Atopic eczema (AE) is a common childhood skin disease associated with pruritus and sleep disturbance.1 2 3 4 5 Childhood AE can substantially influence quality of life (QOL) among affected children and their parents. The extent of QOL impairment is often correlated with eczema severity, skin dehydration, and staphylococcal infection.6 Additionally, many affected children and their parents develop depression, anxiety, and stress symptoms.1 These mental health issues are correlated with disease severity, impaired QOL, and therapeutic non-compliance.1 7 8 A study using the 42-item Depression, Anxiety, and Stress Scales (DASS-42) found that depression, anxiety, and stress symptoms were present in 21%, 33%, and 23% of Hong Kong adolescent patients with AE, respectively.1 These psychological symptoms were significantly correlated with poor QOL.1 A study of Japanese children showed eczema severity was associated with mental health.9 Furthermore, a retrospective, cross-sectional population-based survey of childhood eczema in the United States revealed that increased eczema severity was associated with a higher risk of mental disorders.10 School-aged children with moderate and severe AE have a higher risk of psychosocial problems that can influence their quality of sleep and cognitive development.11 Emotion, attention, interpersonal relationships, and conduct can also be affected by AE.10 12 Moreover, parents are often unaware of potential psychosocial health issues in their children with eczema.13 Most affected children and their parents do not receive appropriate psychological help and support; they also exhibit low symptom recognition. The impacts of childhood eczema on the parent-child dyad have not been extensively studied in terms of healthrelated quality of life (HRQOL), eczema severity, or mental health status.14

This study was performed to examine associations between mental health issues and disease severity in children or adolescents with AE and their parents using the concise validated 21-item Chinese version of DASS-42 (DASS-21).1 15 16 17

This 2-year cross-sectional survey was conducted between November 2018 and October 2020. Participants with a diagnosis of AE and their parents were recruited at the paediatric dermatology clinic of a university-affiliated hospital in Hong Kong. Eczema was clinically diagnosed in accordance with the United Kingdom Working Party’s Diagnostic Criteria for Atopic Dermatitis.18 Participants and their parents received information about the study including objectives, procedures, voluntary participation, and right of withdrawal. Non-Chinese participants and individuals aged <11 years who were not accompanied by a parent during recruitment were excluded from the study.

The questionnaires were self-administered and supervised by research staff. Parents would help complete the Children’s Dermatology Life Quality Index (CDLQI), Infants’ Dermatitis Quality of Life Index (IDQOL), Nottingham Eczema Severity Score (NESS), and Patient-Oriented Eczema Measure (POEM) for their younger children. The DASS-21 was individually administered to all parents and to children aged >11 years.

The validated Chinese version of the three-item NESS, completed by children aged >11 years or the parents of children aged ≤11 years, was used to determine eczema severity in participating children.19 20 The presence of eczema and number of nights affected by skin itchiness each week in the past 12 months were rated from 1 to 5. A higher score indicated greater eczema severity. Additionally, areas of skin with eczematous lesions (eg, rash, lichenified skin, and/or bleeding) were recorded. Scores on the NESS were categorised as mild (3 to 8), moderate (9 to 11), and severe (12 to 15) eczema. Subjective measurements were determined using the validated seven-item Chinese translation of the POEM, which was also completed by children aged >11 years or the parents of children aged ≤11 years.21 22 Each item was scored from 0 to 4, with a maximum aggregate score of 28. A higher score indicated greater eczema severity in the past week (ranges of 0-2, 3-7, 8-16, 17-24, and 25-28 correspond to clear, mild, moderate, severe, and very severe levels of eczema, respectively).

Health-related QOL was evaluated using the Chinese version of the 10-item CDLQI23 and the 10-item IDQOL.24 The CDLQI was completed by children aged ≥4 years with guidance from parents, whereas the IDQOL was completed by parents of children aged <4 years. Each item on the two scales was scored from 0 to 3, with a maximum aggregate score of 30. A higher score indicated greater eczema-related HRQOL impairment in the past week (CDLQI ranges of 0-1, 2-6, 7-12, 13-18, and 19-30 correspond to no, small, moderate, very large, and extremely large effects on HRQOL, respectively; these ranges for IDQOL are 0-1, 2-5, 6-10, 11-20, and 21-30, respectively).

Mental health was assessed by measuring depression, anxiety, and stress in children with eczema and their parents using the validated Chinese version of the DASS-21. This scale has been used to examine symptoms of depression, anxiety, and stress among individuals with dermatitis or eczema.1 17 The DASS-21 was individually administered to all parents and to children aged >11 years. The DASS-21 composite score can be divided into the DASS Depression, DASS Anxiety, and DASS Stress domains. The total score for each domain ranges from 0 to 42.25 A higher score indicates greater emotional distress in that domain (DASS Depression ranges of 0-9, 10-13, 14-20, 21-27, and ≥28 correspond to normal, mild, moderate, severe, and extremely severe levels, respectively; these ranges for DASS Anxiety are 0-7, 8-9, 10-14, 15-19, and ≥20, whereas they are 0-14, 15-18, 19-25, 26-33, and ≥34 for DASS Stress).

Clinical data were de-identified and analysed using SPSS (Windows version 25.0; IBM Corp, Armonk [NY], United States). Frequency distributions were used to describe the demographic and clinical characteristics of participants. Continuous variables with normal distributions were expressed as means ± standard deviations (corrected to 1 decimal place). Nominal and ordinal variables were expressed in numbers with percentage (corrected to 1 decimal place). Independent samples t tests were used to explore sex differences regarding age, education level, disease severity, QOL, and emotional distress in parents and children. Pearson correlation analysis was utilised to examine associations among mental health, eczema severity, and HRQOL in parents and children of both sexes. Multiple linear regression was performed to adjust for variations in parental and child DASS scores and HRQOL according to demographic and clinical variables. P values <0.05 were considered statistically significant.

Among 380 parents (mean age=41.13±6.52 years), 49 were fathers (mean age=42.50±7.49 years) and 331 were mothers (mean age=40.95±6.36 years). Parents’ education levels were primary to secondary (n=124, 13 males), post-secondary (n=26, 1 male), and undergraduate or above (n=81, 14 males) [Table 1]. Parents reported moderate to extremely severe depression (n=58, 2 males), moderate to extremely severe anxiety (n=101, 5 males), and moderate to extremely severe stress (n=90, 6 males). Parents with a higher education level had lower levels of depression, anxiety, and stress (Fig 1). Compared with fathers, mothers generally had higher overall DASS-21 depression, anxiety, and stress scores (P<0.001-0.005) [Table 1].

Among 432 children (mean age=9.61±5.41 years), 218 were boys (mean age=9.15±5.44 years) and 214 were girls (mean age=10.06±5.35 years). Most children had moderate to severe/very severe disease according to the POEM (n=290) and NESS (n=291). Over half of the children displayed a moderate to extremely large impact on QOL in the CDLQI (n=171, 50.4%) and IDQOL (n=56, 62.9%). Small numbers of children had moderate to extremely severe depression (n=36), anxiety (n=43), and stress (n=30). There were no significant sex differences in disease severity, HRQOL, or emotional distress in the DASS (Table 2).

Disease severity in terms of NESS, POEM, and HRQOL (ie, CDLQI and IDQOL) was generally worse among infants than among older children (Fig 2). Thus, eczema severity and QOL generally appeared to improve with age. Correlation analysis demonstrated that depression, anxiety, and stress levels were significantly associated with NESS, POEM, and CDLQI, regardless of sex (Table 3).

Correlation analysis revealed that eczema severity (NESS and POEM) and HRQOL (CDLQI) were associated with depression, anxiety, and stress levels (DASS-21) among children and parents, regardless of sex (Table 3 and Fig 3). Moreover, depression, anxiety, and stress levels in mothers were significantly correlated with NESS, POEM, IDQOL, and CDLQI. Paternal anxiety and stress levels were correlated with NESS, POEM, and CDLQI (P<0.001 to 0.034). However, paternal depression was only correlated with POEM (P=0.014) [Table 3].

Maternal depression showed a marginal association with higher anxiety levels in boys with eczema (n=42, r=0.311; P=0.045) [Table 3]. However, considering the small number of pairs, no clinical or statistical inferences should be made regarding sex differences in mental health among children and parents. Additionally, there were no statistically significant associations between the mental health of children and parents concerning depression, anxiety, and stress levels in the DASS-21 (Table 3). Regression analysis showed that the child’s HRQOL and parental age mostly explained variation in parental anxiety and stress, whereas parental education level explained variation in parental depression (Table 4). Younger parents had higher risk of developing more anxiety and stress compared with the older parents. Depression level of parents with primary to secondary education was 58% higher than their counterparts with post-secondary education or above. Conversely, the child’s eczema severity and HRQOL mostly explained the child’s emotional distress. Eczema severity and parental emotional distress significantly affected HRQOL in children of all ages (Table 4).

There was no psychological or physiological discomfort resulted from administration of the surveys.

Psychological symptoms of depression, anxiety, and stress were prevalent among children with AE and their parents. Our findings indicate associations between the mental health of children and parents and the eczema severity in those children. Increased eczema severity in children and adolescents led to greater emotional distress in parents and children, regardless of sex. Similarly, psychological symptoms in children and their parents were negatively correlated with the child’s eczema severity (NESS and POEM) and HRQOL impairment (CDLQI or IDQOL), regardless of sex. These strong correlations suggest that psychological symptoms, eczema severity, and impact on QOL have mutually detrimental effects. The DASS depression, anxiety, and stress scores were generally higher among mothers than among fathers, suggesting that mothers (the primary caregivers for children with eczema) were more strongly affected. The present study showed that eczema severity can adversely affect emotions and QOL among parents and children, highlighting the need for further exploration of biopsychosocial interactions among children and adolescents with eczema. Children with severe disease reportedly have more problems with depression and internalising behaviour.26 Behavioural issues can lead to adverse social interactions with peers, further reducing self-esteem and HRQOL. Therefore, interactions among parental perception of the child’s disease severity, the child’s treatment adherence, the child’s social influence by peers, and the child’s school environment should be considered when clinicians make comprehensive decisions about holistic treatments.

Our results using the DASS-21 are consistent with findings in previous studies1 27 that used the more comprehensive DASS-42. As in previous studies,1 27 we found that caregivers were especially likely to experience anxiety related to care provision in the home.28 29 In the present study, maternal depression was associated with a higher anxiety level, particularly in relation to boys with eczema. Accordingly, the Harmonising Outcome Measures for Eczema initiative recommends documentation of disease severity and QOL impairment in eczema cases.25 30 However, there have been few international initiatives and clinical trials regarding the psychological symptoms of caregivers and patients, particularly in the context of childhood eczema. Therefore, we suggest that clinicians should consider these important measurable domains in terms of therapeutic interventions and psychological support. Childhood eczema treatments mainly focus on pharmacological control of physical symptoms, but they often completely neglect the psychological symptoms of affected children and their parents. A more holistic treatment approach is needed for this potentially devastating common childhood disorder. Given the increasing numbers of proposed assessment tools, we advocate a holistic and comprehensive approach for eczema management that considers children and their families. This treatment tool should use a composite score to continuously evaluate disease severity (in objective and subjective manners), QOL impairment, psychological symptoms, and miscellaneous disease surrogates in affected children and their parents.1 16 21 26

A strength of this study was that compared with the DASS-42, the DASS-21 demonstrated better performance with 50% fewer questions and a shorter completion time. Findings from the DASS-21, but not the DASS-42, were correlated with disease severity as measured by the NESS and POEM.1 These discrepancies could have arisen because the sample size in the present study (using the DASS-21) was threefold greater than the sample size in the previous DASS-42 study.1 In the present study, the DASS-21, especially in child and mother, was moderately to strongly correlated with the CDLQI, IDQOL, NESS, and POEM. Thus, the DASS-21 can effectively represent the degree of emotional distress among parents and children or adolescents with eczema. This questionnaire is available in different languages, potentially allowing it to be used for assessment of patients with other ethnicities. To our knowledge, this is the first study to use the DASS-21 to assess the mental health of parents and children with eczema in a paediatric setting. This study revealed the presence of childhood eczema-related depression, anxiety, and stress in affected children and their parents.

This study had a few limitations including its relatively small sample size, especially concerning father-child pairs. A greater proportion of mothers participated in this study, which is expected because mothers are the main caregivers for children with eczema; they typically accompany their children during medical consultations. Considering that paediatric dermatological clinics also cater adolescent patients aged ≥16 years, a few participants aged 16 to 19 years completed the CDLQI on their HRQOL; although these participants exceeded the suggested age range of ≤16 years, the overall results were not affected.

Another limitation is that the number of recruited mothers, who are normally regarded as the main child caregiver, much outweighs that of recruited fathers. In addition, compared with fathers, mothers may know their child’s health more and get anxious or depressed as the eczema severity of their child escalates over time. Thus, the difference of the role in childbearing, sample size and the understanding of child’s health may affect the findings in parental-child correlations. It should be cautious when the results regarding parental-child correlations are studied and presented. The CDLQI (n=339) is a questionnaire for children, and the IDQOL (n=89) is for infants. The different numbers of participants who completed each of these questionnaires is consistent with the CDLQI coverage of a broader age range, whereas the IDQOL is only suitable for children aged <4 years. Although maternal depression was correlated with boys with anxiety, it is important to note that statistical significance should not be used to infer that there is a sex difference between parent and child groups in terms of mental health; such an inference would constitute overgeneralisation.

Children with eczema and their parents demonstrated mental health impairment, which was correlated with disease severity. Eczema-induced anxiety, stress, and other mental health issues in affected children and their parents should be considered by healthcare professionals during comprehensive assessments for the treatment of eczema. In addition to primary eczema, possible secondary psychiatric symptoms should be monitored in children with moderate to severe eczema and their parents. Childhood eczema severity and the mental health of affected children and their parents should be simultaneously evaluated to prevent and manage secondary psychological problems.

Concept or design: KL Hon.
Acquisition of data: PH Lam.
Analysis or interpretation of data: PH Lam, P Ip.
Drafting of the manuscript: PH Lam, KL Hon.
Critical revision of the manuscript for important intellectual content: KL Hon, S Loo, MJ Koh, CHY Chan, CK Li, P Ip.

As an editor of the journal, KL Hon was not involved in the peer review process. Other authors have disclosed no conflicts of interest.

The authors thank all children and parents who participated in this research.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

This research was approved by the Joint Chinese University of Hong Kong–New Territories East Cluster Clinical Research Ethics Committee, Hong Kong (Ref No.: CRE.2018.401). Written informed consent was obtained from participants and parents prior to the research.

1. Hon KL, Pong NH, Poon TC, et al. Quality of life and psychosocial issues are important outcome measures in eczema treatment. J Dermatolog Treat 2015;26:83-9. Crossref

2. Leung AK, Hon KL, Robson WL. Atopic dermatitis. Adv Pediatr 2007;54:241-73. Crossref

3. Leung TN, Hon KL. Eczema therapeutics in children: what do the clinical trials say? Hong Kong Med J 2015;21:251-60. Crossref

4. Hon KL, Lam PH, Ng WG, et al. Age, sex, and disease status as determinants of skin hydration and transepidermal water loss among children with and without eczema. Hong Kong Med J 2020;26:19-26. Crossref

5. Hon KL, Wong KY, Leung TF, Chow CM, Ng PC. Comparison of skin hydration evaluation sites and correlations among skin hydration, transepidermal water loss, SCORAD index, Nottingham Eczema Severity Score, and quality of life in patients with atopic dermatitis. Am J Clin Dermatol 2008;9:45-50. Crossref

6. Holm EA, Wulf HC, Stegmann H, Jemec GB. Life quality assessment among patients with atopic eczema. Br J Dermatol 2006;154:719-25. Crossref

7. Slattery MJ, Essex MJ, Paletz EM, et al. Depression, anxiety, and dermatologic quality of life in adolescents with atopic dermatitis. J Allergy Clin Immunol 2011;128:668-71. Crossref

8. Magin PJ, Pond CD, Smith WT, Watson AB, Goode SM. Correlation and agreement of self-assessed and objective skin disease severity in a cross-sectional study of patients with acne, psoriasis, and atopic eczema. Int J Dermatol 2011;50:1486-90. Crossref

9. Kuniyoshi Y, Kikuya M, Miyashita M, et al. Severity of eczema and mental health problems in Japanese schoolchildren: the ToMMo Child Health Study. Allergol Int 2018;67:481-6. Crossref

10. Wan J, Takeshita J, Shin DB, Gelfand JM. Mental health impairment among children with atopic dermatitis: a United States population-based cross-sectional study of the 2013-2017 National Health Interview Survey. J Am Acad Dermatol 2020;82:1368-75. Crossref

11. Fishbein AB, Cheng BT, Tilley CC, et al. Sleep disturbance in school-aged children with atopic dermatitis: prevalence and severity in a cross-sectional sample. J Allergy Clin Immunol Pract 2021;9:3120-9.e3. Crossref

12. Schmitt J, Apfelbacher C, Chen CM, et al. Infant-onset eczema in relation to mental health problems at age 10 years: results from a prospective birth cohort study (German Infant Nutrition Intervention plus). J Allergy Clin Immunol 2010;125:404-10. Crossref

13. Walker C, Papadopoulos L, Hussein M. Paediatric eczema and psychosocial morbidity: how does eczema interact with parents’ illness beliefs? J Eur Acad Dermatol Venereol 2007;21:63-7. Crossref

14. Ali F, Vyas J, Finlay AY. Counting the burden: atopic dermatitis and health-related quality of life. Acta Derm Venereol 2020;100:adv00161. Crossref

15. Wong KC. Psychometric investigation into the construct of neurasthenia and its related conditions: a comparative study on Chinese in Hong Kong and Mainland China [dissertation]. Hong Kong: The Chinese University of Hong Kong; 2009.

16. Lam PH, Hon KL, Leung KK, Leong KF, Li CK, Leung TF. Self-perceived disease control in childhood eczema. J Dermatolog Treat 2022;33:1459-64. Crossref

17. Gong X, Xie XY, Xu R, Luo YJ. Psychometric properties of the Chinese versions of DASS-21 in Chinese college students [in Chinese]. Chinese J Clin Psychol 2010;18:443-6.

18. Williams HC, Burney PG, Pembroke AC, Hay RJ. The U.K. Working Party’s Diagnostic Criteria for Atopic Dermatitis. III. Independent hospital validation. Br J Dermatol 1994;131:406-16. Crossref

19. Emerson RM, Charman CR, Williams HC. The Nottingham Eczema Severity Score: preliminary refinement of the Rajka and Langeland grading. Br J Dermatol 2000;142:288-97. Crossref

20. Hon KL, Ma KC, Wong E, Leung TF, Wong Y, Fok TF. Validation of a self-administered questionnaire in Chinese in the assessment of eczema severity. Pediatr Dermatol 2003;20:465-9. Crossref

21. Hon KL, Kung JS, Tsang KY, Yu JW, Cheng NS, Leung TF. Do we need another symptom score for childhood eczema? J Dermatolog Treat 2018;29:510-4. Crossref

22. Gaunt DM, Metcalfe C, Ridd M. The Patient-Oriented Eczema Measure in young children: responsiveness and minimal clinically important difference. Allergy 2016;71:1620-5. Crossref

23. Salek MS, Jung S, Brincat-Ruffini LA, et al. Clinical experience and psychometric properties of the Children’s Dermatology Life Quality Index (CDLQI), 1995-2012. Br J Dermatol 2013;169:734-59. Crossref

24. Lewis-Jones MS, Finlay AY, Dykes PJ. The Infants’ Dermatitis Quality of Life Index. Br J Dermatol 2001;144:104-10. Crossref

25. Gerbens LA, Prinsen CA, Chalmers JR, et al. Evaluation of the measurement properties of symptom measurement instruments for atopic eczema: a systematic review. Allergy 2017;72:146-63. Crossref

26. Hon KL, Kam WY, Lam MC, Leung TF, Ng PC. CDLQI, SCORAD and NESS: are they correlated? Qual Life Res 2006;15:1551-8. Crossref

27. Duran S, Atar E. Determination of depression, anxiety and stress (DAS) levels in patients with atopic dermatitis: a case-control study. Psychol Health Med 2020;25:1153-63. Crossref

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30. Spuls PI, Gerbens LA, Simpson E, et al. Patient-Oriented Eczema Measure (POEM), a core instrument to measure symptoms in clinical trials: a Harmonising Outcome Measures for Eczema (HOME) statement. Br J Dermatol 2017;176:979-84. Crossref

Despite high-quality care, many patients admitted to the intensive care unit (ICU) do not survive; therefore, management of the dying process is a required skill among modern healthcare professionals.1 Life-sustaining technology has advanced sufficiently that it is possible to maintain vital organ function despite the knowledge that the patient’s return to health and an acceptable quality of life is no longer feasible. In these situations, a decision to limit life-sustaining treatment (LST) has become a common clinical practice in most countries worldwide.2 3 4 5 6 In recent decades, attempts to define desirable principles for end-of-life care according to a global professional consensus have achieved considerable success.3 Nevertheless, decision-making processes for death and dying are likely to be heavily influenced by regional and cultural norms and expectations; thus, it is reasonable to expect different medical practices related to end-of-life decisions. Several local and international surveys of healthcare professionals have revealed regional differences in attitudes towards end-of-life ethical concerns, as well as substantial differences in clinical practices.7 8 9 10 11 Limited prospective observational data from international studies support the existence of regional variability in end-of-life practices.5 12 13

Hong Kong is a special administrative region of China with an overwhelmingly Chinese population; nevertheless, it maintains an independent fiscal budget and healthcare system. The Hong Kong Hospital Authority, funded by the Hong Kong SAR Government, provides >90% of hospital-based services available for the local population; although nearly all healthcare workers in the public health services exhibit Chinese ethnicity, health services are based on Western medical conventions.14 Hong Kong is considered a high-income region, and recently published patient outcomes data indicate that the Hong Kong Hospital Authority provides high-quality intensive care services.15 The juxtaposition of a Western medical system and a culturally Chinese population creates a situation where Western medical practices (driven by Western cultural and ethical values) may conflict with Chinese cultural values, particularly at the end of life when deep-rooted cultural beliefs may become more relevant. A small number of studies have explored end-of-life care practices in Hong Kong ICUs; these include a survey of ICU physicians’ ethical attitudes concerning end-of-life care8 and a prospective observational study regarding end-of-life practices at a single tertiary university hospital.16 No observational territory-wide data have been published thus far. Additionally, end-of-life practices in Europe have substantially changed in recent decades17; similar changes may have occurred in Hong Kong, although previous comparative data are sparse.16 Multiple Hong Kong ICUs participated in the recent worldwide Ethicus-2 study,13 18 with the understanding that the Hong Kong data would be accessible for secondary analysis. The aim of this study was to provide a detailed description of current end-of-life care practices in Hong Kong.

This study constituted a secondary analysis of the Ethicus-2 database, focusing on the Hong Kong data. The Ethicus-2 study was a prospective, multicentre, global observational study of end-of-life practices in 199 ICUs across 36 countries.13 17 All 15 adult ICUs in publicly funded hospitals in Hong Kong were invited to participate by the Hong Kong study coordinator, representing the Hong Kong Society of Critical Care Medicine. Eight ICUs in Hong Kong participated.

Consecutive adult patients admitted to the ICU over an individual ICU-selected 6-month period between 1 September 2015 and 30 September 2016 with LST limitation or death were included. Follow-up continued until death or 2 months from the initial decision to limit LST. End-of-life categories included withholding LST, withdrawing LST, active shortening of the dying process, failed cardiopulmonary resuscitation (CPR), and brain death. These categories were mutually exclusive; if more than one limitation was triggered in a particular case, the most stringent limitation was chosen (ie, active shortening of the dying process was considered more stringent than LST withdrawal, followed by LST withholding).

Data were collected by the senior physician, or a representative, responsible for making end-of-life decisions. De-identified patient data were entered into a secure online database. Collected data included age; sex; religion; end-of-life category; admission date, time, and diagnoses; chronic disorders; use of ventilation and vasopressors, sedatives, or analgesics; date and time of hospital and ICU admission; and date and time of death or discharge from the ICU or hospital. End-of-life process data collected included type, date, and time of LST; presence of information about patient wishes; discussions with the patient or their family; degree of concurrence between the decision and patient/family wishes; and reasons for treatment decisions.

Data quality was monitored by concurrent audit and feedback, with a quality review involving 5% of all patients.17 Categorical variables were reported as numbers and percentages within end-of-life groups. After normality assessment using the Shapiro–Wilk test, continuous variables were reported as means (standard deviations) or medians (interquartile ranges [IQRs]), as appropriate. Differences among LST withholding, LST withdrawal, and no LST limitation groups were compared using analysis of variance, the Kruskal–Wallis H test, or the Chi squared test, as appropriate. Subsequent pairwise group comparisons were performed with Bonferroni correction for multiple tests. All analyses were performed using SPSS software (Windows version 27.0; IBM Corp, Armonk [NY], United States).

This prospective observational study has been reported in accordance with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) checklist for observational studies.

The eight participating ICUs were distributed across Hong Kong; at least two ICUs represented each of the New Territories, Kowloon, and Hong Kong Island. Two ICUs were located in academic university hospitals (comprising 20 and 25 acute ICU beds, respectively), and the remainder were located in medium-to-large regional hospitals (ranging from 12 to 22 acute ICU beds per unit).

Among the 4922 consecutive patients screened during the study period, 548 (11.1%) patients with LST limitation (withholding or withdrawal) or death (failed CPR or brain death) were included in the study. Life-sustaining treatment limitation occurred in 455 (83.0%) patients, including 353 (77.6%) with decisions to withhold LST and 102 (22.4%) with decisions to withdraw LST. Of the 93 patients who died without LST limitation, 80 (86.0%) had failed CPR, and 13 (14.0%) experienced brain death (Fig 1). No patients underwent shortening of the dying process.

Patient characteristics are summarised in Table 1; knowledge of patient and family/surrogate wishes, as well as the timing of end-of-life processes, are described in Table 2. Patients without LST limitation had a shorter duration of ICU stay (median: 3 days, IQR=1-6) compared with patients who had decisions to withhold (median: 4 days, IQR=2-13) or withdraw (median: 6 days, IQR=3-11) [P<0.001].

The prevalences of treatments withheld or withdrawn at the initial and final decisions to limit LST are shown in Figure 2. Higher percentages of patients had endotracheal tube (P=0.009), renal replacement therapy (P<0.001), and sedation/analgesia (P=0.002) withheld at the final decision, compared with the initial decision. Similarly, higher percentages of patients had endotracheal tube, mechanical ventilation, vasopressor, and renal replacement therapy withdrawn at the final decision (all P<0.001), compared with the initial decision.

Information about decision-making practices for patients with LST limitation is provided in Table 3. In the majority of cases, the ICU physician was involved in key aspects of end-of-life decision-making and implementation. The responsible ICU physicians’ explanations of the reasons and considerations for supporting end-of-life decisions are provided in Table 4. The primary clinical reason for limiting LST was unresponsiveness to maximal therapy; the patient’s best interest, perceived good medical practice, and autonomy were key decision-making considerations.

This is the first large, multicentre, prospective, observational study of end-of-life care practices in Hong Kong ICUs. Our main findings were that LST limitation preceded >80% of patient deaths, and that death occurred in the vast majority of patients with LST limitation; only 4% of patients with LST limitation were alive at 2 months. Only 15% of ICU patients died after failed CPR (ie, without any LST limitations). Advance directives were rarely available, and no cases of active shortening of the dying process (euthanasia) were reported. Life-sustaining treatment limitation occurred in the majority (83.0%) of patients, predominantly via withholding (77.6%); withdrawal was less common (22.4%) [Fig 1]. High rates of LST limitation, such as those observed in this study, are generally presumed to reflect good end-of-life practices and have been associated with the presence of written end-of-life guidelines,19 such as those provided by the Hong Kong Hospital Authority.20

Regarding treatments that were withdrawn or withheld, the withholding of CPR universally accompanied all limitation decisions. Nutrition, hydration, and sedation were rarely withheld or withdrawn at any time, consistent with guidance from professional bodies in Hong Kong that additional safeguards are necessary when considering these actions.20 At the time of the initial limitation decision, there was relatively frequent withholding of vasopressors and renal replacement therapy; withholding or withdrawal of endotracheal tubes was less common. Although the patterns of LST limitation were similar between the initial and final decisions, such that withholding remained more prevalent than withdrawal, a substantial increase was observed in the prevalence of LST withdrawal at the time of the final decision. This finding may reflect the common Chinese cultural perspective that LST withholding and withdrawal are not ethically equivalent, with a documented preference for withholding over withdrawal as an end-of-life care strategy.8 11 The increase in withdrawal prevalence at the time of the final decision across key treatment categories (eg, vasopressors, mechanical ventilation, and renal replacement therapy) suggests that, with increasing prognostic certainty and clear progression towards death, LST withdrawal becomes more acceptable. There also appeared to be a greater reluctance to adopt withdrawal strategies early in the ICU stay, evidenced by the longer interval between ICU admission and initial limitation, if the initial limitation was withdrawal. This tendency may also reflect the need for greater prognostic certainty prior to the implementation of a withdrawal strategy. Comparisons with international data indicate that although the high rate of LST limitation prior to death is similar to practices in other countries, the early and more frequent use of withholding (rather than withdrawal) remains distinct from practices reported in North America, North and Central Europe, and Asia.13

Comparative historical data from Hong Kong are limited. A single-centre observational study conducted between 1997 and 1999 showed that LST limitation occurred in 59% of patients,16 although its LST limitation categories are not fully aligned with those of the current study. Notably, the mean interval between ICU admission and LST limitation in this previous study was nearly 8 days,16 whereas the median interval in the current study was 1.8 days (IQR=0.5-7); this difference suggests that recognition of the need for LST limitation is occurring much earlier in Hong Kong, consistent with a pattern observed in Europe during the same period.17 21 When LST limitation is indicated, earlier intervention leads to a shorter duration of patient discomfort; the observed reduction in time to limitation may represent a meaningful practice improvement over time.

Despite similar rates of LST withholding/withdrawal, the low rate of survival after LST limitation in Hong Kong (3%-4%)—comparable to the findings in a previous pan-European study12—contrasts with current European ICU outcomes, where the combined survival rate after LST withdrawal or withholding was 20%.17 This difference may possibly be attributed to implementing LST in patients at the very end-of-life when prognostic certainty is greater. The earlier implementation of end-of-life interventions may represent an area for further exploration to improve end-of-life ICU practices and minimise suffering.

Key practices in end-of-life decision-making included the initiation of discussions to limit LST by ICU physicians in the vast majority of cases; when such discussions began, ICU physicians were always involved in end-of-life decision-making processes. Notably, shared decision-making between ICU physicians and families was the predominant model reported. These findings align with the best practices described in recent international expert consensus documents.1 3 Despite frequent use of the shared decision-making model, direct or indirect knowledge of the patient’s wishes regarding LST was available for fewer than half of patients (40.3%); in the vast majority of cases (94.6%), this information was transmitted by relatives rather than by the patient themselves. Only 33 (6.0%) patients had decision-making capacity during the decision-making process, and only two (0.4%) patients had advance directives (Table 2). These results highlight the need to encourage patients to discuss their wishes regarding future end-of-life care preferences with relatives, or communicate such wishes through the use of advance directives, ensuring that patients receive the preferred level of care at this critical time. Nevertheless, levels of agreement among all parties regarding end-of-life decisions were high, and delays in decision-making due to disagreement were uncommon.

Advance directives in Hong Kong ICUs were rarely available, possibly due to selection bias; individuals with advanced disease and a greater likelihood of advance directives may have lower ICU admission priority. However, the current rate of advance directive use in North American ICUs at the end of life is nearly 50%.18 A relatively recent population-based study demonstrated very low public awareness of advance directives in Hong Kong, such that 86% of participants reported no previous knowledge of the advance directive concept.22 However, once informed of this concept, the majority of participants indicated a willingness to consider using such directives. The legislative process to formalise advance directive use in Hong Kong has substantially progressed, and there is a recognised need for public education and healthcare professional–specific guidance to promote the use of these directives.23 24

In the present study, the most common diagnostic categories at ICU admission were respiratory (43.4%) and sepsis-related (38.0%) [Table 1], similar to reported findings in most other regions worldwide.18 There were no substantial age or sex differences regarding LST limitation, but there were distinct differences in ICU admission diagnoses, such that limitation was less likely in patients with cardiovascular conditions and more likely in patients with sepsis or gastrointestinal disease. The vast majority of patients exhibited at least one co-morbidity, again similar to recently reported findings in other regions.18 Intriguingly, no patients with cancer were among those who died without LST limitation.

The primary clinical reasons for initiating LST limitation included unresponsiveness to maximal therapy, multiorgan failure, and neurologic failure; in few cases, the limitation arose from a family request or mainly in relation to quality of life (Table 4). Overwhelmingly, the primary consideration for decision-making was the patient’s best interest, followed by the principle of good medical practice, defined as the recognition that continued maximal therapy would not be beneficial for the patient (Table 4). These observations closely match the responses recently provided by a group of international experts who were asked to rank the triggers they would likely use in clinical practice to initiate discussions about LST limitation.1

Two questions related to decision-making and patient treatment wishes revealed an interesting observation. Across all end-of-life categories, approximately 70% of physicians in charge of end-of-life decision-making reported that if the patient’s wishes were known, they were followed. In contrast, when a surrogate’s treatment wishes were known, they were followed in nearly every case (Table 2). These responses indicate that the family’s treatment preferences are respected more frequently compared with known patient preferences, in contrast to guidelines from the Medical Council of Hong Kong25 and the Hospital Authority.20 Both guidelines clearly state that treatment preferences should be sought via communication with patients and family when possible, and a consensus should be reached; however, when conflicting views cannot be reconciled, the patient’s treatment preferences should supersede the family’s preferences.20 25 It is possible that physicians prioritised the family’s preferences because few patients were capable of direct communication; there was low certainty regarding perceived patient wishes when communicated through third parties. Nevertheless, this finding warrants further investigation and reflection among Hong Kong ICU healthcare professionals.

Most communication related to end-of-life decision-making occurred between ICU physicians and family/surrogates; nurses, primary physicians, and consulting physicians were involved in fewer than half of the reported cases. It has been suggested that this relatively low percentage of nurse involvement is an underestimate because most data were reported by physicians who may be unaware of nurse involvement.26 Decision agreement between healthcare staff and family members, as well as among family members, was reportedly very high (>95%) [Table 3]. Disagreements between family and staff were rare, as were delays in implementing end-of-life care because of disagreement, indicating a high level of acceptance of the decision-making process by the public and healthcare professionals in Hong Kong.

This study’s strengths included its involvement of a large number of patients over a 6-month period, provision of detailed follow-up data for up to 2 months, prospective design, and representation of most public ICUs in Hong Kong. Moreover, the data were provided by the physician in charge of end-of-life decision-making, with support from clear definitions and uniform collection across ICUs; they were also subjected to external quality control measures, minimising measurement bias. The main limitations were the lack of random ICU allocation and inclusion of consenting ICUs only, which may have introduced selection bias.

Data from the majority of Hong Kong ICUs, spanning the entire territory and representing both academic and non-academic ICUs, revealed that LST limitation occurs in most patients prior to death in ICU. Practices generally align with recommendations from local professional bodies and key international consensus documents. Although decision-making is usually initiated by ICU physicians, shared decision-making between medical staff and family/surrogates is the predominant model. Because a loss of decision-making capacity is common in the ICU, patients should be encouraged to communicate their wishes regarding end-of-life care through dialogue with relatives or more formal methods. Certain practices and outcomes observed in Hong Kong are more similar to those reported in North America and Europe than to patterns in other parts of Asia.

Concept or design: CL Sprung, A Avidan, GM Joynt.
Acquisition of data: GM Joynt, SKH Ling, LL Chang, PNW Tsai, GKF Au, DHK So, FL Chow, PKN Lam.
Analysis or interpretation of data: A Lee, GM Joynt.
Drafting of the manuscript: GM Joynt.
Critical revision of the manuscript for important intellectual content: All authors.

All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

All authors have disclosed no conflicts of interest.

No funding was obtained to conduct this research from any funding agency in the public, commercial, or not-for-profit sectors. The Walter F and Alice Gorham Foundation funded the international co-ordination of the Ethicus-2 study. The Foundation had no part in the design and conduct of the research; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

This research was approved by the relevant Research Ethics Committee for each of the participating centres, including:
(1) Tuen Mun Hospital—The New Territories West Cluster Research Ethics Committee of Hospital Authority, Hong Kong (Ref No.: NTWC/CREC/15078);
(2) Prince of Wales Hospital and North District Hospital—The Joint Chinese University of Hong Kong—New Territories East Cluster Clinical Research Ethics Committee, Hong Kong (Ref No.: 2015.080);
(3) Caritas Medical Centre—The Kowloon West Cluster Research Ethics Committee of the Hospital Authority, Hong Kong [Ref No.: KW/EX-15-103(88-02)];
(4) Kwong Wah Hospital—The Kowloon West Cluster Research Ethics Committee of the Hospital Authority, Hong Kong [Ref No.: KW/EX-15-105(88-04)];
(5) Pamela Youde Nethersole Eastern Hospital—The Hong Kong East Cluster Research Ethics Committee of the Hospital Authority, Hong Kong (Ref No.: HKEC-2015-028);
(6) Princess Margaret Hospital—The Kowloon West Cluster Research Ethics Committee of the Hospital Authority, Hong Kong [Ref No.: KW/EX-15-104(88-03)]; and
(7) Queen Mary Hospital—Institutional Review Board of The University of Hong Kong / Hospital Authority Hong Kong West Cluster, Hong Kong (Ref No.: UW 15-361).

The requirement for informed patient consent was waived by the relevant Clinical Research Ethics Committees as the study was observational only, where all collected data were anonymised at source and only de-identified data were passed on to the co-ordinating centre for analysis, and risk to participants was minimal.

Gary KF Au, Department of Intensive Care, Kwong Wah Hospital, Hong Kong SAR, China
Alexander Avidan, Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
KC Chan, Department of Intensive Care, Tuen Mun Hospital, Hong Kong SAR, China
WM Chan, Adult Intensive Care Unit, Queen Mary Hospital, Hong Kong SAR, China
LL Chang, Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China
FL Chow, Department of Intensive Care, Caritas Medical Centre, Hong Kong SAR, China
Gavin Matthew Joynt, Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
Gladys WM Kwan, Department of Intensive Care, Tuen Mun Hospital, Hong Kong SAR, China
Philip KN Lam, Department of Intensive Care, North District Hospital, Hong Kong SAR, China
Anna Lee, Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
E Leung, Adult Intensive Care Unit, Queen Mary Hospital, Hong Kong SAR, China
Steven KH Ling, Department of Intensive Care, Tuen Mun Hospital, Hong Kong SAR, China
CH Ng, Department of Intensive Care, Kwong Wah Hospital, Hong Kong SAR, China
HP Shum, Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China
Dominic HK So, Department of Intensive Care Unit, Princess Margaret Hospital/Yan Chai Hospital, Hong Kong SAR, China
Charles L Sprung, Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
L Sy, Department of Intensive Care, North District Hospital, Hong Kong SAR, China
Polly NW Tsai, Adult Intensive Care Unit, Queen Mary Hospital, Hong Kong SAR, China
HH Tsang, Department of Intensive Care, Kwong Wah Hospital, Hong Kong SAR, China
WT Wong, Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China

1. Joynt GM, Lipman J, Hartog C, et al. The Durban World Congress Ethics Round Table IV: health care professional end-of-life decision making. J Crit Care 2015;30:224-30. Crossref

2. Vincent JL. Forgoing life support in western European intensive care units: the results of an ethical questionnaire. Crit Care Med 1999;27:1626-33. Crossref

3. Sprung CL, Truog RD, Curtis JR, et al. Seeking worldwide professional consensus on the principles of end-of-life care for the critically ill. The Consensus for Worldwide End-of-Life Practice for Patients in Intensive Care Units (WELPICUS) study. Am J Respir Crit Care Med 2014;190:855-66. Crossref

4. Phua J, Joynt GM, Nishimura M, et al. Withholding and withdrawal of life-sustaining treatments in low-middle-income versus high-income Asian countries and regions. Intensive Care Med 2016;42:1118-27. Crossref

5. Lobo SM, De Simoni FH, Jakob SM, et al. Decision-making on withholding or withdrawing life support in the ICU: a worldwide perspective. Chest 2017;152:321-9. Crossref

6. Wong WT, Phua J, Joynt GM. Worldwide end-of-life practice for patients in ICUs. Curr Opin Anaesthesiol 2018;31:172-8. Crossref

7. Attitudes of critical care medicine professionals concerning forgoing life-sustaining treatments. The Society of Critical Care Medicine Ethics Committee [editorial]. Crit Care Med 1992;20:320-6. Crossref

8. Yap HY, Joynt GM, Gomersall CD. Ethical attitudes of intensive care physicians in Hong Kong: questionnaire survey. Hong Kong Med J 2004;10:244-50.

9. Yaguchi A, Truog RD, Curtis JR, et al. International differences in end-of-life attitudes in the intensive care unit: results of a survey. Arch Intern Med 2005;165:1970-5. Crossref

10. Bito S, Asai A. Attitudes and behaviors of Japanese physicians concerning withholding and withdrawal of life-sustaining treatment for end-of-life patients: results from an Internet survey. BMC Med Ethics 2007;8:7. Crossref

11. Weng L, Joynt GM, Lee A, et al. Attitudes towards ethical problems in critical care medicine: the Chinese perspective. Intensive Care Med 2011;37:655-64. Crossref

12. Sprung CL, Cohen SL, Sjokvist P, et al. End-of-life practices in European intensive care units: the Ethicus study. JAMA 2003;290:790-7. Crossref

13. Avidan A, Sprung CL, Schefold JC, et al. Variations in end-of-life practices in intensive care units worldwide (Ethicus-2): a prospective observational study. Lancet Respir Med 2021;9:1101-10. Crossref

14. Kong X, Yang Y, Gao J, et al. Overview of the health care system in Hong Kong and its referential significance to mainland China. J Chin Med Assoc 2015;78:569-73. Crossref

15. Ling L, Ho CM, Ng PY, et al. Characteristics and outcomes of patients admitted to adult intensive care units in Hong Kong: a population retrospective cohort study from 2008 to 2018. J Intensive Care 2021;9:2. Crossref

16. Buckley TA, Joynt GM, Tan PY, Cheng CA, Yap FH. Limitation of life support: frequency and practice in a Hong Kong intensive care unit. Crit Care Med 2004;32:415-20. Crossref

17. Sprung CL, Ricou B, Hartog CS, et al. Changes in end-of-life practices in European intensive care units from 1999 to 2016. JAMA 2019;322:1692-704. Crossref

18. Feldman C, Sprung CL, Mentzelopoulos SD, et al. Global comparison of communication of end-of-life decisions in the ICU. Chest 2022;162:1074-85. Crossref

19. Mentzelopoulos SD, Chen S, Nates JL, et al. Derivation and performance of an end-of-life practice score aimed at interpreting worldwide treatment-limiting decisions in the critically ill. Crit Care 2022;26:106. Crossref

20. Hospital Authority, Hong Kong SAR Government. Working Group on review of Hospital Authority Clinical Ethics Committee (HKCEC) guidelines related to EOL decisionmaking. HA Guidelines on Life-Sustaining Treatment in the Terminally Ill. 2020. Available from: https://www.ha.org.hk/haho/ho/psrm/LSTEng.pdf. Accessed 4 Jul 2023.

21. Lesieur O, Herbland A, Cabasson S, Hoppe MA, Guillaume F, Leloup M. Changes in limitations of life-sustaining treatments over time in a French intensive care unit: a prospective observational study. J Crit Care 2018;47:21-9. Crossref

22. Chung RY, Wong EL, Kiang N, et al. Knowledge, attitudes, and preferences of advance decisions, end-of-life care, and place of care and death in Hong Kong. A population-based telephone survey of 1067 adults. J Am Med Dir Assoc 2017;18:367.e19-27. Crossref

23. Food and Health Bureau, Hong Kong SAR Government. End-of-Life Care: Legislative Proposals on Advance Directives and Dying in Place Consultation Report. July 2020. Available from: https://www.healthbureau.gov.hk/download/press_and_publications/consultation/190900_eolcare/e_EOL_consultation_report.pdf. Accessed 4 Jul 2023.

24. Fong BY, Yee HH, Ng TK. Advance directives in Hong Kong: moving forward to legislation. Ann Palliat Med 2022;11:2622-30. Crossref

25. Medical Council of Hong Kong. Code of professional conduct: for the guidance of registered medical practitioners. Revised October 2022. Available from: https://www.mchk.org.hk/english/code/files/Code_of_Professional_Conduct_(English_Version)_(Revised_in_October_2022).pdf. Accessed 4 Jul 2023.

26. Benbenishty J, Ganz FD, Anstey MH, et al. Changes in intensive care unit nurse involvement in end of life decision making between 1999 and 2016: descriptive comparative study. Intensive Crit Care Nurs 2022;68:103138. Crossref

The advent of highly active antiretroviral therapy (HAART) in 1996 led to a substantial decrease in the incidence of opportunistic infections among people living with human immunodeficiency virus (HIV) in many regions.1 2 3 Nonetheless, HIV-associated tuberculosis (TB) remains an important global health challenge. The World Health Organization estimated that 10.6 million people were living with TB worldwide in 2021, 6.7% of whom were living with HIV.4 In the same year, 1.6 million people died of TB, including 187 000 people who were living with HIV.4 The burden of HIV-associated TB considerably varies across countries and regions.5 6 The prevalence of HIV-associated TB in individual areas reportedly changes over time.7 8 9 Awareness of changes in the epidemiology and clinical manifestations of patients with HIV-associated TB can help policymakers formulate timely relevant prevention and control measures. It can also help improve treatment outcomes for patients with HIV-associated TB.

In Hong Kong, the TB case notification rate has exhibited an overall decreasing trend over the past few decades.10 In 2021, the provisional number of TB cases reported to the Department of Health was 3741.11 The corresponding TB notification rate was 50.5 per 100 000 inhabitants, a substantial decrease from 84.1 per 100 000 inhabitants in 2006.11 The overall prevalence of HIV infection in the general adult population has remained low (<0.1%).12 The epidemiology and clinical manifestations of HIV-associated TB during the period 1996 to 2006 in Hong Kong have been reported.13 Notably, the report showed that TB had become an increasingly important acquired immunodeficiency syndrome (AIDS)–defining illness in Hong Kong, surpassing Pneumocystis jirovecii pneumonia as the most common primary AIDS-defining illness in 2005; the two illnesses represented 39% and 31% of all such illnesses, respectively, in 2005.13 The presentation of HIV-associated TB is often atypical.13 Considering the declining prevalence of TB in the general population and accompanying decrease in TB transmission in Hong Kong, the implementation of strategies to enhance screening for latent TB infection, the increased use of molecular tests for TB diagnosis, and the expansion of HAART in recent years, we conducted a retrospective review of data regarding patients with HIV-associated TB that were reported to the TB-HIV Registry of the Department of Health during the period 2007 to 2020. We aimed to identify temporal trends in the epidemiology and clinical manifestations of HIV-associated TB during that period.

We retrospectively reviewed data contained within the TB-HIV Registry, which captured information regarding nearly all cases of HIV-associated TB diagnosed in the Tuberculosis and Chest Service and Special Preventive Programme (SPP) under the Department of Health, as well as cases referred from regional hospitals of the Hong Kong Hospital Authority, during the period 2007 to 2020. The details of data contained in the TB-HIV Registry, along with the criteria for TB as a primary AIDS-defining illness, were described in a previous report.13 There have been no changes in the criteria for TB as a primary AIDS-defining illness since the last report. Where necessary, both clinic records and hospital discharge records were reviewed. All data were imported into Epi Info14 and exported to statistical software SPSS (Windows version 26.0; IBM Corp, Armonk [NY], US) for analysis. The Cochran–Armitage trend test in XLSTAT software (Lumivero, Denver [CO], US) was used to identify trends in the proportion of reported AIDS cases with TB as a primary AIDS-defining illness during the study period. The Cochran–Armitage trend test was also used to examine changes in demographic features and clinical manifestations during the same period. Where relevant, we compared the demographic features of patients reported to the TB-HIV Registry during the study period with the features of a historical cohort from the period 1996 to 200613 using the Chi squared test. P values <0.05 were considered statistically significant.

This study was an extension of a previous study designed to evaluate the public health programme for HIV-associated TB in Hong Kong15; it did not constitute research on human participants. Throughout the review process, we implemented all reasonable precautions to protect the confidentiality of personal data and excluded personally identifiable information from the electronic database.

All 390 cases reported to the TB-HIV Registry from 1 January 2007 to 31 December 2020 were included in this retrospective analysis. Information about whether TB constituted a primary AIDS-defining illness was available for 363 of 390 (93.1%) patients, where TB was listed as a primary AIDS-defining illness in 251 of those cases (69.1%). Overall, TB as a primary AIDS-defining illness represented a decreasing trend of 18.3% of 1375 reported AIDS cases during the period 2007 to 202012 (Cochran–Armitage trend test, P<0.001) [Fig], compared with 28.2% (192/680; Chi squared test, P<0.001) among the historical cohort of patients reported during the period 1996 to 2006.13

Trends in demographic features, including age, sex, case category, ethnicity, residence, primary source of care (first presentation), and smoking status, for the 390 HIV-associated TB cases reported to the TB-HIV Registry during the study period are shown in Table 1. The proportion of female patients significantly increased whereas that of ever-smokers significantly decreased (Cochran–Armitage trend test, P=0.035 and P=0.029, respectively). No significant trends were detected in other variables examined. Additionally, the proportions of Chinese individuals and permanent residents were lower in the present cohort than in the historical cohort of 1996 to 200613 (260/390, 66.7% vs 152/190, 80.0%; Chi squared test, P=0.001 and 258/390, 66.2% vs 144/190, 75.8%; Chi squared test, P=0.018, respectively). The proportion of female patients was significantly higher in the present cohort than in the historical cohort13 (82/390, 21.0% vs 21/190, 11.1%; Chi squared test, P=0.003).

Trends in clinical manifestations, including symptoms, presence of pulmonary TB, radiographic features (for cases with abnormalities on chest radiographs), presence of extrapulmonary TB (EPTB), most common EPTB sites, sputum smear positivity status, drug susceptibility patterns, presence of TB risk factors, CD4 cell count at TB diagnosis, presence of other AIDS-defining illnesses at the time of co-infection, and antiretroviral therapy (ART) status (among patients with a diagnosis of HIV infection before TB), among the 390 TB cases are presented in Tables 2 and 3. The proportions of patients presenting with site-specific symptoms (other than chest-related symptoms) and with EPTB both significantly increased during the period 2007 to 2020 (Cochran–Armitage trend test, P=0.029 and P=0.008, respectively) [Table 2]. The most common EPTB sites were lymph nodes (42.8%), pleura (21.5%), and abdomen (13.8%). Among patients who underwent sputum smear tests, the proportion of patients with sputum smear positivity significantly decreased (Cochran–Armitage trend test, P=0.006) [Table 2]. Among patients with lung parenchymal lesions on chest radiographs, a decreasing trend was observed in the proportion of patients in which the lower zone was the predominant lesion site (Cochran–Armitage trend test, P=0.045) [Table 3]. Among patients with a diagnosis of HIV infection before TB, the proportion of patients receiving ART at TB diagnosis significantly increased (Cochran–Armitage trend test, P=0.003) [Table 2].

This study revealed a decreasing trend in the proportion of reported AIDS cases with TB as a primary AIDS-defining illness during the period 2007 to 2020. The overall proportion (18.3%) was also lower than the proportion (28.2%) in the historical cohort of cases reported during the period 1996 to 2006.13 The proportions of Chinese individuals and permanent residents were lower, whereas the proportion of female patients was higher, in our cohort compared with the historical cohort.13 The proportions of female patients and patients with extrapulmonary involvement significantly increased, whereas the proportions of ever-smokers and the proportion with sputum smear positivity among pulmonary TB cases significantly decreased during the period 2007 to 2020. A decreasing trend was observed in the proportion of patients with pulmonary TB in which the lower zone was the predominant site of lung parenchymal lesions. Among patients with a diagnosis of HIV infection before TB, an increasing trend was observed in the proportion of patients receiving ART.

In Hong Kong, TB is considered an AIDS-defining illness when the disease is extrapulmonary. Pulmonary TB and cervical lymph node TB are considered AIDS-defining illnesses only when the CD4 cell count at the time of TB diagnosis is <200/μL, as recommended by the Scientific Committee of the Advisory Council on AIDS in 1994.16 Since then, there have been no changes in the criteria for TB as an AIDS-defining illness among individuals infected with HIV. The decreasing trend in Hong Kong regarding the proportion of reported AIDS cases with TB as a primary AIDS-defining illness might be due to decreased community transmission of TB through better TB control, the expansion of HAART since its introduction in 1997, and (perhaps to a lesser extent) increased acceptance of testing for latent TB infection and preventive treatment for TB among HIV-infected individuals since the early 2000s. Similar decreasing trends related to HAART-induced improvements in immune status among HIV-infected individuals have also been identified during studies conducted in some other countries.7 9 17 In an observational, retrospective study of AIDS cases included in the Barcelona AIDS register between 1994 and 2005, decreases were observed regarding the incidence of TB as an AIDS-defining illness among both native and immigrant populations.7 Another study examining trends in the incidence of AIDS-defining opportunistic illnesses over a 25-year period in Brazil showed a reduction in TB incidence from 1991-1993 to 2009-2012.9 A prospective cohort study of participants in the HIV Outpatient Study at 12 HIV clinics within the US indicated that TB incidence decreased after HAART introduction.17 Conversely, among participants in the HOMER cohort study (HAART Observational Medical Evaluation and Research) conducted during the period 1996 to 2007 in Canada, no statistically significant trends were observed in the proportion of cases with TB as the AIDS-defining illness, probably because the small number of TB cases reported in each time period limited the ability to detect significant changes in the reported cases.18 Another study examining AIDS notification data in Australia during the period 1993 to 2000 revealed that the proportion of AIDS cases with TB as the AIDS-defining illness was higher during 1996 to 2000 (post-HAART era) than during 1993 to 1995 (pre-HAART era); the authors attributed this difference to the increasing proportion of Australian patients with AIDS who had been born in sub-Saharan Africa and Asia during the 1990s, among whom the risk of TB was considerably higher.19 Further studies examining trends in TB as an AIDS-defining illness, as well as location-specific factors that may influence such trends in the post-HAART era, are warranted to facilitate control strategies for HIV-associated TB.

Further attention is needed regarding the observation of higher proportions of non-Chinese individuals (mostly Asians and Africans, who have much higher TB incidence than the rate among Hong Kong Chinese individuals) and non-permanent residents of Hong Kong in the 2007-2020 cohort compared with the historical 1996-2006 cohort. Similar findings of higher incidences of AIDS-associated TB in foreign-born populations from countries with much higher TB incidence compared with the native population have been reported on the basis of some studies conducted in developed countries.7 20 21 These observations highlight the need for TB screening and prophylaxis for people living with HIV who were born in countries with a high background prevalence of TB.

Intriguingly, we observed an increasing trend in the proportion of women during the period 2007 to 2020. The reason for this increase is unclear; it may be related to changes in the societal roles of men and women that influence exposure risk. The role of an increased proportion of EPTB (reportedly associated with female sex and observed throughout our cohort, as discussed below) requires further investigation.

The proportion of ever-smokers significantly decreased during the period 2007 to 2020, consistent with the findings of some studies conducted in the US.22 23 In an analysis of patients from a HIV surveillance system in the US, the prevalence of current smoking declined from 37.6% in 2009 to 33.6% in 2014.22 In another prospective cohort study that examined smoking trends among HIV-positive patients in the US, a decline in the annual prevalence of current smoking from 1984 to 2012 was also reported; however, disparities were noted according to race, ethnicity, and education.23 Nonetheless, because smoking increases HIV-related and non–HIV-related morbidity and mortality among people living with HIV, smoking cessation interventions remain an essential component of routine care for such individuals.

The predominance of the lower zone as the site of lung parenchymal lesions on chest radiographs is a relatively common feature among patients with HIV-associated pulmonary TB, according to our previous report on the 1996 to 2006 cohort13 and some other reports.24 25 The present study showed that the lower zone was less frequently the predominant site of lung parenchymal lesions during the period 2007 to 2020. The proportion of patients in the 2007 to 2020 cohort with the lower zone as the predominant site (16.7%) was also lower compared with the proportion of patients in the historical 1996 to 2006 cohort (32.4%).13 This difference may be related to the higher CD4 cell count at TB diagnosis among patients in the current cohort compared with patients in the historical cohort (median CD4 cell counts at TB diagnosis: 100/μL and 78/μL, respectively). Nonetheless, lower zone involvement was present in approximately one-sixth of pulmonary TB cases reported during 2007 and 2020. A high index of suspicion is required for the accurate and timely diagnosis of pulmonary TB in people living with HIV.

A decreasing trend was observed in the proportion of patients with sputum smear positivity during the period 2007 to 2020. The overall proportion of patients with sputum smear positivity in the 2007 to 2020 cohort (36.6%) was also lower than the proportion in the historical cohort of 1996 to 2006 (42.2%)13; it was similar to the proportion identified during a population database study in South Korea (36.4%).26 These results suggest that TB cases have been diagnosed at increasingly earlier stages due to enhanced active TB screening efforts among people living with HIV, as well as the increased use of molecular testing that enhanced the diagnosis of smear-negative cases in Hong Kong. These results highlight the need for continued TB screening efforts and early detection of TB among people living with HIV.

Our findings indicate that EPTB became more common among HIV-associated TB patients during the period 2007 to 2020. The overall proportion of patients with EPTB was also higher in the present cohort compared to that reported in a local study that examined risk factors for mortality in an earlier cohort (2006 to 2015) and that in the historical 1996 to 2006 cohort (71.0%, 64.9%,15 and 62.6%,13 respectively). These differences may have arisen through enhanced diagnosis of EPTB with the increased use of molecular testing in Hong Kong. An increasing trend of extrapulmonary involvement among TB patients has also been reported in some other studies, although such studies are mostly population-based.27 28 29 Few reports have been published regarding temporal trends in EPTB specifically among HIV-associated TB patients.30 Further studies are needed to examine these trends and associated factors.

Strengths of this study included its use of cohort data from the TB-HIV Registry covering a relatively long period (14 years) to study temporal changes in the epidemiology and clinical manifestations of HIV-associated TB. However, some limitations should be considered when interpreting the results of this study. First, the TB-HIV Registry may not capture all HIV-associated TB cases—some patients encountered in the SPP were not referred to a chest clinic but underwent anti-TB treatment in private clinics or other countries. The total number of HIV-associated TB cases in the HIV Surveillance Report of SPP was approximately 10% higher than the number in the TB-HIV Registry; the difference mostly comprised non-permanent residents temporarily staying in Hong Kong. Nonetheless, data from the HIV Surveillance Report showed a similar decreasing trend in TB as a primary AIDS-defining illness during the study period (data not shown). Second, this study utilised a retrospective design, and data present in the database of the TB-HIV Registry may be incomplete. Information regarding some parameters such as case category, co-morbidities, and CD4 cell count was unavailable for some patients. To overcome this limitation, we traced and reviewed relevant clinical records from chest clinics and hospitals when necessary. Therefore, we expect minimal bias due to missing data. Finally, the sample size may have led to insufficient statistical power for detecting temporal changes in some less common parameters.

This study showed that TB has become less important as a primary AIDS-defining illness in Hong Kong over the 14 years of the study period. Nonetheless, it remains the second most common primary AIDS-defining illness after P jirovecii pneumonia. Important temporal changes were also observed in the patterns of demographic features and clinical manifestations. Continued surveillance regarding the patterns of demographic features and clinical manifestations is needed to inform policymakers during the formulation of TB control strategies to improve patient care and treatment outcomes among people living with HIV. This surveillance is especially important in situations such as the coronavirus disease 2019 era, during which resources from TB programmes may be diverted to management of the global pandemic.

Concept or design: ACK Chan, SS Huang.
Acquisition of data: ACK Chan, SS Huang.
Analysis or interpretation of data: ACK Chan, SS Huang.
Drafting of the manuscript: ACK Chan, SS Huang.
Critical revision of the manuscript for important intellectual content: KH Wong, CC Leung, MP Lee, TY Tsang, WS Law, LB Tai.

All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

All authors have disclosed no conflicts of interest.

The authors thank all of their colleagues in the Tuberculosis and Chest Service and the Special Preventive Programme of the Department of Health who provided assistance and support to make this paper possible. The authors also thank Ms Ida KY Mak, Research Officer at the Tuberculosis and Chest Service of the Department of Health, for her dedicated efforts in maintaining the Tuberculosis–Human Immunodeficiency Virus Registry and assisting with the analysis.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

This research was a retrospective analysis of observational data routinely collected in a local Registry as part of the ongoing evaluation of the public health programme for human immunodeficiency virus–associated tuberculosis in Hong Kong. Approval for the evaluation and exemption from obtaining informed patient consent has been granted by the Ethics Committee of the Department of Health of the Hong Kong SAR Government (Ref No.: L/M 416/2017).

1. Low A, Gavriilidis G, Larke N, et al. Incidence of opportunistic infections and the impact of antiretroviral therapy among HIV-infected adults in low- and middleincome countries: a systematic review and meta-analysis. Clin Infect Dis 2016;62:1595-603. Crossref

2. B-Lajoie MR, Drouin O, Bartlett G, et al. Incidence and prevalence of opportunistic and other infections and the impact of antiretroviral therapy among HIV-infected children in low- and middle-income countries: a systematic review and meta-analysis. Clin Infect Dis 2016;62:1586-94. Crossref

3. Rubaihayo J, Tumwesigye NM, Konde-Lule J. Trends in prevalence of selected opportunistic infections associated with HIV/AIDS in Uganda. BMC Infect Dis 2015;15:187. Crossref

4. World Health Organization. Global Tuberculosis Report 2022. Geneva: World Health Organization; 2022. Available from: https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-report-2022. Accessed 4 Jul 2024.

5. World Health Organization. WHO releases new global lists of high-burden countries for TB, HIV-associated TB and drug-resistant TB. 2021. Available from: https://www.who.int/news/item/17-06-2021-who-releases-new-global-lists-of-high-burden-countries-for-tb-hiv-associated-tb-and-drug-resistant-tb. Accessed 4 Jul 2024.

6. Benito N, Moreno A, Miro JM, Torres A. Pulmonary infections in HIV-infected patients: an update in the 21st century. Eur Respir J 2012;39:730-45. Crossref

7. Martin V, García de Olalla P, Orcau A, Caylà JA. Factors associated with tuberculosis as an AIDS-defining disease in an immigration setting. J Epidemiol 2011;21:108-13. Crossref

8. González-García A, Fortún J, Elorza Navas E, et al. The changing epidemiology of tuberculosis in a Spanish tertiary hospital (1995-2013). Medicine (Baltimore) 2017;96:e7219. Crossref

9. Coelho L, Cardoso SW, Amancio RT, et al. Trends in AIDS-defining opportunistic illnesses incidence over 25 years in Rio de Janeiro, Brazil. PLoS One 2014;9:e98666. Crossref

10. Centre for Health Protection, Department of Health, Hong Kong SAR Government. Annual Report. Tuberculosis and Chest Service. 2020. Available from: https://www.info.gov.hk/tb_chest/doc/Annual_Report_2020.pdf. Accessed 16 Nov 2022.

11. Centre for Health Protection, Department of Health, Hong Kong SAR Government. Notification & death rate of tuberculosis (all forms), 1947-2022. Available from: https://www.chp.gov.hk/en/statistics/data/10/26/43/88.html. Accessed 17 Nov 2022.

12. Centre for Health Protection, Department of Health, Hong Kong SAR Government. HIV Surveillance Report—2020 Update. 2021. Available from: https://www.chp.gov.hk/ files/pdf/aids20.pdf. Accessed 16 Nov 2022.

13. Chan CK, Alvarez Bognar F, Wong KH, et al. The epidemiology and clinical manifestations of human immunodeficiency virus–associated tuberculosis in Hong Kong. Hong Kong Med J 2010;16:192-8.

14. Centers for Disease Control and Prevention, United States Government. Epi Info. Available from: https://www.cdc.gov/epiinfo/index.html. Accessed 4 Jul 2024.

15. Chan CK, Wong KH, Lee MP, et al. Risk factors associated with 1-year mortality among patients with HIV-associated tuberculosis in areas with intermediate tuberculosis burden and low HIV prevalence. Hong Kong Med J 2018;24:473-83. Crossref

16. Scientific Committee of the Advisory Council on AIDS Hong Kong. Classification system for HIV infection and surveillance case definition for AIDS in adolescents and adults in Hong Kong. 1995. Available from: https://www.aids.gov.hk/pdf/g40.pdf. Accessed 16 Nov 2022.

17. Buchacz K, Baker RK, Palella FJ Jr, et al. AIDS-defining opportunistic illnesses in US patients, 1994-2007: a cohort study. AIDS 2010;24:1549-59. Crossref

18. Jafari S, Chan K, Aboulhosn K, et al. Trends in reported AIDS defining illnesses (ADIs) among participants in a universal antiretroviral therapy program: an observational study. AIDS Res Ther 2011;8:31. Crossref

19. Dore GJ, Li Y, McDonald A, Ree H, Kaldor JM; National HIV Surveillance Committee. Impact of highly active antiretroviral therapy on individual AIDS-defining illness incidence and survival in Australia. J Acquir Immune Defic Syndr 2002;29:388-95. Crossref

20. Camoni L, Regine V, Boros S, Salfa MC, Raimondo M, Suligoi B. AIDS patients with tuberculosis: characteristics and trend of cases reported to the National AIDS Registry in Italy—1993-2010. Eur J Public Health 2012;23:658-63. Crossref

21. Dore GJ, Li Y, McDonald A, Kaldor JM. Spectrum of AIDS-defining illnesses in Australia, 1992 to 1998: influence of country/region of birth. J Acquir Immune Defic Syndr 2001;26:283-90.

22. Frazier EL, Sutton MY, Brooks JT, Shouse RL, Weiser J. Trends in cigarette smoking among adults with HIV compared with the general adult population, United States—2009-2014. Prev Med 2018;111:231-4. Crossref

23. Akhtar-Khaleel WZ, Cook RL, Shoptaw S, et al. Trends and predictors of cigarette smoking among HIV seropositive and seronegative men: the multicenter AIDS cohort study. AIDS Behav 2016;20:622-32. Crossref

24. Affusim C, Abah V, Kesieme EB, et al. The effect of low CD4+ lymphocyte count on the radiographic patterns of HIV patients with pulmonary tuberculosis among Nigerians. Tuberc Res Treat 2013;2013:535769. Crossref

25. Chamie G, Luetkemeyer A, Walusimbi-Nanteza M, et al. Significant variation in presentation of pulmonary tuberculosis across a high resolution of CD4 strata. Int J Tuberc Lung Dis 2010;14:1295-302.

26. Kim JM, Kim NJ, Choi JY, Chin BS. History of acquired immune deficiency syndrome in Korea. Infect Chemother 2020;52:234-44. Crossref

27. Ben Ayed H, Koubaa M, Marrakchi C, et al. Extrapulmonary tuberculosis: update on the epidemiology, risk factors and prevention strategies. Int J Trop Dis 2018;1:006.

28. Peto HM, Pratt RH, Harrington TA, LoBue PA, Armstrong LR. Epidemiology of extrapulmonary tuberculosis in the United States, 1993-2006. Clin Infect Dis 2009;49:1350-7. Crossref

29. Sandgren A, Hollo V, van der Werf MJ. Extrapulmonary tuberculosis in the European Union and European Economic Area, 2002 to 2011. Euro Surveill 2013;18:20431. Crossref

30. Mohammed H, Assefa N, Mengistie B. Prevalence of extrapulmonary tuberculosis among people living with HIV/AIDS in sub-Saharan Africa: a systemic review and meta-analysis. HIV AIDS (Auckl) 2018;10:225-37. Crossref

Benign prostatic hyperplasia (BPH) is characterised by a non-malignant growth in the prostate gland that can cause a wide range of lower urinary tract symptoms (LUTS). These symptoms can greatly reduce a patient’s quality of life (QoL) and may eventually lead to acute retention of urine (AROU).

Current standard treatments for BPH include conservative, pharmacological, and surgical approaches. For patients who fail to successfully complete a trial without catheter (TWOC) after AROU secondary to BPH, surgical intervention remains the main therapeutic approach. Surgical treatment options for BPH have evolved from electrosurgical resection to enucleation, ablation of the prostate, and other techniques.1 Transurethral resection of the prostate (TURP), first performed over 90 years ago, continues to be regarded as the gold standard for the treatment of BPH with prostatic volumes of 30 to 80 mL.2 Although TURP results in statistically significant improvements in symptom scores and maximum urinary flow rate (Q_max), it has some limitations. Perioperative morbidities and complications of TURP include infection, bleeding, urinary retention, incontinence, urethral stricture, erectile dysfunction, and ejaculatory dysfunction. Additionally, TURP requires general or spinal anaesthesia and postoperative hospitalisation. Through technological advancements, several minimally invasive procedures (eg, UroLift and prostatic artery embolisation) have been developed for specific groups of patients with BPH to minimise the aforementioned limitations.3 4 5 Among these new-generation BPH surgical approaches, transurethral water vapour thermal therapy (WVTT) provides some of the best surgical outcomes.

Transurethral WVTT uses the thermodynamic principle of convective energy transfer, whereas other techniques (eg, transurethral microwave thermotherapy or transurethral needle ablation of the prostate) involve conductive heat transfer.6 The thermal therapy system consists of a generator with a radiofrequency power supply that creates water vapour from sterile water, as well as a disposable transurethral delivery device. The tip of the delivery device contains an 18-gauge needle with 12 small emitter holes circumferentially arranged for water vapour dispersion into the targeted prostatic tissue. The release of thermal energy causes tissue necrosis. The most important characteristic of this technique is that, during treatment of the transitional zone, energy is only deposited within this specific region of the prostate. Reviews of histological evidence and magnetic resonance images have revealed that thermal lesions are limited to the transitional zone without affecting the peripheral zone, bladder, rectum, or striated urinary sphincter.7 8 At 6 months after treatment, the total prostatic volume is reduced by 28.9% and the resolution of thermal lesions, as determined by gadolinium-enhanced magnetic resonance imaging, is almost complete.8

A pilot study showed that transurethral WVTT can serve as a safe and effective treatment in men with LUTS due to BPH.8 In the first multicentre, randomised controlled study, 197 men were enrolled and randomised in a 2:1 ratio to treatment with the transurethral WVTT or a sham procedure.9 The sham procedure consisted of rigid cystoscopy with sound effects that mimicked the thermal treatment. The primary efficacy endpoint was met at 3 months: relief of symptoms, measured as a change in International Prostate Symptom Score (IPSS), was detected in 50% of patients in the thermal treatment group compared with 20% of patients in the sham procedure group (P<0.0001). In the thermal treatment group, the Q_max increased by 63%—from 9.9 mL/s to 16.1 mL/s (P<0.0001)—after 3 months. This clinical benefit was sustained throughout the study period, with a 54% improvement at the 12-month follow-up. In the most recent update regarding 5-year outcomes, the improvement in voiding (as measured by IPSS and uroflowmetry) had persisted for 5 years, with a surgical retreatment rate of 4.4%.10

Thus far, studies of transurethral WVTT for BPH have mainly focused on Caucasian populations. To provide information regarding its tolerability and effectiveness in the Chinese population, this study investigated the safety profile and efficacy of transurethral WVTT under local anaesthesia alone for BPH among Chinese patients in Hong Kong.

This retrospective study investigated transurethral WVTT for benign prostatic enlargement. The inclusion criteria included Chinese ethnicity and clinical indications for surgical treatment, including AROU or symptomatic LUTS due to benign prostatic enlargement. Exclusion criteria included active urinary tract problems such as infection, bleeding disorder, bladder pathologies (eg, bladder stones and neurogenic bladder), and urethral stricture, as well as urological malignancies including bladder and prostate cancer.

The procedure was performed with perioperative antibiotic prophylaxis. Patients were placed in the dorsal lithotomy position. After local anaesthesia, cystoscopy was performed to assess the anatomy of the bladder and prostate. A specialised handpiece with an optical lens was inserted under direct visual guidance into the prostate channel. Treatment began with the needle tip visually positioned and inserted approximately 1 cm distal to the bladder neck. Each treatment lasted for 9 seconds. After 9 seconds, an audible signal was produced by the system and the treatment needle was retracted. The handpiece was then repositioned 1 cm distal to the previous treatment site; repositioning was repeated until reaching a treatment site immediately proximal to the verumontanum. During each water vapour injection, the majority of the targeted tissue was treated. All treatment cycles involving one lateral lobe were completed as a group to utilise residual heat from prior treatments involving that lobe. Subsequently, the contralateral lateral lobe was treated in a similar manner. An enlarged median lobe could be treated by positioning the needle at a 45-degree angle towards the targeted lobe using the same technique. After the procedure, a 14-Fr Foley catheter was inserted. A 1-week course of antibiotic treatment was administered after surgery.10 Patients were discharged with the urethral catheter and readmitted for a TWOC at approximately 1 to 2 weeks after surgery. Upon satisfactory completion of the TWOC, patients were scheduled for follow-up at 3 months postoperatively.

Preoperative parameters and perioperative outcomes were collected and tabulated using SPSS software (Windows version 28.0; IBM Corp, Armonk [NY], United States). Descriptive statistics were used to summarise the demographic data and perioperative patient characteristics. Paired sample t tests were used to compare continuous variables with normal distributions; the Mann-Whitney U test was used to compare continuous variables with skewed distributions, and the Chi squared test was used to compare categorical variables. Two-sided P values of <0.05 were considered statistically significant.

Between June 2020 and December 2021, 50 eligible patients were included in this study. The median age was 71.5 years (interquartile range [IQR]=64-75.25). In terms of indications, 27 patients (54%) had symptomatic BPH, 13 patients (26%) had AROU with a urethral catheter, and 10 patients (20%) had AROU without a urethral catheter. Of the 50 patients, 39 (78%) were categorised as American Society of Anesthesiologists class 2, whereas the remaining 11 were categorised as class 3. Most patients (68%) did not use any antiplatelet or anticoagulant therapy. The numbers of patients using aspirin, clopidogrel, dual antiplatelet therapy, and apixaban were 11 (22%), three (6%), one (2%), and one (2%), respectively. All antiplatelet and anticoagulant agents were temporarily discontinued before the operation (Table 1).

The mean preoperative prostatic volume was 56.7 mL (standard deviation [SD]=24.6; range, 29.2-119.0). The mean operation time was 25.1 minutes (SD=8.4). All procedures were conducted under local anaesthesia alone. Lignocaine 1% with adrenaline was injected into the periprostatic space using a transperineal approach. The mean pain scores for transrectal ultrasound probe insertion, transperineal local anaesthesia injection, and transurethral WVTT were 2, 5, and 4, respectively.

Only one patient (2%) required bladder irrigation for 5 days postoperatively; that patient had been taking apixaban before surgery. All other patients were discharged on the same day with a urethral catheter. A TWOC was planned at around 1 week (for the AROU without urethral catheter or symptomatic BPH group) to 2 weeks (for the AROU with urethral catheter group) after surgery. Forty-eight patients (96%) in our study successfully completed a TWOC within 3 weeks postoperatively; the median time was 7 days (IQR=7-14). The median successful TWOC times were 14 days (IQR=8-21) for the AROU with urethral catheter group and 7 days (IQR=7-12) for the AROU without urethral catheter or symptomatic BPH group. Two patients (4%) with an initially unsuccessful TWOC began temporary clean intermittent self-catheterisation; they were subsequently weaned from this management approach on postoperative days 40 and 45, respectively.

Five patients (10%) had unplanned hospital admission within 30 days postoperatively due to surgical complications (Clavien–Dindo grade 1). The reasons for readmission are listed in Table 2.

There were significant differences in preoperative and 3-month postoperative parameters, including prostate-specific antigen level, post-void residual urine (PVRU) level, Q_max, IPSS, and QoL assessment. Table 3 shows the medians and IQRs of these data. As indicated in Table 4, the mean differences in PVRU, Q_max, IPSS, and QoL score were -41 mL (SD=107), +6.6 mL/s (SD=5.4), -10.9 points (SD=5.8), and -2.2 points (SD=1.5), respectively.

No patients in this study exhibited de novo retrograde ejaculation or stress urinary incontinence at 3 months postoperatively. However, there were three reported cases (6%) of new-onset erectile dysfunction postoperatively. All three patients had temporary erectile dysfunction that resolved within 6 months postoperatively without requiring medication.

Our study is the first to focus on the application of transurethral WVTT (Rezūm therapy) under local anaesthesia alone among Chinese men with BPH. Our results demonstrated clinically significant outcomes comparable to other treatments for BPH. Transurethral WVTT provided effective symptomatic improvement, as illustrated by a decrease in PVRU of 41 mL, an increase in Q_max of 6.6 mL/s, and a substantial decrease in IPSS of 10.9 at the 3-month follow-up (Table 4). These results were also comparable to outcomes in a recent international study of this therapy.10 The postoperative outcome was favourable, with a successful TWOC rate of 96% within 3 weeks postoperatively. Moreover, all patients with urethral catheters before surgery successfully completed a TWOC after transurethral WVTT. The median successful TWOC time was 7 days postoperatively. However, compared with data from other studies (4.1 to 5 days),11 12 our centre had a longer duration of catheterisation, which could be explained by our centre’s policy of scheduling a TWOC on postoperative days 7 and 14 for patients without and with a urethral catheter before surgery, respectively. Five patients were readmitted within 30 days after surgery due to haematuria, post-obstructive diuresis, recurrent AROU, and urinary tract infection with AROU (Table 2). All were uneventfully discharged without further readmission; none of them developed postoperative urinary incontinence. Three patients reported de novo erectile dysfunction, higher than the rate observed in the recent international study.10 However, the rate remained significantly lower than that associated with TURP.13 Considering the minimally invasive nature of this procedure, it could revolutionise future management of BPH.

The current management algorithm for BPH does not include transurethral WVTT as a first-line treatment due to the relative lack of evidence regarding its mid- to long-term efficacy and safety.2 However, it has considerable potential in the management of BPH because of unique advantages compared with TURP. Transurethral WVTT can be an office-based procedure with a short learning curve. If a surgeon completes 10 cases of transurethral WVTT under supervision, he/she will become independent from a surgical trainer. Because BPH is a particularly common urological disease and often requires surgical management,14 the minimally invasive nature of transurethral WVTT can help reduce the number of patients waiting for operations in overcrowded hospital facilities. The results of our study provide initial evidence that transurethral WVTT is well-tolerated among patients under local anaesthesia alone. We did not administer any sedation to the patients because they might move during the operation, resulting in a high risk of water vapour leakage. Such leakage would lead to inadequate treatment.

In Hong Kong, total health costs represent about 19% of the total government budget,15 and public in-patient health costs in 2021/2022 constituted 32% of total health costs.16 Operation time is one of the most important factors affecting in-patient costs. According to a meta-analysis by Mamoulakis et al17 in 2009, the mean operation time for TURP ranged from 39 to 79 minutes. In the present study, the mean operation time was 25.1 minutes. Thus far, no studies have directly assessed the cost-effectiveness of transurethral WVTT in the Chinese population. In the United States, a cost-effectiveness analysis of six therapies for BPH, published in 2018,18 showed that transurethral WVTT was more cost-effective than other minimally invasive therapies, such as combination medical treatment and UroLift. Moreover, McVary et al10 reported that the 5-year retreatment rate after transurethral WVTT was 4.4%, which was significantly lower than that after UroLift therapy (13.6%) reported by Roehrborn et al.5

Notably, transurethral WVTT leads to lower incidences of bleeding, urgency, urge incontinence, and ejaculatory dysfunction compared with TURP.19 The more favourable side-effect profile has resulted in considerable interest concerning its potential to replace TURP as the first-line surgical treatment in the future. No head-to-head trials have compared other surgical modalities with transurethral WVTT. Indirect comparison through a meta-analysis revealed that TURP outperformed transurethral WVTT by providing greater relief of LUTS,19 although it carried a greater cost and higher complication rate.18 Although pharmacological treatment is currently the first-line treatment for moderate to severe LUTS, it is associated with complications such as dizziness, postural hypotension, reduced libido, and erectile dysfunction. Gupta et al20 compared standard medical therapy with transurethral WVTT using cohort data from the MTOPS trial (Medical Therapy of Prostatic Symptoms); they showed that transurethral WVTT had superior outcomes in terms of QoL, IPSS, and prostatic volume reduction. Considering these advantages, transurethral WVTT can be regarded as a first-line treatment option for patients with symptomatic LUTS who prefer a short operation, rather than lifelong pharmacological treatment.

There were some limitations in this study. First, a substantial proportion of our patients had been catheterised preoperatively (74%) and thus could not undergo uroflowmetry studies before the operation. Due to the coronavirus disease 2019 pandemic and the associated community isolation policy, some other patients did not complete uroflowmetry studies. However, all IPSS data were able to be collected via telemedicine, ensuring the inclusion of those data in the analysis. Second, our study did not have a sufficient number of patients to allow subgroup analysis of patients with different indications for transurethral WVTT; future studies should explore treatment outcomes among patients with different indications for transurethral WVTT. Third, our inclusion period was prolonged, partly due to the coronavirus disease 2019 pandemic and partly because transurethral WVTT mainly was regarded as a self-financed item in our centre; these aspects led to some difficulty in accumulating a sufficient number of patients for analysis. Finally, this study used a single-arm design with a relatively short follow-up period; additional studies are needed to assess long-term treatment outcomes and retreatment rates after transurethral WVTT under local anaesthesia alone.

Transurethral WVTT is a safe and effective treatment for benign prostatic hyperplasia in the Chinese population. It can also be conducted in an office setting under local anaesthesia alone, avoiding use of the surgical theatre and its associated costs.

Concept or design: KL Lo, CF Ng.
Acquisition of data: KL Lo.
Analysis or interpretation of data: A Mok, ICH Ko.
Drafting of the manuscript: KL Lo, A Mok, ICH Ko.
Critical revision of the manuscript for important intellectual content: All authors.

All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

As an editor of the journal, CF Ng was not involved in the peer review process. Other authors have disclosed no conflicts of interest.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

This research was approved by the Joint Chinese University of Hong Kong–New Territories East Cluster Clinical Research Ethics Committee, Hong Kong (Ref No.: 2019.662). The patients were treated in accordance with the tenets of the Declaration of Helsinki and have provided written informed consent for all treatments and procedures and consent for publication.

1. Kahokehr A, Gilling PJ. Landmarks in BPH—from aetiology to medical and surgical management. Nat Rev Urol 2014;11:118-22. Crossref

2. Gravas S, Cornu JN, Gacci M, et al. EAU guidelines on management of non-neurogenic male lower urinary tract symptoms (LUTS), incl. benign prostatic obstruction (BPO). 2022. Available from: https://d56bochluxqnz.cloudfront.net/documents/full-guideline/EAU-Guidelines-on-Non-Neurogenic-Male-LUTS-2022.pdf. Accessed 8 May 2024.

3. Teoh JY, Chiu PK, Yee CH, et al. Prostatic artery embolization in treating benign prostatic hyperplasia: a systematic review. Int Urol Nephrol 2017;49:197-203. Crossref

4. Abt D, Hechelhammer L, Müllhaupt G, et al. Comparison of prostatic artery embolisation (PAE) versus transurethral resection of the prostate (TURP) for benign prostatic hyperplasia: randomised, open label, non-inferiority trial. BMJ 2018;361:k2338. Crossref

5. Roehrborn CG, Barkin J, Gange SN, et al. Five-year results of the prospective randomized controlled prostatic urethral L.I.F.T. study. Can J Urol 2017;24:8802-13.

6. Magistro G, Chapple CR, Elhilali M, et al. Emerging minimally invasive treatment options for male lower urinary tract symptoms. Eur Urol 2017;72:986-97. Crossref

7. Dixon CM, Rijo Cedano E, Mynderse LA, Larson TR. Transurethral convective water vapor as a treatment for lower urinary tract symptomatology due to benign prostatic hyperplasia using the Rezūm(®) system: evaluation of acute ablative capabilities in the human prostate. Res Rep Urol 2015;7:13-8. Crossref

8. Mynderse LA, Hanson D, Robb RA, et al. Rezūm system water vapor treatment for lower urinary tract symptoms/benign prostatic hyperplasia: validation of convective thermal energy transfer and characterization with magnetic resonance imaging and 3-dimensional renderings. Urology 2015;86:122-7. Crossref

9. McVary KT, Gange SN, Gittelman MC, et al. Minimally invasive prostate convective water vapor energy ablation: a multicenter, randomized, controlled study for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia. J Urol 2016;195:1529-38. Crossref

10. McVary KT, Gittelman MC, Goldberg KA, et al. Final 5-year outcomes of the multicenter randomized sham-controlled trial of a water vapor thermal therapy for treatment of moderate to severe lower urinary tract symptoms secondary to benign prostatic hyperplasia. J Urol 2021;206:715-24. Crossref

11. Dixon CM, Cedano ER, Pacik D, et al. Two-year results after convective radiofrequency water vapor thermal therapy of symptomatic benign prostatic hyperplasia. Res Rep Urol 2016;8:207-16. Crossref

12. Rowaiee R, Akhras A, Lakshmanan J, Sikafi Z, Janahi F. Rezum therapy for benign prostatic hyperplasia: Dubai’s initial experience. Cureus 2021;13:e18083. Crossref

13. Pavone C, Abbadessa D, Scaduto G, et al. Sexual dysfunctions after transurethral resection of the prostate (TURP): evidence from a retrospective study on 264 patients. Arch Ital Urol Androl 2015;87:8-13. Crossref

14. Lee YJ, Lee JW, Park J, et al. Nationwide incidence and treatment pattern of benign prostatic hyperplasia in Korea. Investig Clin Urol 2016;57:424-30. Crossref

15. Hong Kong SAR Government. The 2023-24 Budget. Budget speech. Available from: https://www.budget.gov.hk/2023/eng/budget30.html. Accessed 5 May 2024.

16. Health Bureau, Hong Kong SAR Government. Hong Kong’s domestic health accounts (DHA) 2021/22. Available from: https://www.healthbureau.gov.hk/statistics/en/dha.htm. Accessed 5 May 2024.

17. Mamoulakis C, Ubbink DT, de la Rosette JJ. Bipolar versus monopolar transurethral resection of the prostate: a systematic review and meta-analysis of randomized controlled trials. Eur Urol 2009;56:798-809. Crossref

18. Ulchaker JC, Martinson MS. Cost-effectiveness analysis of six therapies for the treatment of lower urinary tract symptoms due to benign prostatic hyperplasia. Clinicoecon Outcomes Res 2018;10:29-43. Crossref

19. Tanneru K, Jazayeri SB, Alam MU, et al. An indirect comparison of newer minimally invasive treatments for benign prostatic hyperplasia: a network meta-analysis model. J Endourol 2021;35:409-16. Crossref

20. Gupta N, Rogers T, Holland B, Helo S, Dynda D, McVary KT. Three-year treatment outcomes of water vapor thermal therapy compared to doxazosin, finasteride and combination drug therapy in men with benign prostatic hyperplasia: cohort data from the MTOPS trial. J Urol 2018;200:405-13. Crossref

Unhealthy dietary patterns, generally characterised by low dietary diversity, skipping breakfast, low consumption of fruits and vegetables, and frequent consumption of energy-dense/nutrient-poor foods and sugar-sweetened beverages, are common among children worldwide.1 2 It is particularly important for young children to adopt healthy dietary patterns because eating habits and food preferences in childhood can influence dietary patterns in adulthood.3 Similar to children in other regions, Hong Kong children have a high prevalence of unhealthy dietary patterns.4 A cross-sectional survey evaluating infant and young child feeding practices in Hong Kong identified numerous dietary problems, including dietary imbalance (eg, high protein but low fibre intake), overdependence on the use of formula milk, inadequate intake of vegetables and fruits, and unhealthy snacking and sugary beverage habits.5 A previous study revealed a need for dietary improvement among Hong Kong pre-school children.6 Key recommendations included a balanced diet, better nutritional adequacy, and greater independence during mealtimes (ie, self-feeding).6 Indeed, inappropriate behaviours during mealtimes, such as lack of self-feeding, food refusal, picky eating, and prolonged meals, are common in young children.7 8 Children with inappropriate mealtime behaviours may be susceptible to insufficient nutrient and/or energy intake.9 However, there is limited information available regarding the mealtime behaviours of typically developing pre-school children in Hong Kong.

Family home food environments (FHFEs), ie, parental food choices and preparation, avoidance of unhealthy foods, and family mealtime environments, have strong associations with children’s dietary habits and body weight.10 11 12 Parental use of nutrition labels to make healthier food choices has been linked to a lower probability of overweight or obesity in their children.13 Similarly, children with limited access to unhealthy foods are reportedly more likely to maintain a normal body weight.14 A review focusing on the effects of family and social environment on children’s dietary patterns found that a structured mealtime environment—namely, regular meals with family members and screen-free mealtimes—was associated with healthy food consumption patterns in children.15 In summary, children’s mealtime behaviours and FHFEs are important for healthy eating among young children. Thus far, no studies have provided an overview of eating behaviours and FHFEs among pre-school children in Hong Kong.

The use of a report card at the country-/region-level can provide a valuable overview of the prevalence of health behaviours through a conventional letter grading system (ranging from A+ to F).16 This framework has been used to evaluate various health-related behaviours (eg, physical activity,17 18 19 sedentary behaviour,17 18 19 smoking behaviour,20 and dietary patterns20 21 22) in children and youth. The findings of such report cards offer insights concerning the extent to which health behaviours are adopted in specific communities and provide targeted recommendations for health behaviours at the individual or public level.16 23 Moreover, the publication of these report cards can facilitate health promotion awareness and catalyse policy changes that motivate individuals to commit to health behaviours.16 19 24 Thus far, only one published report card (the Healthy Active Kids South Africa [HAKSA] Report Card) has revealed dietary patterns among children and youth.21 However, the HAKSA Report Card only covered the intake of fruits, vegetables, and unhealthy snacks; other essential aspects of healthy eating (eg, daily breakfast consumption, dietary variety, mealtime behaviours, and FHFEs) were not considered. Additionally, because the evidence underlying the grading criteria for various aspects of healthy eating was not explicitly stated, the findings of the HAKSA Report Card might not provide useful benchmarks concerning how well individuals adhere to healthy eating standards or recommendations adopted by health authorities. Therefore, we aimed to address the aforementioned research gaps through a cross-sectional study that developed the Healthy Eating Report Card for Pre-school Children in Hong Kong, using a grading scale and evidence-based benchmarks to assess the current prevalence of healthy eating behaviours and favourable FHFEs among pre-school children in Hong Kong.

Our Report Card assesses various indicators of Children’s Eating Behaviours (ie, Children’s Dietary Patterns and Children’s Mealtime Behaviours) and FHFEs (ie, Parental Food Choices and Preparation, Avoidance of Unhealthy Foods, and Family Mealtime Environments). Each indicator and its specific items are assigned letter grades based on predefined benchmarks, revealing how well pre-school children in Hong Kong meet the recommendations and standards established by the government and published literature concerning pre-school children’s healthy eating behaviours and FHFEs (Tables 125 26 27 28 29 30 31 and 223). The findings may enhance the understanding of eating behaviours and FHFEs among pre-school children in Hong Kong. Additionally, the Healthy Eating Report Card established in our study will be useful for future studies examining healthy eating among young children in other countries or regions.

We recruited 538 Hong Kong parent-child dyads from eight local kindergartens in three main regions of Hong Kong (29.55% of children from the New Territories, 62.64% of children from Kowloon, and 7.81% of children from Hong Kong Island). The children were aged between 2 and 6 years with a mean age of 4.10 years (standard deviation=0.92); 49.63% of the children were boys. Of the children, 33.77%, 29.46%, and 36.77% were in grades K1, K2, and K3, respectively. Respondents were mainly mothers (85.63%), followed by fathers (13.25%) and other legal guardians (1.12%). The mean respondent age was 36.62 years (standard deviation=5.84).

This cross-sectional study examined the prevalence of healthy eating behaviours and favourable FHFEs among Hong Kong pre-school children in October 2021. We sent invitation letters to 89 randomly selected local kindergartens across 18 districts in Hong Kong (excluding international schools and special needs schools). Eight kindergartens agreed to participate in this study and distribute our questionnaire to eligible parents. The inclusion criteria required participants to: (1) be Chinese parents or guardians; (2) have at least one child in grades K1 to K3; and (3) have sufficient Chinese reading ability to complete the questionnaire. Schools and parents were both asked to provide written informed consent. Parents completed a parent-reported questionnaire (comprising the Healthy Eating Report Card items) about their children’s eating behaviours and FHFEs, which typically required 15 minutes to complete. Respondents received a HK$50 supermarket voucher as a token of appreciation for their participation.

The design of our Healthy Eating Report Card was based on the conceptual framework established by the Report Card on Physical Activity for Children and Youth, which offers a comprehensive grading framework and benchmarks to evaluate health behaviours.16 17 18 19 20 21 22 23 The Global Matrix 3.0 Physical Activity Report Card for Children and Youth has been used in 49 countries to evaluate the prevalence of physical activity behaviours among children and youth.23 Using a similar assessment framework, our Healthy Eating Report Card evaluated the prevalence of healthy eating behaviours and favourable FHFEs among Hong Kong pre-school children. The Healthy Eating Report Card Questionnaire consisted of 21 items which were developed based on the healthy eating guidelines and recommendations of the Department of Health of Hong Kong.25 26 The items were aligned with the five indicators of our Report Card, including two Children’s Eating Behaviours indicators (ie, Children’s Dietary Patterns and Children’s Mealtime Behaviours) and three FHFEs indicators (ie, Parental Food Choices and Preparation, Avoidance of Unhealthy Foods, and Family Mealtime Environments), to determine whether the children adhered to healthy eating behaviours and were involved in healthy FHFEs. Participants responded to questionnaire items using a 5-point Likert scale (ranging from ‘always’ to ‘never’), yes/no questions, open-ended questions, and multiple-choice questions. The questionnaire is provided in online supplementary Appendix 1.

Benchmarks for each indicator were established in accordance with recommendations and guidelines for healthy eating behaviours and FHFEs from the Hong Kong SAR Government and published literature.25 26 27 28 29 30 31 Based on the results of the questionnaire, we used a benchmark framework to determine the letter grade for each indicator that reflected the percentage of participants who met the predetermined benchmarks. A sub-grade was also determined for each indicator item. The questionnaire items and criteria of questionnaire answers related to the benchmarks are displayed in online supplementary Appendix 2.25 26 28 29 30 31 The grading system for the Healthy Eating Report Card was derived from the grading rubric of the Global Matrix 3.0 Physical Activity Report Card for Children and Youth, ie, A (≥80%, Excellent); B (60%-79%, Good); C (40%-59%, Fair); D (20%-39%, Poor); and F (<20%, Very poor).23 Plus (+) and minus (-) signs were used to show the upper or lower 5% of each grade.23 The proposed benchmarks and the grading scheme are shown in Tables 125 26 27 28 29 30 31 and 2,23 respectively.

Due to the percentage calculation, responses to 5-point Likert scale questions in the questionnaire were converted to binary variables; responses of ‘sometimes’, ‘often’ and ‘always’ were categorised as ‘yes’, whereas responses of ‘never’ and ‘rarely’ were categorised as ‘no’.32 All statistical analyses were performed using SPSS software (Windows version 26.0; IBM Corp, Armonk [NY], United States). Missing values ranged from 0.19% to 2.79% for questionnaire items because of nonresponses to some items. The descriptive statistics revealed valid percentages for each indicator item, along with 95% confidence intervals (CIs). The arithmetic mean for each indicator was calculated by summing the valid percentage for each item of the indicator, then dividing that value by the number of corresponding items. This arithmetic mean represents the average percentage of participants who met predefined benchmarks for that indicator.

The letter grades of our Healthy Eating Report Card are summarised in Table 3. The descriptive statistics of the Report Card are displayed in online supplementary Appendix 3. The average grades of Children’s Eating Behaviours indicators and FHFEs indicators were ‘C’ and ‘B’, respectively, showing that the eating behaviours of Hong Kong pre-school children were classified as Fair, whereas FHFEs were classified as Good (Table 3). On average, nearly half of the pre-school children (52.88%; 95% CI=51.26%-54.50%) adhered to healthy eating behaviours, whereas more than half of the parents (70.87%; 95% CI=69.34%-72.40%) provided their children with favourable FHFEs.

Nearly all children (97.58%) had three regular meals daily. However, only 24.34% of the children ate a variety of foods. Approximately half of the children had adequate vegetable and fruit intakes (50.84% and 58.40%, respectively). Moreover, 55.76% did not have a formula milk-drinking habit. Additionally, around half of the children had low consumption of unhealthy snacks and sugary beverages (52.25% and 58.87%, respectively) [online supplementary Appendix 3]. Overall, Children’s Dietary Patterns was graded ‘C+’ (Fair), signifying that approximately half of the children (55.37%; 95% CI=53.98%-56.75%) adhered to healthy dietary patterns.

Fewer than half of the children (43.02%) did not require parental assistance to finish a meal. Only 38.32% of the children could remain seated during mealtimes. Of the children, 49.15% and 67.98% did not exhibit picky eating behaviours and were willing to try new foods, respectively. Nearly half of the children (49.35%) did not exhibit slow-eating behaviours (online supplementary Appendix 3). Children’s Mealtime Behaviours was graded ‘C’ (Fair), showing that approximately half of the children (49.92%; 95% CI=46.28%-55.07%) exhibited desirable mealtime behaviours.

More than half of the parents (63.69%) used nutrition labels. Similarly, more than half of the parents (70.26%) considered low oil/salt/sugar food options for their children. Approximately half of the parents used low-fat cooking methods and reduced the use of sugar- or salt-containing condiments (53.53% and 43.58%, respectively) [online supplementary Appendix 3]. Parental Food Choices and Preparation was graded ‘C+’ (Fair), revealing that approximately half of the parents (57.88%; 95% CI=55.49%-60.28%) made healthy food choices and prepared healthy meals for their children.

Half of the parents (52.04%) did not reward their children with unhealthy snacks or drinks. A large majority of the parents (90.15%) limited the frequency and quantity of unhealthy foods (online supplementary Appendix 3). Therefore, Avoidance of Unhealthy Foods was graded ‘B’ (Good), signifying that more than half of the parents (71.10%; 95% CI=68.66%-73.53%) controlled their children’s access to unhealthy foods.

A large majority of the children dined with their parents or family members and ate the same food as other family members (93.47% and 95.50%, respectively). More than half of the parents (61.08%) did not allow their children to use screen devices during mealtimes (online supplementary Appendix 3). Family Mealtime Environments was graded ‘A-’ (Excellent), showing that most children (83.46%; 95% CI=81.63%-85.29%) were involved in structured family mealtime environments.

This study aimed to develop the Healthy Eating Report Card for Pre-school Children in Hong Kong, which assessed the prevalence of healthy eating behaviours and favourable FHFEs among pre-school children in Hong Kong. We established evidence-based benchmarks to guide the process of grading Children’s Eating Behaviours indicators and FHFEs indicators, then utilised letter grades to illustrate how well children adhered to healthy eating behaviours. Children’s Dietary Patterns and Children’s Mealtime Behaviours were graded ‘C+’ and ‘C’, respectively, signifying that eating behaviours in Hong Kong pre-school children were Fair; the average overall grade was ‘C’. Our findings indicate that approximately half of the pre-school children in Hong Kong adhered to healthy eating behaviours. Parental Food Choices and Preparation, Avoidance of Unhealthy Foods, and Family Mealtime Environments were graded ‘C+’, ‘B’, and ‘A-’, respectively, showing that FHFEs were Good; the average overall grade was ‘B’. Our results revealed that more than half of the pre-school children in Hong Kong were involved in a healthy home eating environment. Taken together, these findings enhance the understanding of pre-school children’s eating behaviours and FHFEs in Hong Kong.

Our Report Card showed that the eating behaviours of Hong Kong pre-school children were classified as Fair; some unhealthy dietary patterns and undesirable mealtime behaviours were prevalent because nearly half of the children did not meet predefined benchmarks for Children’s Eating Behaviours indicators. Previous research33 concerning the eating habits of Hong Kong pre-school children showed that more than half of the surveyed children (78.8%) had a habit of eating breakfast. Nevertheless, fewer than half of the children achieved the recommended daily intakes of vegetables (19.6%) and fruits (47.3%), respectively.33 Some studies identified a high prevalence of formula milk drinking among Hong Kong pre-school–aged children, such that 77% of 4-year-old children continue to drink formula milk.5 34 Overdependence on formula milk may reduce appetite in children and impede their development of healthy eating habits.35 Lo et al33 found that, on average, children consumed high energy-dense foods (eg, candy/chocolate, sweet crackers, and sugary beverages) more than twice per week; accordingly they suggested that such children should minimise their consumption of these foods. Additionally, an investigation regarding undesirable mealtime behaviours among Hong Kong pre-school children revealed that approximately 70% of the children required >30 minutes to finish a meal; these children often were unwilling to self-feed or finish their meals.6 The present study are consistent with previous research, indicating that there is considerable potential for improvement in eating behaviours among Hong Kong children.

As mentioned above, the HAKSA Report Card assessed a few aspects of the dietary patterns of South African children and youth aged 3 to 8 years in 2018. Although using a grading rubric similar to our Report Card, the HAKSA Report Card only involved two indicators, namely Fruit and Vegetable Intake (graded ‘D’) and Snacking, Sugar-Sweetened Beverages, Dietary Sodium, and Fast Food Intake (graded ‘F’).21 Our Report Card may provide better coverage of healthy dietary patterns because it included assessments of regular daily meals, food variety, and formula milk-drinking habits, with a particular focus on pre-school children aged 2 to 6 years. Despite the discrepancies between studies, the healthy dietary patterns observed in our Report Card were more favourable than patterns observed in the HAKSA Report Card.21 This difference also implies that standards for healthy eating behaviours among children differ between South Africa and Hong Kong. Future studies should develop a cross-ountry/region–level Report Card and establish a global benchmark to comprehensively analyse global variations in healthy eating, thereby raising global awareness and stimulating global discussion regarding the promotion of healthy eating.

Very little is known about FHFEs of children in Hong Kong; therefore, the present study provides initial information concerning parental food choices and preparation, avoidance of unhealthy foods, and family mealtime environments among Hong Kong pre-school children. Based on our findings, the FHFEs of the pre-school children in Hong Kong were classified as Good. This result suggests that parents in Hong Kong attempt to promote healthy diets by limiting their children’s consumption of unhealthy foods. A previous study revealed that Hong Kong parents tended to adopt the ‘control over eating’ approach to feed their children, whereby parents primarily determine the amounts of food that children should eat, including unhealthy snacks.33 Moreover, parents often used food to reward or comfort children.36 The indicator of Family Mealtime Environments in our Report Card showed that most pre-school children had a structured family mealtime environment where they dined with their family and shared the same food with their family members. This finding may be attributed to the Chinese cultural emphasis on shared meals with family members.37 Thus, the results of the present study are consistent with previous research findings.

However, this high grade for Family Mealtime Environments may have increased the average grade for FHFEs indicators. Indeed, parents’ food choices, purchases, and preparation directly influence children’s home food environment and food consumption.38 When we specifically focused on the Parental Food Choices and Preparation indicator, the grade decreased to Fair (letter grade of ‘C+’), signifying that only half of the parents complied with healthy eating practices for their children, such as the use of nutrition labels and adoption of healthy cooking methods. Thus, it is important to promote healthy eating at home, which will facilitate healthy eating behaviours among children. A pilot FHFE intervention of the Healthy Home Offerings via the Mealtime Environment Plus programme, which provided parents and children with nutrition education and meal preparation training and activities, successfully promoted a structured mealtime environment at home and helped to improve dietary intake patterns.39 40 Accordingly, future studies might utilise nutrition education interventions to improve the FHFEs of pre-school children in Hong Kong.

This study had some strengths. In particular, we collected primary data to enhance the understanding of eating behaviours and FHFEs among pre-school children in Hong Kong. Moreover, to our knowledge, this is the first use of a report card framework to comprehensively evaluate the prevalence of healthy eating behaviours among pre-school children.41 The Report Card can serve as an effective awareness-raising tool that provides novel insights concerning the promotion of healthy eating behaviours, as well as recommendations for healthy eating policies and healthy food environments.23

However, this study also had several limitations. First, its cross-sectional design precluded the identification of changes in children’s eating behaviours and FHFEs over time. Future studies could perform longitudinal measurements of variables in the Report Card to reveal changes or stability in healthy eating behaviours among young children; such measurements could also determine whether Report Card scores are predictive of health outcomes in children. An individual-level Healthy Eating Report Card should be developed in future studies to examine the effectiveness of the Report Card on parental intentions towards healthy eating, as well as children’s healthy eating behaviours and favourable FHFEs. Second, although the items of the Healthy Eating Report Card Questionnaire were developed based on the guidelines and recommendations of the Hong Kong SAR Government,25 26 the development of the questionnaire did not include evaluations of its content validity and psychometric properties. Future studies should examine the psychometric properties and other validity aspects of the Report Card questionnaire (eg, factorial validity, convergent validity, and discriminant validity).42 Third, the study relied on parent-reported questionnaires of children’s eating behaviours and FHFEs, which may be susceptible to response biases, social desirability bias, and general response tendencies.43 44 Validation studies comparing parent-reported questionnaires with more objective measures of children’s food intake and observational assessments of mealtime behaviours could be conducted in the future. Finally, the current Report Card does not reflect several components of children’s eating behaviours (eg, the frequency of dining out and the variety of vegetable and fruit consumption) and FHFEs (eg, parental feeding practices and accessibility of healthy food at home). Future studies should investigate whether these components could be included within the Healthy Eating Report Card to provide a more holistic assessment of healthy eating among children.

This study developed the Healthy Eating Report Card for Pre-school Children in Hong Kong to reflect the prevalence of healthy eating behaviours and favourable FHFEs among pre-school children in Hong Kong. The Report Card revealed that Children’s Eating Behaviours were classified as Fair (average grade of ‘C’), whereas FHFEs were classified as Good (average grade of ‘B’). There is considerable potential for improvement in children’s eating behaviours (ie, healthy dietary patterns and appropriate mealtime behaviours) and FHFEs (particularly concerning parental healthy food choices and preparation). We believe that the Report Card can serve as a useful tool for evaluating the prevalence of healthy eating behaviours and favourable FHFEs in young children; it could offer novel insights into strategies for promotion of healthy eating in pre-school setting.

Concept or design: All authors.
Acquisition of data: AWL Wan, DKC Chan.
Analysis or interpretation of data: AWL Wan, DKC Chan.
Drafting of the manuscript: AWL Wan, DKC Chan.
Critical revision of the manuscript for important intellectual content: All authors.

All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

All authors have disclosed no conflicts of interest.

The authors thank Ms Kiko KH Leung, Ms Roni MY Chiu, and Ms Tracy CW Tang from the Department of Early Childhood Education of The Education University of Hong Kong for their assistance in preparing study materials and collecting data. The authors also thank the eight participating kindergartens for aiding in the distribution and collection of questionnaires from parents.

This research was funded by the Research Impact Cluster Fund of the Department of Early Childhood Education, Faculty of Education and Human Development, The Education University of Hong Kong, through an award to the corresponding author. The funder had no role in study design, data collection/analysis/interpretation or manuscript preparation.

The study protocol of this research was approved by the Human Research Ethics Committee of The Education University of Hong Kong (Ref No.: 2020-2021-0420). All schools and parents provided written informed consent for participation in this research and have also consented to the publication of its findings.

The supplementary material was provided by the authors and may include some information that was not peer reviewed. Accepted supplementary material will be published as submitted by the authors, without any editing or formatting. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by the Hong Kong Academy of Medicine and the Hong Kong Medical Association. The Hong Kong Academy of Medicine and the Hong Kong Medical Association disclaim all liability and responsibility arising from any reliance placed on the content.

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