Background
Health is vital to a child's ability to learn and to succeed in life [
1]. Diseases or health problems can prevent a child from fully engaged in learning activities. For instance, studies found that childhood asthma is associated with an increased risk for school problems, including grade failure and learning disability [
2,
3]. As a means of primary prevention, many studies suggested that physical examination can identify high risk groups among school-aged children and also provide clues for secondary prevention [
4,
5]. Physical examination is essential in the school health service component of many school health models, such as the Three-Component model, ACCESS model, the Illinois Department of Health model [
6], and the recent Health Promoting School model [
7]. School entry physical examination has a positive effect upon the high-risk population regarding health, which reduced death from cerebrovascular disease (CVD), heart disease, and so on [
5]. Thus, some schools require physical examination before enrollment or sport activities [
8].
In Fry's opinions [
9], vision, hearing, and growth should be required in school entry examinations "because it may be only the first time that anyone has looked for any abnormality in these areas." The meta-analysis by Ni Bhrolchain [
10] reviewed nine British studies and found 55–132 health problems per 100 children examined, while 28%–75% of them were first identified in routine school entry medical examination. This comparison of routine and selected school entry medical examinations also revealed that, if financially supported, the routine examinations had higher percentages of health problems detected and first identified health problems, more referrals, and better identification of undescended testes and speech delay. Another more comprehensive review also reported more detected health problems and elevated percentages of first identified health problems among elementary school entrants [
4].
The benefits of physical examination for children, if financially supported, are essentially fourfold: First of all, some impairments and physical changes associated with diseases, which parents may be unaware of due to limited medical knowledge, can cause significant disability or handicap. Thus physical examination may raise parents' awareness of potential health problems in their children. Parents' lack of knowledge may also cause health problems to go undiagnosed in childhood. Secondly, early diagnosis followed by effective treatment is likely to improve disease outcomes. Thirdly, physical examination identifies unmet health needs before any negative health impacts occur and provides an effective health check for children who start school with health and developmental disadvantages [
11]. Fourthly, health problems ignored or unknown can be identified by clinicians. From a detailed review of school health records, Elliott and colleagues found 45% of children had at least one problem not previously noted, including undescended testes, heart murmur, squints, hernias, and et al. [
12].
Reduced visual acuity may adversely affect sporting and academic achievement in school. The American Academy of Pediatrics (AAP) and the Canadian Task Force on the Periodic Health Examination recommended that clinicians perform objective vision screening on school-aged children. Moreover, both the American Academy of Ophthalmology (AAO) and the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) recommended that screening after five years of age be carried out during routine school checks [
13]. There is no doubt that the entry into elementary school is a good time for physical examination.
In addition to the vision screening recommendations by the professional organizations to support health examination from early age, research show health problems in childhood are highly associated with adulthood diseases. For example, obese children have an elevated risk of adulthood high blood pressure, non-insulin-dependent diabetes, high triglyceride/cholesterol circulating levels, and fatty liver than non-obese children [
14]. The strong association between childhood obesity and adult diseases shows the importance of early detection and suggests that prevention and treatment of childhood obesity should be pursued to reduce the morbidity and mortality [
15]. Physical examination from the elementary school ages would provide a good track of the physical development and health problems, which can provide parents, schools, and health professionals more information in prevention and treatment. Other examples such as early detection of developmental dysplasia of the hip, dental caries, growth disorders, or myopia would allow prompt surgery, treatment, correction, or rehabilitation as needed before deterioration.
Many studies reported morbidity and prevalence of diseases among school-aged children. These studies, however, focus mostly on one specific health problem (i.e., learning disability, vision, and hearing) considering other potential health problems. Nevertheless, the lack of epidemiological studies which examined students' comprehensive physical health status at the entry point of elementary school creates a problem in that no baseline data is available in assessing and evaluating students' overall health in school. The absence of reliable data have made monitoring the health status of children a challenge [
16] and have made it difficult to manage the extent of public health problems. Through the elementary school entry physical examination, children's health condition can be established, which would help school nurses manage chronic conditions and the school to conduct more effective school health programs. Specifically, free comprehensive physical examinations would eliminate the financial barriers that accompany different levels of urbanization and available medical resources.
Taipei County is the largest county in Taiwan: with a population of 3,641,446 people, Taipei County comprised 16.2% of the total population of Taiwan in 2002 [
17]. Mandatory education is required from the first to ninth grade. To achieve the goals of healthy schools with healthy students, school health promotion programs were launched in Taipei County. Due to the necessity of having baseline data from physical examination at school entry the county offered free comprehensive physical examinations every fall for first graders, the youngest students entering elementary school in the Taiwan education system.
Health and education professionals need information about the prevalence of health problems and their influential factors to develop effective and targeted interventions to reduce health problems in childhood. By reviewing individual disease prevalence reported, students' gender and level of residence urbanization seem to relate to morbidity. From the literature, school children's vision abnormality differed by sex [
18], while asthma [
19], dental caries [
20], and vision screening results differed by urbanization [
18‐
21]. Besides, in Leff's opinion [
22], "school health varies dramatically between inner city, urban, and rural schools." Another study, which found the care needs in schools serving disadvantaged areas to be eight times greater than in other areas, seems to imply the difference is due to residency [
23]. However, the relationships between health status and number of medical resources have rarely been investigated and are still unclear.
Therefore, the aim of this study was to explore the health status of first-graders in Taipei County, identify the top three health problems, and examine the differences between sexes, levels of urbanization, and the quantity of medical resources. This free physical examination was also intended to preliminarily screen health problems so parents could take their children for detailed diagnosis and treatment if necessary.
Methods
Subject
The data used in this comparative descriptive study were collected in the fall of 2002 from the first-graders of all public elementary schools in Taipei County, Taiwan. More than fifty-three thousand (53,053 out of 53,642, 98.9%) students from 203 (out of 211, 96.2%) schools were included in the study. The study was reviewed and approved by the Taipei County Government Education Bureau. Informed written consent was sent to and permission was obtained from the students' parents or guardians. The parents or guardians were required to accompany their children to the physical examination. Students or parents/guardians were free to withdraw from any examination item at any time. The consent form, offered by the Taiwan County Education Bureau, informed parents/guardians that these examinations are non-intrusive with minimum risk. In addition, the students were notified to wear suitable clothing for physical examination.
Measurement
Data from the 2002 Student Entry Physical Examination (SEPE) and Student Medical History Inventory (SMHI) were analyzed. SEPE assessed eyes, teeth, ears-nose-throat (ENT), heart-lung-abdomen (HLA), bones-muscle, reproductive-urinary, skin and other systems grouped by the regulations set by the Taiwan Ministry of Education [
24]. The ICD-9 was used as diagnostic criteria. SMHI, a structural checklist to investigate students' medical history, was filled out by parents/guardians.
Density of the population is the major indicator for the urbanization level in Taiwan. In this study, the levels of urbanization were categorized into 3 groups, urban (above ten thousand), suburban (ranged one thousand to below ten thousand), and rural (below one thousand) based on density of the population (person per square kilometer, km2). Based on this categorization, the distribution of schools was 31.5% urban (n = 64), 49.3% suburban (n = 100), and 19.2% rural (n = 39). The quantity of available medical resources, defined by the number of health care facilities, excluding home care, long-term care, hospice, psychiatric, OB-GYN, and EMS facilities, was obtained from the National Health Insurance Office. The quantity of available medical resources ranged from 1 to 397 (mean = 104.6, SD = 109.8, median = 69.0) and varied by school's township. Because national health insurance is obligatory for Taiwan citizens, the registered health care providers represent the most accurate number of available health care facilities.
Procedure
During the fall semester of 2002, parents/guardians provided consented for their children to participate in the physical examination. A physical examination team including pediatricians, dentists, oculists, and nurses was employed to conduct physical examinations in the health center of each school. In the meantime, the students' parents/guardians were asked to complete and return the SMHI to their children's school.
Data Analysis
Statistical analyses were carried out using the statistical package SPSS. All data were entered, summarized, and analyzed. Frequencies, independent sample t-test, and analysis of variance (ANOVA) along with post hoc tests were used to examine prevalence of health problems between sexes and levels of urbanization while Pearson's correlation coefficients were used to determine its association with the quantity of medical resources.
Results
This study explored the morbidity of health problems among first-graders and its association with sex, levels of urbanization, and quantity of medical resources. Of the 53,053 first-grade students aged six to eight years, 52% were boys (27,359) and 48% were girls (25,694). The morbidity of each physical system is represented by cases per thousand while the prevalence of individual disease is shown by percentage.
Results from Student Medical History Inventory (SMHI)
Results showed 13.7% of students had a medical history of at least one diagnosed illness. The common medical conditions were ranked as follows: allergy (6.7%), asthma (4.1%), hernia (1.5%), Glucose-6-phosphate dehydrogenase deficiency (G6PD, 1.3%), heart disease (0.8%), renal disease (0.6%), tuberculosis (0.6%), hepatitis (0.4%), and epilepsy (0.3%).
Results from Student Entry Physical Examination (SEPE)
Results showed 79.5% of students had at least one health problem and, on average, each student had 1.6 health problems. Table
1 and Table
2 contain the morbidity of the physical systems and the prevalence of the most frequent health problems respectively. The disease prevalence among boys and girls and reported by system examined.
Table 1
Morbidity of physical systems among first-graders (N = 53,053; Boy = 27,359, Girl = 25,694)
Eyes | 47.8 | 46.6 | 49.2*** |
Teeth | 99.8 | 100.5 | 99.0*** |
Ears, Nose, Throat | 3.1 | 3.5 | 2.7*** |
Heart, Lung, Abdomen | 2.0 | 2.1 | 2.2* |
Bones, Muscle | 0.8 | 0.9 | 0.6*** |
Reproductive | 2.2 | 3.4 | 0.8@
|
Skin | 0.6 | 0.6 | 0.6*** |
Total | 159.9 | 161.5 | 158.2*** |
Table 2
Prevalence rates of the most common health problems among first-graders (N = 53,053; Boy = 27,359, Girl = 25,694)
Myopia | 27.1 | 25.8 | 28.5*** |
Caries | 69.6 | 70.0 | 69.1*** |
Obesity | 9.5 | 10.6 | 8.4*** |
Dysarthria | 2.5 | 3.0 | 2.0*** |
Cryptorchidism | - | 2.1 | - |
Heart murmur | 1.5 | 1.6 | 1.5 |
Scoliosis | 0.4 | 0.4 | 0.4 |
Atopic dermatitis | 0.2 | 0.2 | 0.2 |
Eyes
Morbidity of eyes (composed of myopia, hyperopia, amblyopia, strabismus, astigmatism, color-blindness, nystagmus, parachromatism, and ptosis) was 47.8% (boys 46.6%, girls 49.2%). Girls were found to have more significant morbidity of eye problems than boys (p < .001). Myopia (defined as spherical equivalents equal to or less than -0.5 D) was the most serious problem with an overall prevalence of 27.1%. Girls also had higher significant myopia prevalence (28.5%) than boys (25.8%, p < .001).
Teeth
The teeth problems examined included caries, dental calculus, gingivitis, and periodontal disease. The findings showed that the morbidity of dental problems was 99.8%. That is, almost every first-grader had one teeth problem. Boys (100.5%) had higher significant morbidity than girls (99.0%, p < .001). Amongst the dental problems examined, untreated caries was the most popular problem in the first-graders (69.6%). Boys (70.0%) had higher caries prevalence than girls (69.1%) (p < .001).
ENT system
The problems in the ENT system examined included hearing impairment, tympanic membrane perforation, dysarthria, and lip cleft and palate. The morbidity of the ENT system was 3.1%. Boys had higher significant morbidity (3.5%) than girls (2.7%) (p < .001). The most common ENT problem was dysarthria. Boys had a higher prevalence rate as well (3.0% vs. 2.0%, p < .001).
HLA system
The health problems examined in this system were composed of arrhythmia, heart murmur, asthma, and hepatomegalia. On average, the morbidity approximated 2.0%. Heart murmur was the most common condition (1.5%) of the HLA system. In addition, 0.2% of first-graders were found to have asthma (0.2% for boys and 0.1% for girls).
Bones and muscle system
Poliomyelitis, scoliosis, torticollis, kyphosis, lordosis, and arthrosis derformans were examined in this system. The morbidity of this system was 0.8%. The most common problem was scoliosis (0.4%). No difference in sexes was identified.
Reproductive-urinary system
Items examined in the reproductive-urinary system included hernia for both boys and girls except hernia. Boys were also examined for cryptorchidism and scrotal hydroceles. The boys' most common problem was cryptorchidism (2.1%). This system's morbidity was 3.4% for boys and 0.8% for girls.
Skin system
Hemangioma, dermatitis, infection, head-lice, tinea, warts, purpura, and scabes were inspected in the skin system. Morbidity of the skin system was 0.6%, and atopic dermatitis (0.2%) was the most common problem found.
Other systems
The items examined in the other systems included body height, body weight, urine protein, and parasitism. The most common problem was obesity (defined by the Taiwan Ministry of Education [
19] as body weight greater than 20% of ideal weight based on BMI). Obesity prevalence was 9.5%, with boys (10.6%) being significantly more obese than girls (8.4%) (
p < .001).
Three top health problems among levels of urbanization
As presented in Table
2, untreated dental caries, myopia, and obesity were the most prevalent health problems among the first-graders (69.6%, 27.1%, and 9.5%, respectively). To find out if the top three health problems varied by level of urbanization, one-way ANOVA along with Scheffe's post hoc comparisons were conducted. Table
3 indicates that the level of urbanization had a significant association with myopia (
F
(2,199) = 6.1, p < .01) and with caries prevalence (
F
(2,199) = 5.3,
p < .01). For myopia, the first graders' prevalence rates in the urban and suburban area (29.1% and 24.8% respectively) were significantly higher than in the rural area (16.1%) (both
p < .01). In addition to myopia, the first graders from the urban area had a significantly lower prevalence rate of untreated dental caries (66.7%) than the participants from the rural area (79.0%) (
p < .01). Nevertheless, there was no significant difference found among levels of urbanization with regard to obesity prevalence.
Table 3
Differences in prevalence rate of health problems by level of urbanization (N = 53,053; Boy = 27,359, Girl = 25,694)
Myopia | 29.1 | 15.9 | 24.8 | 20.3 | 16.1 | 16.6 | 6.1** | R<U, S |
Caries | 66.7 | 17.4 | 71.3 | 18.2 | 79.0 | 21.4 | 5.3** | U<R |
Obesity | 8.5 | 6.2 | 10.3 | 6.9 | 7.4 | 7.1 | 1.8 | |
Three top health problems and quantity of medical resources
With respect to the relationship between the three most common health problems (caries, myopia, and obesity) and the quantity of available medical resources, the Pearson's correlation coefficient showed .12 for myopia, -.14 for caries, and -.04 for obesity. No significant association was found between the health problems and the quantity of medical resources.
Conclusion
The purpose of this study was to assess the health status of first-graders and to examine the relationship between morbidity and sex, level of residence urbanization, and quantity of available medical resources. It is surely startling to find that, amongst 53,053 school children under eight years, only 20.5% of them had no health problem.
The results showed that 79.5% of first-graders had at least one health problem and, on average, each student had about 1.6 health problems. This study also found that there were significant differences in the prevalence between the sub-groups. Generally, the prevalence of health problems for boys was higher than for girls'. The results also indicated that the prevalence of health problems had a significant relationship with residence. In effect, the students who resided in urban areas tended to have higher prevalence of myopia than those who resided in rural areas. However, the opposite was found to be true with regard to the prevalence of dental caries. The first graders' health problems seemed to be closely related to their lifestyle and shaped by their environmental characteristics. Further investigations along this line are suggested.
From the results of this study, we concluded that: First of all, school-based physical examination can be useful to produce a snapshot of the health profile of first-graders and provide insights as to the general health of these school children. Secondly, these results confirmed an evolving epidemic of health problems among first-graders, as evidenced by an increase in the prevalence of dental caries, myopia, and obesity, along with others. Lastly, sex and level of urbanization were associated with the prevalence of caries and myopia at certain levels. More research is suggested as to what level the genetic, environmental, or behavioral factors contribute.
A SEPE prior to school enrollment would help children who suffer from health problems and need treatment. Because students' physical examination is so valuable, it must be done at high quality standards, be offered to all susceptible students, be properly documented, and be explained to their parents. The findings support that the school authorities need to establish a supervisory mechanism to oversee the physical examination programs and to determine whether they meet the quality standards.
It is also suggested that schools prioritize school health programs based on students' health profiles and needs. The findings suggest that, for first-graders, schools in Taipei County that are located in urban areas need to direct their efforts on the prevention of myopia; and those that are located in rural areas need to focus on the prevention of dental caries. In addition, the school administers, school nurses, teachers, health care providers, and parents should work together to improve children's health.
Like other studies, this study has inevitable limitations. Although the existence of disease was identified, the development stage and severity of the diseases were not recorded. Further investigation is suggested to include this information in the examination records. The nature and severity of diseases will allow comparison of studies and is suggested for future investigations. Besides, this study examined the health status differences only based on sex, level of urbanization, and quantity of medical resources. Research that assesses the genetic, environmental, behavioral contribution, and/or other demographic factors (such as single parent family, parent's income, education level, number of siblings, or socioeconomic status) may be included to explain the origins of the health problems. Further investigations on setting the items and diagnostic criteria in physical examination and more discussions on its scientific and medical implications are suggested.
Competing interests
The author(s) declare that they have no competing interests.
Authors' contributions
RJY conceived and conducted the study. JJS was responsible for the survey data, statistical analyses, and interpreted the results together with HSC. HLH was responsible for synthesizing analyses. KCL planned and conducted the data transfer. All investigators participated in the writing and revision of the paper.