referred for further management.32 33 Sexual history can be obtained and preventive counselling on sexual health issues delivered.34 High-intensity behavioural counselling is recommended to prevent sexually transmitted infections in all sexually active adolescents considered to be at increased risk.
Adolescents and their families should be encouraged to eat together: frequency of family meals has been inversely associated with poor academic performance, depressive symptoms, and risky behaviour such as tobacco and alcohol use.35
Chronic disease prevention and health promotion can begin in childhood. Effective delivery of preventive care to children depends on the combined efforts of health care professionals, social workers, teachers, and parents. Through provision of patient-centred, comprehensive, continuing and coordinated care, primary care physicians play a vital role in preventive care for children. The reference framework provides a common reference and guidance on a spectrum of preventive care activities for children. Adoption of the reference framework, its accompanying two-page summary, patient-education materials, and preventive care checklist enhances delivery of care. Practice of age-appropriate preventive care in different life stages can improve the health and wellbeing of children. Primary care physicians are in a privileged position to incorporate recommendations of the reference framework into clinical practice, and they are encouraged to familiarise themselves with the content of the reference framework. Development of new modules is underway to provide practical tips and information about topical issues already featured in the core document of the reference framework. Health care professionals are encouraged to visit the website of the Primary Care Office at www.pco.gov.hk and watch out for the new modules to be released, as well as information about seminars related to introduction of the reference frameworks. Feedback about implementation of the framework is welcome and will be valuable for revision of the core document and development of future modules.

Appendix. Hong Kong Childhood Immunisation Programme
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