School-based Screening Program Research Articles

Screening for refractive error and fitting with spectacles in rural and urban India: Cost-effectiveness

Objectives: To assess the cost-effectiveness of screening for refractive error and fitting with glasses in India.Methods: We populated a decision tree with the costs of screening and spectacles, prevalence of varying levels of presenting and best corrected visual acuity (BCVA) from two studies, and sensitivity and specificity of screening. We calculated dollars spent per disability adjusted life year (DALY) averted separately in urban and rural areas for school-based screening (SBS) and primary eye care (PEC) programs that fit spectacles to individuals presenting for care. We conducted a series of univariate and probabilistic sensitivity analyses. An intervention was inferred to be highly cost-effective if the incremental cost-effectiveness ratio (ICER) was less than the gross domestic product (GDP) per capita and moderately cost-effective if the ICER was less than three times this level.Results: Compared with no screening, urban SBS was highly cost-effective; rural SBS was moderately cost-effective for ages 5–15 and highly cost-effective for ages 7–15. Both urban and rural PEC were moderately cost-effective in comparison to SBS. Probabilistic sensitivity analysis suggested that SBS is likely the most cost-effective solution for refractive error in India if the 5–15 year old age group is targeted; primary eye care is the best choice if a high value is placed on DALYs and the 7–15 year old age group is targeted.Conclusion: Both SBS and PEC Interventions for refractive error can be considered cost-effective in India. Which is the more cost-effective depends on the choice of targeted age group and area of the intervention.

Eight Years of Building Community Partnerships and Trust: The UCLA Family Medicine Community-Based Participatory Research Experience

Acknowledging the growing disparities in health and health care that exist among immigrant families and minority populations in large urban communities, the UCLA Department of Family Medicine (DFM) sought a leadership role in the development of family medicine training and community-based participatory research (CBPR). Performing CBPR requires that academic medicine departments build sustainable and long-term community partnerships. The authors describe the eight-year (2000-2008) process of building sustainable community partnerships and trust between the UCLA DFM and the Sun Valley community, located in Los Angeles County.The authors used case studies of three research areas of concentration (asthma, diabetes prevention, and establishing access to primary care) to describe how they established community trust and sustained long-term community research partnerships. In preparing each case study, they used an iterative process to review qualitative data.Many lessons were common across their research concentration areas. They included the importance of (1) having clear and concrete community benefits, (2) supporting an academic-community champion, (3) political advocacy, (4) partnering with diverse organizations, (5) long-term academic commitment, and (6) medical student involvement. The authors found that establishing a long-term relationship and trust was a prerequisite to successfully initiate CBPR activities that included an asthma school-based screening program, community walking groups, and one of the largest school-based primary care clinics in the United States.Their eight-year experience in the Sun Valley community underscores how academic-community research partnerships can result in benefits of high value to communities and academic departments.

Changes in tuberculin sensitivity among first-grade students of elementary schools in Evros, Greece due to immigration

To investigate the tuberculin sensitivity trends among first-grade students of elementary schools tested according to the Greek national school-based screening and vaccination programme. Retrospective analysis of tuberculin skin test (TST) results from 1988 to 2004 in unvaccinated first-grade students in Evros, Greece. All 6-7-year-old children who were unvaccinated for tuberculosis were tested by a highly experienced team. This study tested whether gender (male vs female), national origin (native vs foreign-born children) and place of residence (urban vs semi-urban vs rural) correlated with tuberculin reaction positivity. In total, 8588 children (47.1% girls) were tested. Tuberculin reaction positivity was independent of gender. The difference in TST positivity between native and foreign-born children between 1993 and 2004 was highly significant, with substantially more foreign-born children having a positive Mantoux test (P<0.0001). The percentage of children with a positive TST peaked at 13% in 1995 due to initial admission of foreign-born children, originating from countries of the former Soviet Union, into the Greek educational system. In addition, a positive Mantoux test was more common among children living in rural (8.1%) and semi-urban (6.4%) areas compared with children living in urban areas (3.5%, P<0.0001). The increase in TST positivity noted was due to admission of foreign-born children into the Greek educational system. School-based tuberculosis screening programmes should continue in Greece because the prevalence of tuberculosis appears to show substantial variation between years.

Assessing BMI in West Virginia schools: parent perspectives and the influence of context.

West Virginia is a state at the forefront of the obesity epidemic and one that is experiencing immense health and economic costs as a result. The childhood obesity research discussed in this article was conducted over the past 10 years through 4 projects that range from a school-based cardiovascular risk screening program to an evaluation of state legislation targeting childhood obesity via modifications in the school environment. In the course of these projects, we have collected BMI and other health indices on students, provided feedback to students and their parents, and assessed the obesity and health-related beliefs of West Virginians through individual and focus-group interviews and questionnaires. Our work has been accomplished by using an active-consent process, and BMI has typically been only 1 component of the comprehensive health data we collect and feedback we provide. Collaboration with state and local partners and regular dissemination of our findings have been key elements of the approach taken. The research and policy implications of our findings and approach are discussed.

A Randomized, Clinical Trial Evaluating Ready-Made and Custom Spectacles Delivered Via a School-Based Screening Program in China

We sought to evaluate visual performance and satisfaction with ready-made spectacles (RMS) in Chinese school-aged children with uncorrected refractive error. Randomized, double-blind, clinical trial. Junior high school students from urban Guangzhou, China, aged approximately 12 to 15 years with > or =1 diopter (D) of uncorrected spherical equivalent (SE) refractive error. Students were excluded with > or =2.00 D astigmatism, > or =2 D myopic anisometropia, and > or =1 D hyperopic anisometropia and ocular disease affecting vision. Refractive error was determined by cycloplegic subjective refraction. Students were randomly assigned to receive RMS or custom spectacles (CS) and assessed after 1 month of use. We required 175 students to complete in each arm to be able to measure a 15% difference in compliance. Compliance with spectacles lens wear, patterns of use, vision, symptoms, and perceived value. Screening identified 965 of 4607 (20.9%) students with reduced distance vision; 212 of the 965 (22.0%) refused evaluation and 187 of the 965 (20.8%) had <1 D of SE refractive error. Sixty-one (6.3%) were referred for further evaluation and the remaining 495 (51.3%) participated. Social, demographic, and ocular parameters were similar in the 2 groups. Average SE refractive error was -2.57+/-1.31 (mean value +/- standard deviation [SD]). Spectacle vision (Snellen acuity, mean +/- SD) was worse with RMS in the eye with lower SE (20/25(-0.5)+/-0.9 lines vs 20/25(+1)+/-0.7 lines; P = 0.004) and higher SE (20/25(-2)+/-1.2 lines vs 20/25(+1)+/-0.8; P<0.001). There were no differences (P>0.05) in the rate of use (94.3% vs 92.2%), wearing to the 1-month visit (46.9% vs 51.5%), planned use (93.3% vs 93.7%), value (89.5% vs 91.7% "moderate or high value or most valued possession"), or symptoms (blur, 21.1% vs 19.4% [P = 0.8] and other symptoms [P>0.2]). Although visual acuity was better with CS, no difference was found in acceptability in this population of students with predominantly simple myopic refractive error. This study supports the use of RMS in a school-based refractive services program, saving costs and improving the logistics of service delivery.

Cost-effectiveness of a school-based emotional health screening program.

School-based screening for health conditions can help extend the reach of health services to underserved populations. Screening for mental health conditions is growing in acceptability, but evidence of cost-effectiveness is lacking. This study assessed costs and effectiveness associated with the Developmental Pathways Screening Program, in which students undergo universal classroom emotional health screening and those who have positive screens are provided with on-site clinical evaluation and referral. Costs are enumerated for screening and clinical evaluation in terms of labor and overhead and summarized as cost per enrolled student, per positive screen, and per referral. Cost-effectiveness is summarized as cost per student successfully linked to services. School demographics are used to generate a predictive formula for estimating the proportion of students likely to screen positive in a particular school, which can be used to estimate program cost. Screening costs ranged from $8.88 to $13.64 per enrolled student, depending on the prevalence of positive screens in a school. Of students referred for services, 72% were linked to supportive services within 6 weeks. Cost-effectiveness was estimated to be $416.90 per successful linkage when 5% screened positive and $106.09 when 20% screened positive. A formula to estimate the proportion of students screening positive proved accurate to within 5%. Information concerning costs and effectiveness of school-based emotional health screening programs can guide school districts in making decisions concerning resource allocation.

Costs of screening children for hearing disorders and delivery of hearing aids in China

BackgroundThe burden of disease of hearing disorders among children is high, but a large part goes undetected. School-based screening programs in combination with the delivery of hearing aids can alleviate this situation, but the costs of such programs are unknown.AimTo evaluate the costs of a school-based screening program for hearing disorders, among approximately 216,000 school children, and the delivery of hearing aids to 206 children at three different care levels in China.MethodsIn a prospective study design, screening and hearing aid delivery costs were estimated on the basis of program records and an empirical assessment of health personnel time input. Household costs for seeking and undergoing hearing health care were collected with a questionnaire, administered to the parents of the child. Data were collected at three study sites representing primary, secondary and tertiary care levels.ResultsTotal screening and hearing aid delivery costs ranged between RMB70,000 (US$9,000) and RMB133,000 (US$17,000) in the three study sites. Health care cost per child fitted ranged from RMB5,900 (US$760) at the primary care level, RMB7,200 (US$940) at the secondary care level, to RMB8,600 (US$1,120) at the tertiary care level. Household costs were only a small fraction of the overall costs. Cost per child fitted ranged between RMB1,608 and RMB2,812 (US$209–US$365), depending on perspective of analysis and study site. The program was always least costly in the primary care setting.ConclusionHearing screening and the delivery of hearing aids in China is least costly in a primary care setting. Important questions remain concerning its implementation.

Parent Reactions to a School‐Based Body Mass Index Screening Program

This study assessed parent reactions to school-based body mass index (BMI) screening. After a K-8 BMI screening program, parents were sent a letter detailing their child's BMI results. Approximately 50 parents were randomly selected for interview from each of 4 child weight-classification groups (overweight, at risk of overweight, normal weight, underweight) to assess parent recall of the letter, reactions to BMI screening, and actions taken in response to the child's BMI results. Most parents found the BMI screening letter easy to read and had poor recall of numerical information (eg, the child's BMI percentile) but good recall of the child's weight classification (eg, normal weight or overweight). Most parents, and ethnic-minority parents in particular, supported school-based BMI screening. Parents of children whose weight was outside of the normal range were more likely to recall receiving the letter and talking to the child and the child's doctor about it. Parents who recalled their child as being overweight were more likely to report changing the child's diet and activity level. Most parents, and ethnic-minority parents in particular, wanted their child to participate in an after-school exercise program. An overweight condition in parents, but not children, was associated with an interest in family-based cooking and exercise classes. Most parents, and ethnic-minority parents in particular, viewed school-based BMI screening and after-school exercise programs favorably. Parents reported taking action in response to a BMI result outside of the normal range. Parents who were overweight themselves were particularly interested in family cooking and exercise classes.

Developing Culturally Tailored Health Belief-Based Intervention Materials to Improve Child and Parent Participation in a Cardiovascular Screening Program

The Coronary Artery Risk Detection in Appalachian Communities Project was developed to reduce children's future cardiovascular risk by implementing a school-based screening program statewide. Despite the elimination of environmental barriers related to screening cost and accessibility, only half of eligible children participate in the program each year. The authors used the theory of planned behavior to identify health beliefs associated with screening participation. This article describes the process used to identify community health beliefs and the development of theoretically based materials to increase participation. Focus groups and individual interviews were conducted to identify core health beliefs held by parents, community leaders, and children (Phase I). Data obtained were used to expand and revise a Health Beliefs Questionnaire, which was distributed to larger samples (Phase II). This information was used to design recruitment materials that emphasized the benefits of screening while directly addressing potential belief-based barriers to screening participation (Phase III).

Age Variability in the Association Between Heavy Episodic Drinking and Adolescent Suicide Attempts: Findings From a Large-Scale, School-Based Screening Program

ObjectiveAlcohol use is a risk factor for suicidal behavior among adolescents, but it is not clear whether this association is consistent during the adolescent period. This study examined the age-specific associations between heavy episodic drinking (HED) and self-reported suicide attempts in a large and diverse sample of adolescents. MethodScreening data from 32,217 students, between the ages of 11 and 19 years, in 225 schools were analyzed. Logistic regression analyses estimating the impact of HED on self-reported suicide attempts in the past year were performed. ResultsHeavy episodic drinking was significantly associated with self-reported suicide attempts (odds ratio 1.78, p < .05) controlling for depressive symptoms. However, there was substantial age variability in this association, with the association between HED and self-reported attempts stronger among younger adolescents. Among youths aged 13 years and younger, those who reported an episode of HED during the past year were roughly 2.6 times more likely to report an attempt than those who did not report HED in the past year, in contrast to 1.2 times among youths aged 18 years and older. ConclusionsHeavy episodic drinking is a clear risk factor for suicidal behavior among younger adolescents, beyond the risk conveyed by depressive symptoms. Further research investigating the bases for increased suicide risk among younger adolescents engaging in HED is warranted. Results provide support to AACAP's practice parameters calling for attention to substance abuse in the assessment of suicide risk and suggest that routine screening for HED by physicians may improve the detection of adolescent suicide risk, particularly among younger adolescents.

Children at risk identified in an urban scoliosis school screening program: a new model

School-based scoliosis screening programs, although controversial, remain well established. Our hypothesis was that with the addition of several inexpensive and simple measurements (height/weight, questionnaire), the overall impact of our screening program could be dramatically increased. Of the 1,058 children screened, 30 (2.8%) were positive for scoliosis. We found that 284 children (27%) were overweight and 468 (44%) children were overweight or at risk for overweight. Additionally, 61% of children did not have an identified primary health provider. These additional measurements did not change the efficacy of scoliosis screening but dramatically increased the number of children identified at risk for significant health problems.

Cost-effectiveness of screening methods for urinary schistosomiasis in a school-based control programme in Ibadan, Nigeria

To carry out a comparative cost-effectiveness analysis of screening methods for urinary schistosomiasis; terminal haematuria, unqualified haematuria, dysuria, visual urine examination and chemical reagent strip technique, in a school-based control programme. Estimation of costs and determination of cost-effect ratios of the screening methods applied in a school-based screening and treatment programme, from the perspective of a programme manager. A junior secondary school in Ibadan, Nigeria. Cost per number of cases correctly diagnosed. Unqualified haematuria was found to be the most cost-effective method costing N51.06 (US$ 2.16) to diagnose a case correctly, followed by terminal haematuria N58.91 (US$ 2.50) and dysuria N84.24 (US$ 3.57). Despite the relatively high input costs of chemical reagent strip technique over visual urine examination (N22.12 (US$ 0.94) per student vs. N6.44 (US$ 0.27) per student), it was found to be more cost effective costing N304.56 (US$ 12.91) to diagnose a case correctly than visual examination of urine cost of N317.58 (US$ 13.46) per correct case diagnosed. From the viewpoint of a programme manager, interview method of screening by asking for blood in the urine remains the most efficient means of screening for urinary schistosomiasis in school-based control programmes in our environment.

The Development of a Directed Population Approach to Tackle Inequalities in Dental Caries Prevalence among Secondary School Children Based on a Small Area Profile

It has been observed that the prevalence of dental caries among children has declined in the last decade in Germany. However, despite of these improvements there is still a proportion of children suffering from dental decay. The aims of this study were to evaluate if a social gradient in the prevalence of dental caries exists and, based on those findings, to develop a strategy to target those children with heightened risk to develop dental caries in order to assist oral health care professionals to refocus the current uniform school-based dental health programme to a caries preventive strategy based on a directed population approach. A representative, random sample of 12-year olds in Freiburg (Germany) was examined and dental caries was recorded using WHO criteria. Educational attainment of the child's parents was used as an indicator of socio-economic status and classified by use of the CASMIN Educational Classification. A total of 322 children participated. An examination of dental caries score revealed that its distribution was positively skewed. For this reason this study provides summary analyses based on medians and a non-parametric rank-sum test. The Kruskal-Wallis H-test showed a significant difference between median scores across the different educational levels (p-value = 0.015) which was due to lower dental caries levels in children with non-deprived social background. In order to reduce current social inequalities in child oral health the current uniform school-based dental health programme at secondary school level should be developed to a targeted school-based screening and prevention programme.

Passive Versus Active Parental Permission: Implications for the Ability of School‐Based Depression Screening to Reach Youth at Risk*

Depression is prevalent among children and adolescents and often goes untreated with adverse effects on academic success and healthy development. Depression screening can facilitate early identification and timely referral to prevention and treatment programs. Conducting school-based emotional health screening, however, raises the controversial issue of how to obtain informed parental permission. During implementation of a depression screening program in an urban school district in the Pacific Northwest, the district's parental permission protocol changed from passive (information provided to parents via a school mailer with parents having the option to actively decline their child's participation) to active (information provided to parents via a school mailer requiring the written permission of the parents for their child's participation). This change provided an opportunity to examine differences in participation under these 2 conditions. A total of 1533 students were enrolled in this program across both years. Compared to conditions of passive permission, participation was dramatically reduced when children were required to have written parental permission, dropping from 85% to 66% of eligible children. Furthermore, under conditions of active parental permission, participation decreased differentially among student subgroups with increased risk for depression. Successful implementation of school-based emotional health screening programs requires careful consideration of how to inform and obtain permission from parents.

L.I.F.E.: A School-Based Heart-Health Screening and Intervention Program

This article describes the development and growth of Lifestyle Improvements in the Family Environment (L.I.F.E.), a school-based heart-health screening and intervention program. The primary goals of L.I.F.E. through three rounds of grant funding remained constant: (a) to identify cardiovascular risk factors in students and their families and (b) to provide counseling, education, and opportunities to change lifestyle routines that contribute to those risk factors. The program began with direct ties to a university-based research program and grew with evidence-based successes and development of community partnerships. Waves of growth were influenced by capacity-building efforts, partnership development, and resource availability. School nurses managed the screening component and partnered with appropriate others in the intervention programming. School nurses are appropriately positioned to assist families as well as school and community partners in decreasing the incidence of obesity and promoting healthy lifestyle behaviors.

L.I.F.E.: A School-Based Heart-Health Screening and Intervention Program

This article describes the development and growth of Lifestyle Improvements in the Family Environment (L.I.F.E.), a school-based heart-health screening and intervention program. The primary goals of L.I.F.E. through three rounds of grant funding remained constant: (a) to identify cardiovascular risk factors in students and their families and (b) to provide counseling, education, and opportunities to change lifestyle routines that contribute to those risk factors. The program began with direct ties to a university-based research program and grew with evidence-based successes and development of community partnerships. Waves of growth were influenced by capacity-building efforts, partnership development, and resource availability. School nurses managed the screening component and partnered with appropriate others in the intervention programming. School nurses are appropriately positioned to assist families as well as school and community partners in decreasing the incidence of obesity and promoting healthy lifestyle behaviors.

Assessing the oral health of school‐age children and the current school‐based dental screening programme in Freiburg (Germany)

Germany has a three-tiered system of education at secondary school level, divided into the school types 'Hauptschule', Realschule' and 'Gymnasium'. All students receive, when aged 6-12 years, a uniform annual dental examination and oral health education programme. The aim of this cross-sectional study was to report on the dental caries levels of school-age children stratified into these three different school types at secondary school level to enable oral healthcare personnel to administer a focused, school-based dental screening and education programme according to patients' needs rather than a uniform dental examination. A representative, random sample of 12-year-old school children in Freiburg (Germany) was examined and dental caries was recorded using WHO criteria. A total of 322 12-year-old children participated. The mean DMFT was 0.69. An examination of the distribution of the DMFT score revealed that its distribution is positively skewed. For this reason, this study provides summary analyses based on medians and a non-parametric rank sum test. The non-parametric Kruskal-Wallis H-test showed a highly significant difference between median scores across the different school types (P-value = 0.004). The significance was a result of the 'Gymnasium' distribution of DMFT scores which differed markedly from the other two school types. The finding of the present study suggests that it may be useful to stratify the school dental screening and education programme according to school type and to prioritize children who attend 'Realschule' and 'Hauptschule'. This shift should systematically target children with the greatest need for dental care.

Developing School-Based BMI Screening and Parent Notification Programs: Findings From Focus Groups With Parents of Elementary School Students

School-based body mass index (BMI) screening and parent notification programs have been advanced as an obesity prevention strategy. However, little is known about how to develop and implement programs. This qualitative study explored the opinions and beliefs of parents of elementary school students concerning school-based BMI screening programs, notification methods, message content, and health information needs related to promoting healthy weight for school-aged children. Ten focus groups were conducted with 71 participants. Parents were generally supportive of school-based BMI screening. However, they wanted assurance that student privacy and respect would be maintained during measurement and that BMI results would be provided to parents in a neutral manner that avoided weight labeling. They also believed that aggregate results should be disseminated to the larger school community to support healthy change in the nutrition and physical activity environments of schools. Implications for practitioners and researchers are discussed.

Disparities in oral health‐related quality of life in a population of Canadian children

To assess socioeconomic disparities in the oral health-related quality of life in a group of Canadian children. Data were obtained as part of a study designed to assess the functional and psychosocial impact of traumatic dental injury. Clinical data were collected on a random sample of children during a school-based dental screening program that included measures of dental decay experience, treatment needs, dental trauma, fluorosis, and malocclusion. Children with dental trauma and a comparison group of trauma-free children were selected for follow-up. Their parents were mailed a questionnaire concerning the child's personal and family characteristics. Also enclosed was a questionnaire for the child that contained a short form of the Child Perceptions Questionnaire (CPQ) 11-14. Bivariate and multivariate analyses were undertaken to determine whether there were disparities in oral health-related quality of life according to household income. Complete data were collected from 370 children. Mean CPQ11-14 scores showed a gradient across income categories with children from low income households having poorer oral health-related quality of life. Children from households containing only one adult also had higher scores than children living with two or more adults. In both linear and logistic regression analyses household income and family structure remained significant predictors of CPQ11-14 scores after controlling for oral disease variables. Further analyses suggested that oral disorders had little impact on the health-related quality of life of higher income children but a marked impact on lower income children. The highest mean CPQ11-14 scores were observed among low income children with the more severe levels of oral disease. The data indicate that in this group of children there were socioeconomic disparities in oral health-related quality of life. A potential explanation may be differences in psychological assets and psychosocial resources.

COMPONENTS OF THE METABOLIC SYNDROME IN A HISPANIC POPULATION OF SCHOOL-AGED CHILDREN.

Hispanic adults have the highest prevalence of the metabolic syndrome, which imposes a substantial risk for cardiovascular disease and type 2 diabetes. Identification of Hispanic children at risk for the metabolic syndrome is critical for prevention of these chronic illnesses. The purpose of this study was to investigate risk factors that can be used in the primary care setting to identify Hispanic children who have multiple metabolic syndrome components. Eighty-six elementary school students (5-12 years of age; 96% Hispanic) from a school-based health screening program were evaluated for family history of type 2 diabetes and cardiovascular disease in the first- or second-degree relative, body mass index (BMI), acanthosis nigricans (AN), and the following metabolic syndrome components: impaired fasting glucose (glucose ≥ 100 mg/dL), hypertriglyceridemia (≥ 110 mg/dL), low HDL cholesterol (≤ 40 mg/dL), and high blood pressure (systolic or diastolic blood pressure ≥ 90th percentile). Associations between the above risk factors and components of the metabolic syndrome were examined. Among the 86 children, 23% had a BMI ≥ 95th percentile, 22% had AN, 7% had impaired glucose tolerance; 22% had hypertriglyceridemia; 42% had low HDL cholesterol; and 17% had hypertension. The presence of zero, one, two, and three or more features of the metabolic syndrome was 44, 33, 15, and 8%, respectively. As BMI increased, the number of metabolic syndrome components increased (Mantel-Haenszel Χ2 = p