Group Title: BMC Public Health
Title: Morbidity at elementary school entry differs by sex and level of residence urbanization: a comparative cross-sectional study
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Title: Morbidity at elementary school entry differs by sex and level of residence urbanization: a comparative cross-sectional study
Physical Description: Book
Language: English
Creator: Yang, Rea-Jeng
Sheu, Jiunn-Jye
Chen, Huey-Shys
Lin, Kuan-Chia
Huang, Hsiu-Li
Publisher: BMC Public Health
Publication Date: 2007
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Abstract: BACKGROUND:Health is vital to a child's learning in school and success in life. Therefore, early physical examination, and follow-up if necessary, would bring parents' attention to their child's health and would likely improve outcomes. The purposes of this study are twofold: to assess the health status of first-graders and to examine the health status differences between sexes, levels of residence urbanization, and quantity of available medical resources.METHODS:This is a comparative descriptive study. Data from the 2002 Student Entry Physical Examination (SEPE) and Student Medical History Inventory (SMHI) were obtained from 203 public and private elementary schools in northern Taiwan where a population of 53,053 students was included. Frequencies, independent sample t test, one-way ANOVA along with Scheff's post hoc test, and Pearson's correlation were conducted using SPSS.RESULTS:This study showed that 13.7% of students had at least one diagnosed disease from the SMHI reported by parents. Moreover, the SEPE indicated that 79.5% students had at least one health concern. Dental caries, myopia, and obesity were the most prevalent health problems among the first-graders (69.6%, 27.1%, and 9.5%, respectively). Research results show that there were significant differences in the prevalence of dental caries, myopia, and obesity between different sexes and among levels of urbanization. However, the quantity of available medical resources made no significant difference.CONCLUSION:Elementary school entry physical examination is an important way to detect students' health problems. It is suggested that school health interventions consider students' health profiles along with their sex and level of urbanization in planning. More research is needed to find the risk factors of the health problems. Additionally, the creation of a school health committee is suggested to implement and evaluate the entry health examination program.
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General Note: M3: 10.1186/1471-2458-7-358
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Research article

Morbidity at elementary school entry differs by sex and level of
residence urbanization: a comparative cross-sectional study
Rea-Jeng Yangi, Jiunn-Jye Sheu2, Huey-Shys Chen3, Kuan-Chia Lin' and
Hsiu-Li Huang*1


Address: 'Department of Nursing, National Taipei College of Nursing, Pei-Tou, 11219 Taipei City, Taiwan, 2Department of Health Education and
Behavior, University of Florida, Gainesville, Florida, 32611-8210, USA and 3School of Nursing, University of Medicine and Dentistry of New
Jersey, Newark, New Jersey, 07107-3001, USA
Email: Rea-Jeng Yang rea@ntcn.edu.tw; Jiunn-Jye Sheu jjsheu@hhp.ufl.edu; Huey-Shys Chen hueyshys@gmail.com; Kuan-
Chia Lin kuanchia@ntcn.edu.tw; Hsiu-Li Huang* hsiulz@ntcn.edu.tw
* Corresponding author



Published: 25 December 2007 Received: 26 September 2006
BMC Public Health 2007, 7:358 doi:10.1 186/1471-2458-7-358 Accepted: 25 December 2007
This article is available from: http://www.biomedcentral.com/1471-2458/7/358
2007 Yang et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.



Abstract
Background: Health is vital to a child's learning in school and success in life. Therefore, early
physical examination, and follow-up if necessary, would bring parents' attention to their child's
health and would likely improve outcomes. The purposes of this study are twofold: to assess the
health status of first-graders and to examine the health status differences between sexes, levels of
residence urbanization, and quantity of available medical resources.
Methods: This is a comparative descriptive study. Data from the 2002 Student Entry Physical
Examination (SEPE) and Student Medical History Inventory (SMHI) were obtained from 203 public
and private elementary schools in northern Taiwan where a population of 53,053 students was
included. Frequencies, independent sample t test, one-way ANOVA along with Scheff's post hoc
test, and Pearson's correlation were conducted using SPSS.
Results: This study showed that 13.7% of students had at least one diagnosed disease from the
SMHI reported by parents. Moreover, the SEPE indicated that 79.5% students had at least one
health concern. Dental caries, myopia, and obesity were the most prevalent health problems among
the first-graders (69.6%, 27.1%, and 9.5%, respectively). Research results show that there were
significant differences in the prevalence of dental caries, myopia, and obesity between different
sexes and among levels of urbanization. However, the quantity of available medical resources made
no significant difference.
Conclusion: Elementary school entry physical examination is an important way to detect students'
health problems. It is suggested that school health interventions consider students' health profiles
along with their sex and level of urbanization in planning. More research is needed to find the risk
factors of the health problems. Additionally, the creation of a school health committee is suggested
to implement and evaluate the entry health examination program.







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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 pre-
vention, many studies suggested that physical examina-
tion 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 physi-
cal 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 refer-
rals, and better identification of undescended testes and
speech delay. Another more comprehensive review also
reported more detected health problems and elevated per-
centages of first identified health problems among ele-
mentary school entrants [4].

The benefits of physical examination for children, if finan-
cially supported, are essentially fourfold: First of all, some
impairments and physical changes associated with dis-
eases, 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 prob-
lems 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 pre-
viously noted, including undescended testes, heart mur-
mur, 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 clini-
cians perform objective vision screening on school-aged
children. Moreover, both the American Academy of Oph-
thalmology (AAO) and the American Association for
Pediatric Ophthalmology and Strabismus (AAPOS) rec-
ommended 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 examina-
tion from early age, research show health problems in
childhood are highly associated with adulthood diseases.
For example, obese children have an elevated risk of adult-
hood high blood pressure, non-insulin-dependent diabe-
tes, high triglyceride/cholesterol circulating levels, and
fatty liver than non-obese children [14]. The strong asso-
ciation 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]. Phys-
ical 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, treat-
ment, correction, or rehabilitation as needed before dete-
rioration.

Many studies reported morbidity and prevalence of dis-
eases among school-aged children. These studies, how-
ever, focus mostly on one specific health problem (i.e.,
learning disability, vision, and hearing) considering other
potential health problems. Nevertheless, the lack of epide-
miological studies which examined students' comprehen-
sive physical health status at the entry point of elementary
school creates a problem in that no baseline data is avail-
able in assessing and evaluating students' overall health in
school. The absence of reliable data have made monitor-
ing 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 estab-
lished, which would help school nurses manage chronic


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conditions and the school to conduct more effective
school health programs. Specifically, free comprehensive
physical examinations would eliminate the financial bar-
riers that accompany different levels of urbanization and
available medical resources.

Taipei County is the largest county in Taiwan: with a pop-
ulation 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 examina-
tions every fall for first graders, the youngest students
entering elementary school in the Taiwan education sys-
tem.

Health and education professionals need information
about the prevalence of health problems and their influ-
ential factors to develop effective and targeted interven-
tions to reduce health problems in childhood. By
reviewing individual disease prevalence reported, stu-
dents' 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 dif-
fered by urbanization [18-21]. Besides, in Leffs 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 permis-
sion was obtained from the students' parents or guardi-
ans. The parents or guardians were required to accompany
their children to the physical examination. Students or
parents/guardians were free to withdraw from any exami-
nation 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, repro-
ductive-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 struc-
tural 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 kil-
ometer, km2). Based on this categorization, the distribu-
tion of schools was 31.5% urban (n = 64), 49.3%
suburban (n = 100), and 19.2% rural (n = 39). The quan-
tity 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 pro-
vided 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' par-
ents/guardians were asked to complete and return the
SMHI to their children's school.






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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 associ-
ation 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 dehydroge-
nase 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 fre-
quent health problems respectively. The disease preva-
lence among boys and girls and reported by system
examined.


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 signifi-
cant myopia prevalence (28.5%) than boys (25.8%, p <
.001).

Teeth
The teeth problems examined included caries, dental cal-
culus, 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 exam-
ined, 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 hear-
ing impairment, tympanic membrane perforation, dysar-
thria, 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 preva-
lence rate as well (3.0% vs. 2.0%, p < .001).

HLA system
The health problems examined in this system were com-
posed 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-grad-


Table I: Morbidity of physical systems among first-graders (N = 53,053; Boy = 27,359, Girl = 25,694)

Physical system Sum Boy


Eyes
Teeth
Ears, Nose, Throat
Heart, Lung, Abdomen
Bones, Muscle
Reproductive
Skin


Total


Girl Significance


49.2n**
99.0n**

2.2*

0.8c9


158.2n**


Unit: per 100 people
Statistically significant differences between boys and girls: indicates p < .05; *** indicates p < .001.
@indicates not comparable between boys and girls.


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Table 2: Prevalence rates of the most common health problems among first-graders (N = 53,053; Boy = 27,359, Girl = 25,694)


Health problem

Myopia
Caries
Obesity
Dysarthria
Cryptorchidism
Heart murmur
Scoliosis
Atopic dermatitis


Girl Significance


Statistically significant differences between boys and girls: ***indicates p < .001.


ers 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 cryp-
torchidism (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 sys-
tem. 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 Tai-
wan Ministry of Education [19] as body weight greater
than 20% of ideal weight based on BMI). Obesity preva-


lence 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%, respec-
tively). 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 den-
tal 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.

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 Pear-
son's correlation coefficient showed .12 for myopia, -.14
for caries, and -.04 for obesity. No significant association


Table 3: Differences in prevalence rate of health problems by level of urbanization (N = 53,053; Boy = 27,359, Girl = 25,694)


Level of urbanization
Health problem


Myopia
Caries
Obesity


Urban
M SD

29.1 15.9
66.7 17.4
8.5 6.2


Suburban Rural F-value Scheffe's post hoc test
M SD M SD

24.8 20.3 16.1 16.6 6. 1* R 71.3 18.2 79.0 21.4 5.3** U 10.3 6.9 7.4 7.1 1.8


Statistically significant differences between levels of urbanization: indicates p < .01.


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Overall


28.5***
69. 1 ***
8.4***
2.0***

1.5
0.4
0.2


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was found between the health problems and the quantity
of medical resources.

Discussion
General health status
The findings from this study were consistent with the find-
ings from another study on the first-graders in Taipei City,
which revealed that 85.1% of students had at least one
health problem and, on average, each student had 1.6
health problems [25]. There are few morbidity publica-
tions covering solely the first graders to compare in other
countries.

Top three health problems and their association with sex,
level of urbanization, and quantity of medical resources
The top three health problems found were dental caries,
myopia, and obesity. All three may have long-term effects
throughout the lives of first graders.

Dental Caries
Dental caries is a major health problem among school-
children everywhere in the world. They are the main cause
of tooth mortality, dental emergencies, and tooth extrac-
tion in this young age. In Taipei County, the top health
problem among first graders was untreated dental caries
(69.6%). Other studies in Taiwan presented similar trends
[26,27]. Also, this caries prevalence is similar to some
international studies that focused on children of the same
age (i.e., 66.3% for German children [27], 68.4% for India
children [28], 71.4% for Mexican children [29], and
70.1% for North Korean children [30]). However, the
prevalence of students' untreated caries in Taipei County
is higher than in other countries (i.e., 22.0% in America
[31,32], and 38.0% in Africa [33]). These findings suggest
that the prevalence of caries may not only relate to the
country's social-economic status, but also closely relate to
lifestyles. As in the more prevalent countries, caries may
be due to an increased availability of refined sugar prod-
ucts without a concurrent rise in oral health awareness.

With respect to sex difference, the study results showed
the prevalence for boys was higher than for girls. Other
studies showed the same conclusion, with boys having
higher prevalence of caries than girls [27,34]. One study
[26], however, had a reverse finding.

This study demonstrated that the prevalence of untreated
caries was significantly different among the levels of
urbanization. That is, students who lived in a rural area
had the highest prevalence. Different results were found
in Africa, where 38.0% of six-year-old children had caries
with prevalence being higher in urban rather than rural
areas [33]. Although higher prevalence of caries in urban
than in rural areas are often reported from developing
countries, this does not seem to apply to Taipei County. It


is our observation that the children living in all areas of
Taipei County were equally exposed to sweets and soft
drinks, but the difference was the action to treat the decay.
In rural areas, parents tended to ignore the need for treat-
ment for children's caries. They seemed to believe that,
because children's teeth would be replaced by permanent
teeth, they didn't need to take caries seriously even though
the National Health Insurance covered dental treatments
free of charge. The untreated caries remained highly prev-
alent in rural areas and more investigation is needed to
determine its behavioral control from parents.

Myopia
Literature has suggested that the prevalence of myopia is
growing worldwide, and the higher increases were
observed in Asia. This study found myopia to rank as the
second health problem among first-graders, surpassed
only by dental caries. In this study, more than one-fourth
(27.1%) of first-graders had myopia. The high prevalence
of myopia was similar to some findings reported in East
Asia for children at the same age. For instance, prior stud-
ies by Saw and colleagues [21,35] found school children's
myopia prevalence to be 36.7% for Singapore and 18.5%
for Xiamen, China. In contrast with the prevalence of
myopia in Australian children (8.4%) [36], the prevalence
of myopia found in children from Taipei County and
other parts of Asia were a lot higher.

In terms of sex difference, this study showed that girls'
prevalence was higher than boys', which is consistent with
other studies [18,25,37]. Whether the consequences
resulted from genetic or environmental issues still
remains unclear.

This study found myopia prevalence to have significant
variation among the levels of urbanization. The findings
were consistent with the findings from other studies
[18,21,381, which revealed significant differences in the
prevalence of myopia between residence in urban and
rural areas. Children residing in urban areas had a higher
prevalence of myopia than children residing in rural areas.

In Taiwan, the myopia prevalence increases by age and
occurs more at school ages, especially in the past two dec-
ades. Literature shows that the prevalence of myopia has
increased from 5.8% to 20.4% between 1983 and 2000
among students in the first-grade, which increased 3.5
fold in the past two decades [381. The literature also shows
that myopia prevalence increased by grade with 20.4% of
first-graders, 60.6% of sixth-graders, 80.7% of ninth-grad-
ers, and 85% of senior high school students having myo-
pia. In addition, the age at which myopia begins gradually
decreased from fifth-grade to second-grade during the
period from 1983 to 2000 [38]. In Taiwan, the occurrence
of myopia relates to close-to-object studying for longer


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restless time and watching television screen for learning or
entertainment. The phenomena occurred in urban areas
more than in rural areas.

Obesity
Many studies show obesity relates to lower health-related
quality of life [39] and the occurrence of many diseases,
including cardiovascular disease, stroke, diabetes [40-45 ],
certain cancers, kidney failure, asthma, arthritis, gallblad-
der disease, hormonal and reproductive problems, sleep
apnea, impaired immune function, blindness [46,47],
depression, dementia [48-50], and hypertension [51]. The
analysis of large cohorts found that childhood obesity is
an important risk factor for adult obesity as 50% of obese
children were still obese as adults [52].

Childhood obesity has increased in developed countries.
It has become an important health problem of Taiwanese
students in the last decade. In Taipei County, obesity was
found to be the third health problem in this study, with
9.5% of first-graders being obese. The schoolchildren's
prevalence of obesity was consistent with the findings
from other studies [27,53] although slightly lower than
the prevalence of 13.2% that was found in German chil-
dren [27].

In term of sex difference, this study revealed that the prev-
alence of obesity in boys was significantly higher than in
girls. This finding was consistent with some relevant stud-
ies in Taiwan [25,53,54]. However, some studies [27,55]
found no statistical significance. In addition, this study
found that the obesity prevalence has no significant differ-
ence by the levels of urbanization.

Other issues of concern
In SMHI, the parents reported 13.7% of first-graders had
at least one diagnosed medical condition, indicating 0.8%
of students had heart diseases. However, SEPE found that
1.5% of this population had a heart murmur. This finding
showed a sign of possible ignorance or misdiagnosis. In
1998, Liu and colleagues [56] noted that 65.4% of chil-
dren had been misdiagnosed in terms of heart disease,
including 20% of congenital heart disease cases not being
diagnosed. Liu's results implied that physical examination
can be an important strategy to identify high-risk stu-
dents. This study also found results similar to the results
of a study conducted in Taipei City [25 ], such as the prev-
alence of cryptorchidism (2.1% vs. 2.2%), and scoliosis
(1.0% vs.0.9%), while these problems were not reported
in SMHI. To avoid complex complications and to plan for
more efficient treatments, early detection is important,
especially for heart disease and cryptorchidism.

This study also found 0.2% of students had asthma
through SEPE, which reported the same prevalence as in


Taipei City (0.2%) [25]. This prevalence was quite lower
than what had been diagnosed (4.1%) from parents'
reports and also lower than prevalence reported from the
other investigations. For example, Wu and associates had
noted that 8.8% of students had asthma in Taipei County
[57] and that U.S. children's asthma prevalence ranged
11%-25% [19,58]. SEPE might have an inherent limita-
tion with regard to acute or seasonal diseases like asthma
and atopic dermatites.

In addition, this study found no significant relationship
between the quantity of medical resources and the three
most prevalent health problems (i.e., caries, myopia, and
obesity) among the first-graders. It could be due to the
coverage of the obligatory national health insurance and
the convenient public transportation, which has dimin-
ished the discrepancy in medical resources between rural
and urban areas.

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 star-
tling 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 prob-
lems 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 charac-
teristics. Further investigations along this line are sug-
gested.

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-grad-
ers, 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 preva-
lence of caries and myopia at certain levels. More research



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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 mecha-
nism 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 Tai-
pei 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, behav-
ioral 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.

Abbreviations
SEPE: Student Entry Physical Examination

SMHI: Student Medical History Inventory

ENT: ears-nose-throat

HLA: heart-lung-abdomen

Competing interests
The authors) declare that they have no competing inter-
ests.


Authors' contributions
RJY conceived and conducted the study. JJS was responsi-
ble 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.

Acknowledgements
The authors acknowledge the support from the grant by the Bureau of Edu-
cation, Taipei County, Taiwan.

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