Childhood Cancer Education in Hong Kong

By Vinelle Leung

Table of Contents

1. Introduction

2. Background

3. Child Cancer Education in Hong Kong

4. Conclusion

5. References

6. About the Author

1. Introduction

On September 25th 2015, United Nations (UN) member states adopted the 2030 Agenda for Sustainable Development. 17 Sustainable Development Goals (SDGs) with the aim to ‘end poverty, protect the planet, and ensure prosperity for all’ have been set to be achieved within the next 15 years. Goal 3 seeks to ensure health and well-being for all as part of building sustainable societies. One of the targets of Goal 3 is to reduce premature mortality from noncommunicable diseases, including cancer, by one-third by 2030 (UN, 2016). 

In recent years cancer has emerged as a major health problem in Hong Kong. A total of 28,936 new cancer cases and 13,589 deaths were registered in the latest report of Hong Kong Cancer Registry in 2013 (HKCaR, 2015). Although cancer is most commonly diagnosed in older people, children (aged 0-19) represented a mere 0.8% of all new cancers, an average of about 200 new cases. Around one child in every 10,000, were diagnosed each year during the period of 2003 to 2013.  The record of the Children’s Cancer Foundation (CCF) (2015b) shows 169 new cases and 43 death cases in 2015. Childhood cancer stays a significant focus in public health because of its long-term side effects on children’s health throughout all stages of life and its social, economic, and environmental implications for the urban area.

Compared with technological and scientific progress, education is not the most immediate solution to premature mortality from cancer. However, education promotes understanding and nurtures empathy towards child cancer patients through raising public awareness and reducing the knowledge gap about the disease. 

This entry reviews life education at local secondary schools developed by the CCF, the largest children cancer support organisation in Hong Kong through the lens of transformative learning theory. Other childhood cancer organisations in Hong Kong such as Little Life Warriors Society and Children’s Catastrophic Disease Foundation are not discussed in this entry, but their meaningful work to the children and the society should not be undervalued.

2. Background

Among various types of childhood cancers, leukaemias, which are cancers of the bone marrow and blood, are the most common childhood cancers. They account for about 31% (54 cases) of total new childhood cancer cases in Hong Kong in 2014, followed by cancers of the brain, lymph glands, nerve cells, bone, and soft tissue tumours.

The diagnosis of cancer, with the life-threatening connotations, generates anxiety within patients and their family members. Psychological distress is observed among family members including feelings of despair, retreat, and helplessness (Thomas, 1978).

Childhood cancer is not contagious and over 70% are curable (Chronic Illness Alliance, 2016). However, many patients need to go through long and difficult treatments such as phases of chemotherapy, surgery, and radiotherapy, and in some cases, bone marrow and stem cell transplant. Although scientific and medical improvements increase the survival rates and reduce the adverse side effects of treatments, some patients still experience late effects which may impair survivors’ health and affect their quality of life (Chan, 2015). The most common late effects of childhood cancer are neuro-cognitive and psychological, cardiopulmonary, endocrine (e.g., those affecting growth and fertility), musculoskeletal, and second cancers. There is a growing appreciation of childhood cancer as a chronic disease with implications for continuing care, and thus the long-term survivorship experience impacts family members and the whole society (CCF, 2015b).

Research on the public perception of childhood cancers in Hong Kong is limited. Kuan’s (2000) study shows that the public has little knowledge about cancer, and, thus, might not understand the feelings and experiences of children who have cancer and their families. Childhood cancers are rare diseases in Hong Kong. Many caregivers shared their personal experience of being ‘stared at strangely’ and ‘asked annoying and discriminative questions’. They expressed the need to promote public awareness of cancer in children in order to reduce people’s misconceptions about cancers.

3. Child Cancer Education in Hong Kong

The Children’s Cancer Foundation in Hong Kong was established in 1989 by a group of patients’ family members, nurses, and other concerned individuals. One of the missions of the CCF is to improve the quality of life of child cancer patients and their families. The Family Service Centre of CCF reaches out to the community through media and publications, exhibitions, and Life Education for Schools talks at secondary schools (‘the Talks’). The Talks, titled “I Love My Life”, aim to enhance students’ knowledge and understanding towards childhood cancers, and to encourage young people to cherish their lives (CCF, 2013). They are designed in two parts: first, a registered nurse starts with an introduction of the medical aspects of childhood cancers; and next, a cancer survivor and his/her family member hold a session to discuss their experiences.

This approach employed by the CCF is informed by the transformative learning theory introduced by Mezirow (1991). He described that learners transform by ‘interpret[ing] and reinterpret[ing] their sense experience and structures of assumptions through their sense experience’. When experience is too strange or threatening to the way we think or learn, we tend to block it out (‘cognitive distortion’) or interpret it in a compatible way (‘defence mechanism’). Cancers are rarely diagnosed in children, which means that children and their caregivers lack experience and knowledge to interpret the meaning of cancers to their lives and communicate it to the public. Although with the improvement of technology, treatments for cancers have evolved and many cancers are curable, fear towards the disease persists. Leukemias and brain cancers, which have a relatively lower survival rate compared with other types of cancers, have often been dramatised and the adverse effects and symptoms are exaggeratedly emphasised in mass media such as newspapers, movies, songs, novels, and TV drama series. These have reinforced misperceptions of cancers and strengthened the negative association between cancers, death, and the loss of loved ones.

The process of transformation may not necessary solve medical problems but it may challenge one’s meaning structure, the broad sets of predispositions which limit people’s expectations, perceptions, and assumptions (Mezirow, 1997, p. 5); and most importantly, it may reduce unnecessary additional damage to families due to communication barriers and lack of basic knowledge about childhood cancers. A mother who has a child with cancer shared with Kuan (2000):

…when people asked what is the matter with her, I said she's sick. I don't say that it's cancer. For the friends who are not close enough, I don't need to explain, because I'm too tired. If you talk to a friend, there'll be a lot of questions. Why did she get this disease? How's she at the beginning? Talk too much, very tired, really tired. (p. 306)

Learning involves a range of experiences in which knowledge is socially and collaboratively constructed. In this sense it is a process of listening, questioning, relating, symbolising, feeling, and reflecting. Central to Mezirow’s transformative learning theory is the making of meaning and reflection which enables learners to correct distortions in their beliefs and errors in problem-solving. In his words, learning is ‚the process of making a new or revised interpretation of the meaning of an experience, which guides subsequent understanding, appreciation and action’ (p. 1).

In line with this view, the aims of the Talks are to provide basic medical knowledge about childhood cancers, rectify misunderstandings, and eventually change the attitudes and behaviours of secondary school students toward patients and their family members (CCF, 2015a). The Talks consist of two parts: instrumental learning and reflection through life stories.

  • Instrumental Learning

In instrumental learning, people reflect on their own understanding and knowledge of the world through empirical evidence and ensure that their underlying assumptions are correct (Mezirow, 2011). The first part of the Talks is straight-forward. A registered nurse gives a factual introduction about childhood cancers in Hong Kong in order to lay a knowledge base and guide secondary school students (the audience) to proceed to a higher level of learning about childhood cancers. Beyond the construction of knowledge, the nurse answers questions and debunks misperceptions with facts and empirical evidence. The students thus learn what to do as educated people and work to control any unfavourable behaviours when they meet a family with a child who has cancer. Rademacher (2004) describes this approach as ‘a scientific way of knowing’ and ‘a very pragmatic aspect’ of such a kind of learning.

  • Reflection through Life Stories

In the second part of the Talks, survivors share their paths of overcoming the shock of learning that they have a cancer, painful treatment, their methods of coping and motivating themselves to fight for survival, and their reflections. All these stories are presented to students through storytelling. The storytelling approach is an inclusive communication where learners are invited to engage in an organic dialogue with educators (Tyler & Swartz, 2012). When students listen to the Talks, they are invited to debunk their original thoughts about the disease, imagine themselves as survivors in different stages, and develop empathy towards patients. Sometimes, videos and photos of childhood cancer patients are added to amplify a holistic message to audiences.

Building on personal stories about the disease, survivors encourage students to open their minds towards the topic of ‘death' as the diseases is seen through the lens of death. The stories bring in new perspectives to challenge the default assumptions about cancer and death, and create new meanings.

I don’t afraid of death! I have experienced a lot and I can still stand on this stage. I have earned my days. Death may come anyhow and no one can stop it. I had a few times of near-death experience so I am not afraid of it!… My cancer has recurred for a few times but I am still alive. I am very lucky comparing to my friends who died. Because of them I cherish every day and live happily so I will not disappoint them.

Extracted from the conversation with survivor Angel Mui (CCF, 2013)

Centred in the life stories is a message of ‘where there’s life, there’s hope’ (CCF, 2015a, p. 75) — to inspire students to face adversity and help them develop a positive view of life through spreading encouraging experiences. It is a journey of rediscovering hope in one’s life. Some of the survivors are of similar age to the students, which strengthens the association between the survivors and the students when they act on some aspects of engagement throughout the Talks. Students can ask questions and relate the life experiences of the survivors to their own.

4. Conclusion

 The beauty of the transformative learning process is its objective to find coherence in and redefine meaning of forces and relations that make up our lives (Fowler, 1981). By adopting Mezirow’s (1991) transformative learning theory, the Talks is a comprehensive project that meets the aims to promote public awareness of cancer in children and to reduce people’s misconceptions about the disease. Many secondary schools have been enthusiastically signing up for the Talks since its first session in July 2008, and there is a waiting list of around three months (at the time of this publication). CCF has been carefully evaluating the situation of survivors and their family members and selecting appropriate ones to share their life stories.

Childhood cancer is not a topic for all. It is a technical topic of medical knowledge and an emotional discussion about life and death. Secondary school students, i.e. the audience of the Talks, are expected to have prerequisite communicative and reflective abilities in order to bring in new knowledge and experience to ‘an already well-developed symbolic frame of reference’ (Mezirow, 2002, p.10). As suggested by Mezirow (1991), transformative learning is the focus rather than the outcome. Nevertheless, it should be noted that it is challenging to evaluate transformations that take place in secondary school students after they participate in the Talks. Further research is required to study effectiveness of the Talks and social misperceptions towards childhood cancers which students may still accept after.

Hong Kong's first Children Hospital will be commissioning in 2017 (Hospital Authority, 2016). It is hoped that the city will have an advancement in the provision of medical care to children and a more comprehensive support in the community through education and community service.

5. References

Chan, Y. W. (2015). Quality of Life and Morbidities of Childhood Cancer Survivors in Hong Kong. Retrieved from http://dx.doi.org/10.5353/th_b5659995

Children’s Cancer Foundation (2013). Newsletter. Retrieved from https://www.ccf.org.hk/publication.php?id=611

Children’s Cancer Foundation (2015a). The Triumph of Hope. Hong Kong: Children’s Cancer Foundation.

Children’s Cancer Foundation. (2015b). Childhood Cancer Facts and Figures. Retrieved November 16, 2016, from Children’s Cancer Foundation, https://www.ccf.org.hk/information.php?&lang=1

Chronic Illness Alliance. (2016). Cancer. Retrieved November 2, 2016, from Chronic Illness Alliance, http://www.chronicillness.org.au/invisible-illness/cancer/

Cranton, P., & Hoggan, C. (2012). Evaluating Transformative Learning. In The Handbook of Transformative Learning (pp. 520–535). San Francisco: Jossey-Bass.

Fowler, J. W. (1981). Stages of Faith: The Psychology of Human Development and the Quest for Meaning (1st ed.). San Francisco, CA: Harper & Row.

Gillis, S., & Griffin, P. (2008). Competency Assessment. In J. Athanasou (Ed.). Adult Education and Training (pp. 233–256). Sydney: David Barlow Publishing.

Hong Kong Cancer Registry. (2015). Hong Kong Cancer Registry, Hospital Authority. Retrieved October 15, 2016, from http://www3.ha.org.hk/cancereg/Statistics.html#sqs

Hospital Authority. (2016, February ). Hong Kong Children’s Hospital. Retrieved November 2, 2016, from Hong Kong Children’s Hospital, http://www31.ha.org.hk/hkch/en/index.html

Kuan, H. Y. (2000). Identifying the Needs of Chinese Family Caregivers of Children with Cancer in Hong Kong. Retrieved from http://hdl.handle.net/10397/4161

Mezirow, J. (1991). Transformative Dimensions of Adult Learning. San Francisco: Jossey-Bass Inc., U.S.

Mezirow, J. (2002). Transformative Learning: Theory to Practice Transformative Learning Theory. New Directions for Adult and Continuing Education5–12. Retrieved from http://cmapsconverted.ihmc.us/rid=1MCY1CBS9-W00F4X-15W8/Transformative-Learning-Mezirow-1997.pdf

Mezirow, J. (2011, July). Fostering Critical Reflection in Adulthood. A Guide to Transformative and Emancipatory Learning ‘How Critical Reflection triggers Transformative Learning. Retrieved from http://www.ln.edu.hk/osl/conference2011/output/breakout/4.4%20[ref]How%20Critical%20Reflection%20triggers%20Transformative%20Learning%20-%20Mezirow.pdf

O’Neil, J., & Marsick, V. J. (2007). Understanding Action Learning. New York, NY: AMACOM.

Rademacher, L. (2004). Learning to Learn: A Philosophical Guide to Learning. United States: iUniverse, Inc.

Tyler, J. A., & Swartz, A. L. (2012). Storytelling and Transformative Learning. In The Handbook of Transformative Learning (pp. 455–470). San Francisco: Jossey-Bass.

United Nations. (2016, August ). Sustainable Development Goals. Retrieved November 1, 2016, from http://www.un.org/sustainabledevelopment/sustainable-development-goals/

About the Author

Vinelle Leung

MEd, The University of Hong Kong

Email: vincy.lyc@gmail.com

Sleep Problems and Sleep Education for Adolescents in Hong Kong

By Luo Yu

Table of Contents

 1. Introduction

2. Background: Sleep Disorders

3. Sleep Problems among Adolescent Students in Hong Kong

4. Sleep Education as a Solution

5. Recommendations for Sleep Education in Hong Kong

6. Conclusion

7. References

8. Key Terms and Definitions

9. About the Author

1. Introduction

The 2030 Agenda for Sustainable Development adopted by the United Nations General Assembly in 2015, set up 17 Sustainable Development Goals (SDGs). Promotion of mental health and well-being is one of the targets outlined in Goal 3. Psychological problems, such as anxiety and depression, can lead to suicide. Suicide is reported as the second leading cause of death among young people in the 15-29 age group (United Nations, 2016). Studies have shown that long-term sleep problems are positively associated with such psychological problems (Adrien, 2002; Breslau et al.,1996; Richdale, 1999). However, sleep problems are often overlooked by people.

Students in Hong Kong bear a heavy academic burden which may result in sleep problems (Chung & Cheung, 2008). Even though many adolescent students suffer from sleep disturbance, sleep education in Hong Kong only started recently, and various difficulties have been encountered in launching such educational programs. Although sleep education provides adolescents with knowledge about sleep, few consistent outcomes have been observed in improving sleep after sleep education programs (Chan, 2016). The effect of sleep education remains unclear.

This entry begins by explaining different forms of sleep disorder. It then discusses the factors that affect sleep and the current situation of sleep problems among Hong Kong adolescent students. After that, sleep education as a possible solution, and its function and effectiveness in a global context and in Hong Kong, are examined.

2. Background: Sleep Disorders

According to the International Classification of Sleep Disorders, there are three main types of sleep disorders (American Academy of Sleep Medicine, 2014) and they include:

  • Insomnia

Insomnia, also called sleeplessness, is typically characterized by difficulty in initiating and/or maintaining sleep. Usually, people who suffer from insomnia also wake too early and cannot get insufficient amounts of nocturnal sleep.

  • Sleep-Related Breathing Disorder

Dysfunctional sleep breathing is the characteristic feature of sleep-related breathing disorder. Obstructive sleep apnea, the most common type of this disorder, causes inadequate breathing during sleep. Snoring is often seen as a symptom of this disorder.

  • Parasomnia

Parasomnia involves abnormal movements, behavior, emotions, perceptions, and dreams that accompany sleep. Sleepwalking and teeth grinding, for example, belong to this kind of sleep disorder.

3. Sleep Problems among Adolescent Students in Hong Kong

Sleep is a complicated activity that interplays with environmental, physiological and psychological factors. Though the relationship between many sleep-related behaviors and sleep quality remain ambiguous and some factors are in common (e.g. age, gender, family communication, etc.) in adolescents all over the world, there are significant external factors which are relevant to Hong Kong youth.

People spend almost one-third of their lifetime in sleeping. Adolescents, at their transitional stage of physical and psychological development, need more sleep than adults. Nevertheless, sleep deprivation is prevalent among adolescent students in Hong Kong. An epidemiological study has pointed out that the average sleep time among 1629 Hong Kong secondary school students was only 7.3 hours during school nights (Chung & Cheung, 2008), less than the 8 to 9 hours which is commonly suggested for adolescents (National Sleep Foundation, 2000). From 2006 to 2008, the Hong Kong Student Obesity Surveillance (HKSOS) project investigated 22,678 Chinese adolescent students aged 12 to 18 on sociodemographic characteristics, sleep patterns and problems etc. As it demonstrated, only 27.4% of the participants slept more than 8 hours on school nights. Most insomnia disorders involved difficulty in initiating sleep (12.3%), followed by difficulty in maintaining sleep (8.8%) and early morning awakening (7.2%) in the case of participating students (Mak et al., 2012). Another investigation completed by 529 Hong Kong college students indicated that 68.6% of the participants were insomniacs (Sing and Wong, 2010). Accordingly, insomnia is very common among Hong Kong students.

Academic Stress is a major factor in adolescent sleep disorders in Hong Kong. Recent decades have witnessed an increasing academic load for adolescent students (Bjorkman, 2007; Kaplan et al., 2005). Chung and Cheung’s (2008, p. 193) study shows ‘that high perceived stress was the most significant risk factor for sleep disturbance among secondary school students in Hong Kong’. They also discovered that students who have marginal academic performance usually sleep less during the school week than students with better grades. Student in different stages of their studies also demonstrate different sleep quality norms because each study year may have various academic and life pressures. For example, university students in the first and the third years of study are reported to have more sleep problems (Suen et al., 2008).

Academic pressure is not only one major significant risk factor for sleep disorder among adolescent students, it also has an impact on students’ psychological health, as it causes anxiety and depression. Sleep problems exacerbate these mental disorders, and anxiety and depression lead to poorer sleep quality and thus academic performance. Each of these is in an interrelated web of relationship (see Figure 1.).

Figure 1  Relationship between Sleep Problem, Academic Pressure, and Mental Disorders

Figure 1 Relationship between Sleep Problem, Academic Pressure, and Mental Disorders

As a preventative measure, sleep hygiene practice includes different actions that can be taken before sleep or during the daytime to enhance sleep health. Such actions as night eating, drinking alcohol, beverage containing caffeine or dairy product, taking naps during the daytime, performing active exercise, and using electronic devices before sleep may all lead to poorer sleep quality and even insomnia. A survey conducted with 400 university students in Hong Kong found that students who self-reported to have poorer sleep quality got significant lower average scores in sleep hygiene practice assessments (Suen et al., 2008).

4. Sleep Education as a Solution

Education can raise awareness and disseminate knowledge about sleep and thus sleep education is a potential solution to address sleep disorders. Some studies show that psycho-education programs are an effective means in helping the clinical insomnia population (Morin et al., 1994; Murtagh & Greenwood, 1995). Sleep education can increase the level of knowledge about sleep hygiene, sleep patterns, and other related issues.

Sleep education is in its infancy stage. In 2012, a study (Blunden et al., 2012) identified 12 programs in sleep education. Another research designed to assess the prevalence of sleep education in 409 medical schools reported that the average amount of time spent on sleep education in these medical schools is less than 2.5 hours (Mindell et al., 2011). The theoretical underpinning of sleep education is also to be developed.

Additionally, the consistent efficacy of sleep education remains highly complex. The most salient progress observed among all programs was the increase of knowledge about sleep hygiene. The overall sleep parameters across studies had little changes, however. Only 2 studies reported specific improvement in sleep duration. The Sleep Smart program found that adolescents in the intervention group reported more regular sleep-wake patterns during weekdays and weekends after sleep education (Rossi, 2002). In short, sleep education programs for youth improved their knowledge about sleep, while there is less consistent improvement in sleep duration or sleep hygiene. Other findings indicated that good sleep hygiene knowledge is weakly associated with good sleep hygiene practice (Brown et al., 2002). This may partly explain why sleep education program cannot contribute much to good sleep behavior and sleep quality.

Sleep education in Hong Kong is thus in its earliest stage. Only one program on sleep education for Hong Kong adolescent students has been identified. This program, conducted by a team of academics and students in universities in Hong Kong, aims to increase sleep knowledge and promote good sleep practice among school-aged children and teenagers. Twelve primary school and fourteen secondary school students took part in the program. The intervention group which contained 14 randomized schools had seminars, workshops, slogan and painting competitions, and other activities during the three months of the sleep education program. More than 400 workshops and 40 seminars taught by specialists and trained research assistants were held during the campaign. Their topics varied from factors of sleep loss to time and stress management skills. This program also provided teachers and parents with a seminar on sleep knowledge. The outcomes demonstrated that the program was effective in increasing sleep knowledge and improved, at least in short term, adolescent behaviors, psychological health and healthy lifestyle practices. However, it did not clearly achieve its second goal, that is, to change sleep practice.

A few challenges were discussed by the program team. First, before launching this program, all primary and secondary schools in Hong Kong were invited, but most school principals found it difficult to add additional lessons to school and teachers’ schedules. In the end, only 26 schools participated in the project. Second, only 10% of parents attended the seminar designed and provided to them. This indicates that most schools and parents lack awareness of the importance of sleep and sleep education for their children, and prioritize their children’s schoolwork and other activities over sleep health (Chan, 2016).

5. Recommendations for Sleep Education in Hong Kong

Researchers have noted that the outcomes of sleep education are not ideal. There is an increase of knowledge level but no change in sleep parameters. One of the issues identified is that there is no theoretical foundation for such educational programs (Blunden et al., 2012). Blunden et al. (2012) constructed an integrated model of behavior change (see Figure 2). Along with knowledge, motivation is suggested as the very first step before planning a strategy (Azjen, 2002). Apart from knowledge attainment and motivation, however, participants’ attitudes to their behaviors and their subjective norms contribute to behavioral change. For example, whether an adolescent decides to change his/her sleep hygiene practice would depend on his/her understanding of the effects of the behavior, attitude to the current behavior, intent and motivation to change, and the consideration of its importance and his/her readiness to change it.

Figure 2  Representation of an integrated model of behavior change (Adapted from Azjen)

Figure 2 Representation of an integrated model of behavior change (Adapted from Azjen)

Additionally, sleep disorders are not only a problem related to adolescents, but should be prioritized by parents, school teachers, and friends. It is suggested that an informal alliance among students, schools, and parents should be built to achieve greater understanding and results. The Committee of Home-School Co-operation (CHSC) in Hong Kong could play a vital role in blending sleep education in forums, dialogues and other activities. Furthermore, a communicative and mutual-supervisory relationship could be built among adolescent students so that students are able to change their sleep-related behavior under peer motivation and pressure.

Likewise, the government should not be absent in the promotion of sleep education. As mentioned earlier, a heavy academic burden is one of the most significant factors that leads to sleep deprivation. Therefore, the government could set out guidelines to adjust curriculum and assignments to improve the situation. On the other hand, sleep education can also be included into the hidden curriculum, e.g., with rearrangement of the school timetable, organizing sleep education related activities, and providing extracurricular books about sleep health, etc. Other strategies to increase and enhance sleep education need to be explored by different stakeholders.

6. Conclusion

In consideration of the close association of sleep problems and mental illness among adolescents, more attention to sleep quality in adolescents should be granted. Many Hong Kong youth face serious sleep problems, due to academic pressure and other factors. Education, which is usually considered as one of the solutions to address many sustainable developmental issues, can provide more knowledge to adolescent students and help youth obtain better sleep in a short period. However, existing studies have shown that sleep education programs thus far have brought less than consistent success in relation to enhancing sleep behavior and sleep duration. The effect of sleep education in youth is still complicated in many ways. Based on the integrated model of behavior change theory, elements for changing adolescent sleep behavior can be proposed and implemented with the cooperation and support of schools, parents and students.

7. References

Adrien, J. (2002). Neurobiological Bases for the Relation between Sleep and Depression. Sleep Medicine Reviews, 6, 341–351. Doi:10.1053/smrv.2001.020

Ajzen I, Saunders J, Davis LE, & Williams T. (2002). The Decision of African American Students to Complete High School: An Application of the Theory of Planned Behavior. Journal of Educational   Psychology; 94(810e9). Doi: 10.1037//0022-0663.94.4.810

American Academy of Sleep Medicine. (2014). International Classification of Sleep Disorders, third edition (ICSD-3). Darien: Illinois.

Bjorkman, S. M. (2007). Relationships among Academic Stress, Social Support, and Internalizing and Externalizing Behavior in Adolescence. Northern Illinois University.

Blunden, S. L., Chapman, J., & Rigney, G. A. (2012). Are Sleep Education Programs Successful? The Case for Improved and Consistent Research Efforts. Sleep Medicine Reviews, 16(4), 355-370. Doi: 10.1016/j.smrv.2011.08.002

Breslau, N., Roth, T., Rosenthal, L., & Andreski, P. (1996). Sleep Disturbance and Psychiatric Disorders: A Longitudinal Epidemiological Study of Young Adults. Biological Psychiatry, 39, 411–418.

Brown FC, Buboltz WC, Jr, & Soper B. (2002). Relationship of Sleep Hygiene Awareness, Sleep Hygiene Practices, and Sleep Quality in University Students. Behavior Medicine, 28, 33–38.

Chan, D. W. (1997). Depressive Symptoms and Perceived Competence among Chinese Secondary School Students in Hong Kong. Journal of Youth and Adolescence, 26(3), 303-319. Doi: 10.1007/s10964-005-0004-4

Chan, N. Y., Lam, S. P., Zhang, J., Yu, M. W. M., Li, S. X., Li, A. M., & Wing, Y. K. (2016). Sleep Education in Hong Kong. Sleep and Biological Rhythms, 14(1), 21-25. Doi 10.1007/s41105-015-0008-8

Chung, K.F. & Cheung, M.M. (2008). Sleep-wake Patterns and Sleep Disturbance among Hong Kong Chinese Adolescents. Sleep, 31(2):185-194.

Kaplan, D. S., Liu, R. X., & Kaplan, H. B. (2005). School Related Stress in Early Adolescence and Academic Performance Three Years Later: The Conditional Influence of Self-expectations. Social Psychology of Education, 8(1), 3-17. Doi: 10.1007/s11218-004-3129-5

Kliegman, R. M., Behrman, R. E., Jenson, H. B., & Stanton, B. M. (2007). Nelson Textbook of Pediatrics. Elsevier Health Sciences.

Mak K-K, Lee S-L, Ho S-Y, Lo W-S, & Lam T-H, (2012). Sleep and Academic Performance in Hong Kong Adolescents. Journal of School Health, 82, 522-527. Doi: 10.1111/j.1746-1561.2012. 00732.x

Mindell, J. A., Bartle, A., Wahab, N. A., Ahn, Y., Ramamurthy, M. B., Huong, H. T. D., Teng, A. (2011). Sleep Education in Medical School Curriculum: A Glimpse across Countries. Sleep Medicine, 12(9), 928-931. Doi: 10.1016/j.sleep.2011.07.001 .

Morin, C. M., Culbert, J. P., & Schwartz, S. M. (1994). Nonpharmacological Interventions for Insomnia. The American Journal of Psychiatry, 151(8), 1172.

Murtagh, D. R., & Greenwood, K. M. (1995). Identifying Effective Psychological Treatments for Insomnia: A Meta-analysis. Journal of Consulting and Clinical Psychology, 63(1), 79.

National Sleep Foundation (NSF). (2000). Adolescent Sleep Needs and Patterns: Research Report and Resource Guide. National Sleep Foundation.

Prochaska, J. & DiClemente, C.C. (1983) Stages and Processes of Self-change of Smoking: Toward an Integrative Model of Change. Journal of Consulting Clinical Psychology, 51(390e5).

Richdale, A. L. (1999). Sleep Problems in Autism: Prevalence, Cause, and Intervention. Developmental Medicine & Child Neurology, 41(01), 60-66. Doi: 10.1111/j.1469-8749. 1999.tb00012.x

Rossi, C., Vo, O., Marco, C., & Wolfson, A. (2002). Middle School Sleep-smart Program: A Pilot Evaluation. Sleep, 25(A279).

Sing, C. & W. S. Wong (2010). Prevalence of Insomnia and its Psychosocial Correlates among College Students in Hong Kong. Journal of American college health, 59(3), 174-182.

Suen, L. K., Ellis Hon, K., & Tam, W. W. (2008). Association between Sleep Behavior and Sleep-Related Factors among University Students in Hong Kong. Chronobiology international, 25(5), 760-775. Doi: 10.1080/07420520802397186

United Nations (UN). (2016). Progress towards the Sustainable Development Goals. High Level Political Forum on Sustainable Development. New York.

8. Key Terms and Definitions

Adolescent studenta person in the 11-21 age group (Kliegman et al., 2007). It is a transitional stage when physical and psychological changes occur, bringing up self-identity and independence.

About the Author

Luo Yu

MEd, The University of Hong Kong

Email: luoyu.2017@ outlook.com

Education for Sustainable Diet in Hong Kong

By Joseph Hung

Table of Contents

1. Introduction

2. Background

1. Food Production in the Modern World

2. Definition of a Sustainable Diet

3. Factors that Affect Food Choices

3. Education for Sustainable Diet in Hong Kong

1.  The Hong Kong Context: Cultural, Socio-historical, and Economic Background 

2. Formal Curriculum

3. Liberal Studies

4. Conclusion

5. References

6. Key Terms and Definitions

7. Appendix

8. About the Author

1. Introduction

Food is an important topic in early childhood education. At this very early stage children receive messages about food culture, nutrition, and hygiene. In secondary school, students study biochemistry and explore different components of food. Recently the environmental aspect of food production and consumption has been introduced into the curriculum in Hong Kong. However, to achieve sustainable development for the society, it is important to not only include aspects of environmental conservation in food and diet education, but also such issues as equity, poverty reduction, food security, and cultural relevance, among others. Senior Secondary Liberal Studies in the core curriculum of Hong Kong has the potential to incorporate these elements. This entry discusses food literacy education in Hong Kong, and in particular, how Liberal Studies approaches the topic of sustainable diet and may affect people’s dietary choices.

2. Background

2.1. Food Production in the Modern World

Food is important for human life as it is the main source of energy and raw material for our survival and growth. It is also one of the critical economic products that people produce, exchange, and consume. Humans shifted from the hunter-gatherer model of food production to an agrarian one to support a larger population in the period of the Neolithic revolution. Food also evolved with the development of agricultural technology and the eco-geographical setting.

Since World War II, industrialised countries have revolutionised agriculture by increased mechanisation and the widespread use of chemical fertilisers, pesticides, and herbicides. There has also been an increased specialisation of crops and enlargement of farm size and related developments in livestock, followed more recently by the use of biotechnology in modifying plant genetics (Clunies-Ross & Hildyard, 1992). Not all of this development is ideal, however. According to an Oxfam report of 2013, 450 million people, originally farmers, now work as wageworkers in industrialised agricultural settings, of which 60% live in poverty and are facing starvation (Hoffman, 2013).

In addition, industrialised farms have increased pressure on the environment by using chemicals that transform land and machines that emit a large amount of carbon dioxide into the atmosphere. Vermeulen et al. (2012) calculated that food systems contribute 19%-29% of the world’s anthropogenic greenhouse gas emissions. One particularly important aspect is the global production of meat, which is projected to more than double, from 229 million tonnes in 1999 to 465 million tonnes in 2050 (Steinfeld et al, 2006). The expansion of livestock production causes land degradation, increase of fresh water usage, and higher levels of greenhouse gas emission. It has also worsened the food shortage problem worldwide as crops are fed to animals to boost their growth.

2.2. Definition of a Sustainable Diet

Gussow and Clancy (1986) proposed the term “sustainable diet” to “describe recommendations for food choices that support life and health within natural system limits into the foreseeable future”. They stressed the importance of understanding the effects of food choices on food supply, global resources (agricultural, economic, and natural), long-term stability of the food system, and individual nutrition and health (Gussow & Clancy, 1986). Since that time, there have been discussions and applications of the term in the areas of nutrition studies, development studies, and environmental studies, which complicated the term in connection with other concepts.

There is currently no universally agreed definition of a “sustainable diet” (He, 2012).  However, He, the Deputy Director-General of the FAO, proposed that a definition of a sustainable diet should “address sustainability of the whole food supply chain and thus provide guidance on promoting and applying the concept in different agro-ecological zones” (He, 2012). Hence, sustainable diet is informed by a multitude of issues in the production and consumption of food, including environmental, agro-economic, and human nutrition needs. Lairon (2012) lists the following components of a sustainable diet:

             food and nutrient needs, food security and accessibility;

             well-being and health;

             biodiversity, environment and climate;

             equity and fair trade;

             eco-friendly, local and seasonal food; and

             cultural heritage and skills.

2.3. Factors that Affect Food Choices

According to the European Food Information Council (2005), biological, economic, physical, social, and psychological factors, as well as attitudes, beliefs, and knowledge about food influence the way people choose what they eat. These determining factors can be grouped into three categories. First, formal and informal education plays a vital role in promoting food literacy as it shapes citizens’ attitudes and beliefs about food, and transfers necessary knowledge for making sound decisions in choosing it. In Hong Kong, for example, children receive knowledge and develop attitudes about food in formal school settings and at home. Second, social and cultural habits of a place have a big influence on how its people choose their food. These factors include cultural heritage (culinary style), religious rules and the effect of commercial culture. Third, economic forces behind the food supply chain are manifested in the availability and affordability of certain products. Hong Kong, as a city influenced both by the Chinese cultural background and a globalised economy, provides a great diversity of food choices.

3. Education for Sustainable Diet in Hong Kong

3.1. The Hong Kong Context: Cultural, Socio-historical, and Economic Background

Hong Kong is a city in South China that used to be a British colony. It is one of the world’s financial centres, and its per capita GDP is in the world’s top ten (World Bank, 2014). However, it was not a prosperous place in the past. Historically Hong Kong was a popular refuge for Chinese nationals when Mainland China was at war or during political movements. Poor Chinese immigrants had to struggle for life in the city. The experience of World War II and the Chinese civil war as well as starvation in China put an emphasis on food security and food safety over other things in the view of Hong Kong’s older generation. Currently, Hong Kong imports over 95% of its food from all over the world.

However, in good times, Hong Kong people consume the best of food products and enjoy a great variety of culinary styles. The mainstream home-cooked food is southern Chinese style, or the ‘Guangdong’ style. There are few taboos in food choice. Hong Kong people eat different types of meat (including internal organs), fish, and vegetables. Most people think that eating meat is essential for potency and nutrition. In banquets, rare and valuable food products, such as shark fin soup, abalone, groupers, and others are offered to show generosity to the guests and show off one’s wealth.

Culturally, Hong Kong is also influenced by its colonial past and the openness of the economy. Western-style food is seen as sophisticated and is served in most restaurants, along with Chinese-style food. The city is also rich in restaurants with Japanese, Korean, and Indian cuisines as well as transnational fast food chains. This variety affects the dietary choices of young people.

The Hong Kong Department of Health has been promoting a healthy diet for years, recommending particularly that residents of Hong Kong reduce fat and salt consumption. Such a diet can lower the risks of diabetes, heart disease, and obesity. A committee for reduction of salt and sugar in food was established by the Hong Kong government in 2015. However, since food has long been seen as an area the Department of Health should be responsible for, little emphasis has been placed on other aspects of diet such as those related to the environment.

In 2012, Green Monday, as part of a global movement, was established in Hong Kong to promote a vegetarian diet. The movement made a very strong media statement about the environmental problems that may arise due to the great increase in meat production. At the same time, the issue of food waste has become a concern in the city, as the landfills have started reaching their limits. Hong Kong people have thus only started to pay attention to the environmental issues surrounding food production and consumption. With the launch of Liberal Studies in 2009, teaching and learning about food can be revitalised.

3.2. Formal Curriculum

In Hong Kong, issues related to food are taught in general studies (primary school), integrated science and integrated humanities (junior secondary), and Liberal Studies (senior secondary). There have been studies carried out about food and health education in Hong Kong in the past (such as Chan et al., 2009), but no research has been done about sustainability in food systems (i.e., the whole process of food production and distribution). Students study basic knowledge about nutrition, hygiene, balanced diet, and malnutrition/obesity in the primary years (Education Bureau (EDB), 2002a). In junior secondary years, they learn about food in geography (farmland), economics (modes of production), and biology (the digestive system and human nutrition). Although the curriculum encourages project learning and other integrated teaching approaches (EDB, 2002b; EDB, 2002c), different schools choose issues they teach, and food is not always a popular choice in their project learning exercises. In the curriculum, the production of food is barely touched upon.

3.3. Liberal Studies

In senior secondary schools, all students study Liberal Studies as a compulsory subject. Liberal Studies has sustainability as one of the main concepts in Module 6 of the syllabus, and food production and consumption are popular topics in teaching and assessment. The DSE examination, for example, has a number of questions about food (see Appendix 1 for a list of all topics in the DSE LS examination about food since 2012). The examination assesses students’ knowledge about food safety, food and health, food culture, starvation, free trade and globalisation, as well as vegetarianism and human choice of food. It is likely that students gain a good understanding of the relationship between food and sustainability after studying the subject. However, this is not guaranteed, because teachers can choose other issues in their teaching to illustrate issues of sustainability.

Besides knowledge, development of specific attitudes and values are also key goals in Liberal Studies teaching and learning. Students, through their critical study of different issues and concepts from various perspectives, develop their own belief systems. The expected learning outcome of the subject includes an “appreciation for the values of [students’] own and other cultures, and for universal values, and [commitment] to becoming responsible and conscientious citizens” (EDB, 2014).

In most of the above educational initiatives, an “ESD1” approach is employed, as students study specific knowledge about the subject and develop “informed [and] skilled behaviour and ways of thinking” (Vare and Scott, 2007). However, “ESD2” is critical in the long-term as it builds the capacity to think, test ideas, and explore dilemmas and contradictions. In a fast-paced society such as Hong Kong, ESD2 is a much-needed approach to complement ESD1 in order to effect changes. Current and future residents of Hong Kong should learn how to make responsible choices in food products through education for sustainable diet. The spirit of the Liberal Studies curriculum should then include an ESD2 approach.

An obstacle to the shift in teaching for sustainable diet relates to implementation of the Liberal Studies curriculum. Teachers training still lags behind the curriculum changes of 2009, as teachers are not all prepared to teach such varied issues. Yet the way teachers make sense of the curriculum and choose their teaching strategies has a strong influence on the learning outcome (Mak, 2011). Furthermore, since education is only one of the factors that affect food choice, the strong cultural factor still dominates the decision-making processes of people. In addition, even though students pay attention to food mileage or sustainability, the shortage of locally produced food and the relatively high price of environmentally friendly food is a major problem that affects their choice.

4. Conclusion

Education is one of the major factors that affects the sustainable choice of diet. In Hong Kong, like many other places, students learn about food with a focus on its nutritional value. The environmental issues in food choices and sustainability are a novelty. The formal schooling system is fast in responding to global demands, with the introduction of Liberal Studies in 2009. However, improvement in teacher training is critical to achieve desired learning outcomes. Since cultural and economic influences are also strong, whether Hong Kong people can adopt a more sustainable diet depends on education.

References

Clunies-Ross, T. & Hildyard, N. (1992). The Politics of Industrial Agriculture. London: Earthscan Publications.

Education Bureau (EDB). (2002a). General Studies for Primary Schools Curriculum Guide. The Government of HKSAR.

Education Bureau (EDB). (2002b). Science Education: Key Learning Area Curriculum Guide (Primary 1 - Secondary 3). The Government of HKSAR.

Education Bureau (EDB). (2002c). Personal, Social and Humanities Education: Key Learning Area Curriculum Guide (Primary 1 - Secondary 3). The Government of HKSAR.

Education Bureau (EDB). (2014). Liberal Studies: Curriculum and Assessment Guide (Secondary 4-6). The Government of HKSAR.

European Food Information Council (EUFIC). (2005). The determinants of food choice. EUFIC Review, 4/2005. Retrieved October 26, 2015, from http://www.eufic.org/article/en/expid/review-food-choice/

Gussow, J. D. & Clancy, K. L. (1986). Dietary guidelines for sustainability. Journal of Nutrition Education, 18, 1-5.

He, C. C. (2012). Opening addresses. Sustainable Diets and Biodiversity: Directions and Solutions for Policy, Research and Action. FAO. Retrieved October 27, 2015, from http://www.fao.org/docrep/016/i3004e/i3004e.pdf

Hoffman, B. (2012). Behind the Brands: Food Justice and the Big 10 Food and Beverage Companies. Oxfam. Retrieved October 27, 2015, from https://www.oxfam.org/sites/www.oxfam.org/files/bp166-behind-the-brands-260213-en.pdf

Lairon, D. (2012). Biodiversity and sustainable nutrition with a food-based approach. Sustainable Diets and Biodiversity: Directions and Solutions for Policy, Research and Action. FAO. Retrieved October 27, 2015, from http://www.fao.org/docrep/016/i3004e/i3004e.pdf

Mak, K. W. (2011). Making Sense of New Senior Secondary Liberal Studies in Hong Kong Curriculum Reform: Teacher Perspectives. The Chinese University of Hong Kong.

Steinfeld, H., Gerber, P. J., Wassenaar, T., Castel, V., Rosales, M. & de Haan, C. (2006). Livestock’s Long Shadow: Environmental Issues and Options. Food and Agriculture Organization of the United Nations (FAO), Rome. Retrieved October 6, 2015, from http://www.fao.org/docrep/010/a0701e/a0701e00.HTM

Vare, P. & Scott, W. (2007). Learning for Change: Exploring the Relationship between Education and Sustainable Development. Journal of Education for Sustainable Development, 1(2). Doi: 10.1177/097340820700100209

Vermeulen, S. J, Campbell, B. M. & Ingram J. S. I. (2012). Climate Change and Food Systems. Annual Review of Environment and Resources, 37, 195-222. Retrieved October 27, 2015, from http://www.annualreviews.org/doi/abs/10.1146/annurev-environ-020411-130608

World Bank, The (WB). (2014). 2014 World Development Indicators. Washington, D.C.: International Bank for Reconstruction and Development/The World Bank.

Key Terms and Definitions

Sustainable Diet: food choices that support life and health within natural system limits into the foreseeable future. There is no universally agreed definition, but for a diet to be recognised as sustainable, it usually prioritises the following components: nutrition needs, food security, health and well-being, biodiversity and the environment, fair trade, and cultural heritage.

Food System: the whole process in which food is produced, distributed and consumed. Industrialised agriculture with giant transnational food companies distributing food products globally is the dominant food system in the modern world.

Food Literacy: The knowledge, skills and attitudes about food. Traditionally it has been composed of knowledge related to food choice and processing (nutrition and cookery), but is moving toward understanding of food systems and the environmental and social impacts of food production and consumption.

Appendix 1 A List of HKEAA Liberal Studies question papers with “food” topics since 2012

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About the Author

Joseph Hung

MEd, The University of Hong Kong

Email: joehung.hk@gmail.com