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EFFECTS OF PRESCHOOL SCREENING FOR VISION AND HEARING ON PREVALENCE OF VISION AND HEARING PROBLEMS 6-12 MONTHS LATER
1014
Screening EFFECTS OF PRESCHOOL SCREENING FOR VISION AND HEARING ON PREVALENCE OF VISION AND HEARING PROBLEMS 6-12 MONTHS LATER WM. FELDMAN BARBARA SACKETT
RUTH A. MILNER SUE GILBERT
Departments of Pediatrics and Clinical Epidemiology and Biostatistics, McMaster University Medical Centre, Hamilton, Ontario, Canada In order to determine whether children screened 6-12 months previously for vision and hearing had fewer vision and hearing problems than a non-screened cohort, a trained nurse-tester examined 763 screened and 743 non-screened kindergarten children matched for age, sex, and socioeconomic status. The screened cohort had significantly fewer vision problems (10%) than the unscreened (15%). The difference for moderately severe problems (visual activity 20/50 or worse) was also significant. 58% more screened than unscreened children were wearing glasses. The screened cohort had more hearing problems (16·8%) than the non-screened group (14%), but the difference was not statistically significant. There was a marked seasonal variation in prevalence of hearing problems, the frequency in November and December being twice that in April, presumably a result of increased frequency of upper respiratory problems in those months. Preschool hearing screening, unlike vision screening, is not associated with improved end results.
Summary
INTRODUCTION
The rationale for preschool screening of children for physical and developmental problems is that affected children who are detected by screening programmes will be treated and, therefore, better off than affected children who have not been screened. This rationale rests on certain assumptions-first, that treatment is efficacious; second, that the screening tests are sensitive, specific, accurate, and reliable; and third, that compliance with the treatment recommendations is high. The only assumption about vision and hearing screening of preschool children that has been shown to be valid is the second assumption. A computer literature search going back 13 years identified few studies which have been designed to answer the question: is a screened population better off than a non-screened one? Kohler and Stigmar’ found that 7-year-old children who had undergone visual screening tests had significantly fewer problems than those who had not been screened. Unfortunately, there are serious methodological flaws in this study, the main one being that no attempt was made to ensure that the non-screened cohort was similar to that which was screened. Also, the authors do not describe socioeconomic comparisons between the two groups, or other variables such as accessibility to health-care resources, which might have influenced the outcome. There have been no randomised controlled trials attempting to answer questions about the benefits of preschool screening. Except for the study of Kohler and Stigmar,none of the four cohort studies 1-4 set out to answer the question that is posed in our investigation. Thus, we set out to answer the
question: Is a cohort of preschool children which undergoes vision and hearing screening tests better off than a matched comparison cohort which’has not had such screening? SUBJECTS AND METHODS
Subjects The two cohorts examined were: (1) a group of children screened before entry into kindergarten in Halton County, Ontario, and (2) a group of children not screened before school entry, in HamiltonWentworth region. The two areas chosen to represent these two counties were, for geographic convenience, Burlington and Hamilton City. Preschool screening in Burlington had been public health policy for years; in Hamilton, the policy was to defer screening until after school entry. A potential bias was the possibility of discrepancy in socioeconomic status in Burlington and Hamilton. To eliminate this problem, parents’ education levels were taken as a measure of socioeconomic status since education probably plays a larger part in the recognition of health problems and the seeking of health care than does the income level, particularly in an area where over 95% of the population is covered by government health insurance. The socioeconomic level of children attending each school was assumed to be similar to that of the area from which the school population was drawn. To ensure that the distribution of socioeconomic levels in our two cohorts was similar school catchment boundaries were translated onto a map which displayed census tracts. For each school the socioeconomic level was estimated by determining what proportion of each census tract contributed children to that school and then weighting the parental education distribution accordingly. For the total distribution, all census tracts in the designated areas were added together. 17 schools in Hamilton and 18 schools in Burlington were chosen to provide over 730 children in each group. There are no significant racial or ethnic differences in the 2 com-
mittees, and accessibility
opticians,
and
to ophthalmologists, otolaryngologists, audiologists is similar.
Sample Size It was agreed that a 50% lower rate of uncorrected problems in the screened group would be considered to be a clinically significant difference. Where the prevalence of both hearing and visual defects was assumed to be 5%, and the a level to be 0 - 05 and the 0 level to be of 0 - 2, a sample size of 696 would have been required to show a 50% difference between the groups. Allowing for a number of children who would not fit the criteria for the group, it was estimated that 730 children in each group should be examined.
Assessments The two cohorts of schoolchildren underwent systematic hearing and vision assessment in their kindergarten year. The Burlington children had been screened 6-12 months earlier and the Hamilton children were scheduled to be screened after our assessment. The preschool vision and hearing screening tests on the Burlington children were done by public health nurses who used the "Illiterate E" and verbal auditory screening test for children (VASC) audiometer ; their criteria for pass/fail were the same as those we subsequently used. Children who failed a second screen were referred to their family doctor who either confirmed the findings themselves or referred the children for specialist care. No records were kept of whether parents or doctors complied with the follow-up care, but the Public Health Department judged compliance to be high. In order to minimise a bias that could be caused by seasonal variations and associated respiratory infections and allergies leading to serous otitis media and hearing loss, the nurse-tester who did the assessments for our study alternated weekly between the previously screened and unscreened cohorts. The nurse-tester was a registered nurse with work experience and interest in paediatrics. She was trained in both vision and hearing screening methods by an audiologist and an optometrist. The nursetester’s results were regularly compared with those ofa senior paedi-
1015 atric clinic
nurse-tester.
Differences between the
two were
negli-
gible.
TABLE II-DIFFERENCES IN VISION STATUS BETWEEN UNSCREENED AND SCREENED COHORTS TESTED 6-12 MONTHS AFTER SCREENING
A Madsen pure-tone audiometer was used with ’Audiocup’ (Madsen) noise-excluder shells on the headset. The audiometer was calibrated every three months in case daily transport by car from disturb its accuracy, but it remained in order throughout. The Illiterate E screening instrument was used with the ’Good-Lite’ eye chart at a distance of 10 feet (3 metres).
school
to
school
might
perfect operating
Criteria for
Hearing and
Vision’
Hearing.-A child failed the screening test if he could not hear at 25 decibels two of four speech frequencies: 500, 1000, 2000, and 4000 in one or both ears. Inability to hear at 30 decibels or more was classified as a moderate to severe defect. Vision. -Children with glasses were tested with their glasses. The final line in which the child could read 5 of the 6 letters was regarded as his visual acuity. Vision of 20/30 in both eyes was considered normal ; 20/40 in either or both eyes was mild impairment; and 20/50 or more in either or both eyes was moderate impairment. RESULTS
Demographic Data To balance the distribution of socioeconomic status between Burlington- and Hamilton, the areas recognised as the north and east ends of Hamilton City were removed from the study. This results in similar distributions of socioeconomic status between the two cities (table 1). For practical purposes, Hamilton City minus the north and east sections and Burlington City excluding the rural sections were chosen as the target areas. Sex and age distributions of the two populations were similar. In Hamilton, the ratio of boys to girls was 1’17, and in Burlington it was 1’04. The mean age for the Hamilton group was 66 - 4 months and that for the Burlington group was 65,6 6 months. Vision 10% in the Burlington group and 1507o in the Hamilton group had visual impairment, a higher prevalence than the predicted 5%. These prevalence figures reflect vision problems for all children including those wearing glasses at the time of testing. The 50% difference between the group screened before entry to school and the unscreened group was
statistically significant (p=<0’01)
VA =visual
acuity
*p=<0-01
z
Hearing The prevalence of hearing defects was 16’ 8% for Hamilton and 14’1% for Burlington. This difference was not statistically significant, but. both percentages were higher than predicted. There was a marked seasonal variation in prevalence of hearing defects, with twice as many test failures in both cities in November and December as in April and May (see accompanying figure). DISCUSSION was associated with 50% fewer vision and 79% fewer moderate to severe vision overall problems problems 6-12 months after the screen. 58% more children in the already screened group were wearing glasses. Hearing screening was not associated with fewer hearing problems. Vision screening works because the screening procedure is adequate, compliance of patients in follow up is satisfactory, and the interventions (glasses, patching, strabismus surgery) are efficacious. There are several possible reasons why hearing screening is not useful. The first is the screening procedure itself. Although impedance audiometry is a more sensitive test for assessing middle-ear fluid than is pure-tone audiometry,5 it may be too sensitive; the number of children who have abnormal tympanograms but who pass pure-tone audiometry (i.e., who hear normally) is too high for tympanometry to be used
Vision
screening
(table n).
TABLE I-EDUCATIONAL LEVELS IN MODIFIED HAMILTON AREAS AND BURLINGTON
Results of assessment of hearing in relation Failure is inability frequencies..
to
hear
at
to
month of hearing test.
25 dB sounds of at least two of four
speech
1016
routine screening at the pre-school level. As a measure of telling us what we want to know-i.e., whether children can hear the spoken word-the VASC audiometer for pre-school children (used in the Burlington screening programme) and the pure-tone audiometer (used in the present study) are more appropriate. Tympanometry is mentioned because it is in great vogue as a screening tool in North America. We did not as
it because it is too sensitive. The next possibility is lack of compliance with recommended therapeutic measures, but there is no reason why parents should comply with regard to vision problems (screened children have significantly fewer vision problems than unscreened, and 58% more screened children wear glasses) and yet not comply with regard to hearing problems. The third and likeliest possibility is that medical and surgical therapies for the commonest cause of hearing deficit, namely, serous otitis media, are not effective. Olson et al.’7 found that children with serous otitis media did not improve when treated medically, and Brown et al. found no improvement in hearing beyond the initial 3 months in ears in which tubes had been inserted. Similarly, there is no conclusive evidence9that tonsillectomy and adenoidectomy materially affect serous otitis media. Hearing is important in language and development but deficits in hearing are thought to be more important in this regard in the first 2 years of life than at the immediate preschool age." In addition, one must balance the potential benefits of knowing a child has difficulty in hearing (appropriate classroom placement, &c.) against the risks of labelling a child with a transient self-limited hearing loss as being hard of hearing. Indeed, it is important to look at side-effects of
use
Community Health TEACHERS AND PUPILS AS HEALTH WORKERS M. V.
JOSEPH
Department of Pœdiatrics, Hospital, Kangazha,
M. G. D. M.
India
ALTHOUGH schools are an obvious target for health promotion, their potential is often neglected in developing countries. Health workers are scarce and expensive, and existing programmes tend to concentrate on curative care. Lately, however, there has been a recognition that schoolteachers and even pupils can become effective health educators. 1,2 In Kerala we have taken this concept further by training teachers and pupils to engage in curative, preventive, and promotive care. As a primary step we reviewed the health problems in a few selected schools.3 Simple ailments such as deficiency states and skin disease accounted for 85% of the morbidity—conditions amenable to prevention and treatment at school level. THE PROGRAMME
Our target
area was
rural, situated in Central Kerala.
were selected within 20 km of a hospital; the average number of pupils was 1000. In this community the literacy rate is 95% and schoolteachers are held in high esteem. The programme was implemented in four phases, each consisting of one school year.
Thirty schools
"The Menace of Mass Screenscreening as a recent editorial ing" has suggested."’I We thank Dr I. Cunningham and Dr J. Chamberlain, Medical Officers of and their staffs for their help; the Boards of Education for their cooperation; Dr David Sackett for reviewing the paper; and Linda Teiml and Anne Glover for typing the manuscript.
Health,
This work was funded by the Ontario Ministry of Health (grant no. DM375), and it has been presented at the Annual Meeting of the Ambulatory
Pediatric Association, San Antonio, Texas,
on
April 28,
1980.
Requests for reprints should be addressed to W. F., Department of Paediatrics, McMaster University Medical Center, Hamilton, Ontario L8N 3Z5, Canada. ’
REFERENCES L, Stigmar G. Visual disorders in 7 year old children with and without previous screening. Acta Paed Scand 1978; 67: 373-77. Kaplan GJ, Fleshman JK, Bender TR, Baum C, Clark PS. Long term effects of otitis media in a ten year cohort study of Alaskan Eskimo children. Pediatrics 1973; 52:
1. Kohler
vision
2.
577-85. 3. Kohler
L, Svenmngsen NW, Lindquist B. Early detection of preschool health problems-role of perinatal risk factors Acta Paed Scand 1979; 68: 229-37. 4. Tibbenham AD, Peckham CS, Gardiner PA. Vision screening in children tested at 7, 11, and 16 years. Br Med J 1978; i: 1312-14. 5. Doyle PJ, Morwood D. Middle ear disease in native Indian children in British Columbia-incidence of disease and an evaluation of screening methods. J
Otolaryngol 1976; 5: 103-15. 6. Paradise JL, Smith CG. Impedance screening for preschool children. Ann Otol Rhinol Laryngol 1979; 88: 56-65. 7. Olson AL, Klein SW, Charney E, et al. Prevention and therapy of serous otitis media by
8. 9. 10. 11.
oral decongestant: A double blind study in pediatric practice. Pediatrics 1978, 61: 679-84. Brown MJK, Richards SH, Ambergaokar AG. Grommets and glue ear: A five-year follow-up of a controlled trial. J Roy Soc Med 1978; 71: 353-56. Shaikh W, Vayda E, Feldman W. A systematic review of the literature on evaluative studies of tonsillectomy and adenoidectomy. Pediatrics 1976; 57: 401-07 Holm VA, Kunze LH. Effect of chronic otitis media on language and development Pediatrics 1969; 43: 833-39. Editorial. The menace of mass screening. Am J Pub Hlth 1977; 67: 601-02.
Phase
I- Training of Teachers
The teacher attended a short course at the base hospital, then established a school health unit equipped with simple medicines and first-aid facilities. Continued training and administration was the responsibility of the base hospital and a visiting health worker formed the link between school health unit and hospital. Teachers had four days’ intensive training, ending in a practical test at one of the schools: they were required to identify scabies, skin sepsis, trachoma, vitamin-A deficiency, nutritional anaemia, and dental caries. The training was modified according to the problems of particular areas-thus, some teachers had instruction in the recognition of, say, leprosy or malaria. In addition, all had to acquire the following skills: (1) screening for growth failure; (2) screening of vision and hearing; (3) first-aid and symptomatic treatment; (4) identification of common, infectious disease and application of their quarantine regulations; and (5) imparting health education. In our experience this training is adequate, provided that continuing training is offered and the work is supervised
periodically. To start a school unit, a stock of medicines and simple equipment such as a weighing machine and vision chart are acquired. A register is maintained in which the teacher carefully notes the cases, the symptoms, the treatment offered, and follow-up results, need for referral, and so on. A special register is maintained for children who need follow-up treatment. The teacher administers simple medicines according to standing instructions. The programme is now being extended to other schools: a school with an established unit and a trained teacher functions as the new training centre.
Phase 2-Pupils
as
Participants and Beneficiaries
Between 6 and 10 pupils from each school were put through an initial training. They were trained to perform the following functions: (1) assist the teacher in record-keeping; (2) appraise pupils’ health with daily reporting to the teacher; (3) assist teacher in dispensing; (4) promote immunisation among pupils; (5) organise
Screening EFFECTS OF PRESCHOOL SCREENING FOR VISION AND HEARING ON PREVALENCE OF VISION AND HEARING PROBLEMS 6-12 MONTHS LATER WM. FELDMAN BARBARA SACKETT
RUTH A. MILNER SUE GILBERT
Departments of Pediatrics and Clinical Epidemiology and Biostatistics, McMaster University Medical Centre, Hamilton, Ontario, Canada In order to determine whether children screened 6-12 months previously for vision and hearing had fewer vision and hearing problems than a non-screened cohort, a trained nurse-tester examined 763 screened and 743 non-screened kindergarten children matched for age, sex, and socioeconomic status. The screened cohort had significantly fewer vision problems (10%) than the unscreened (15%). The difference for moderately severe problems (visual activity 20/50 or worse) was also significant. 58% more screened than unscreened children were wearing glasses. The screened cohort had more hearing problems (16·8%) than the non-screened group (14%), but the difference was not statistically significant. There was a marked seasonal variation in prevalence of hearing problems, the frequency in November and December being twice that in April, presumably a result of increased frequency of upper respiratory problems in those months. Preschool hearing screening, unlike vision screening, is not associated with improved end results.
Summary
INTRODUCTION
The rationale for preschool screening of children for physical and developmental problems is that affected children who are detected by screening programmes will be treated and, therefore, better off than affected children who have not been screened. This rationale rests on certain assumptions-first, that treatment is efficacious; second, that the screening tests are sensitive, specific, accurate, and reliable; and third, that compliance with the treatment recommendations is high. The only assumption about vision and hearing screening of preschool children that has been shown to be valid is the second assumption. A computer literature search going back 13 years identified few studies which have been designed to answer the question: is a screened population better off than a non-screened one? Kohler and Stigmar’ found that 7-year-old children who had undergone visual screening tests had significantly fewer problems than those who had not been screened. Unfortunately, there are serious methodological flaws in this study, the main one being that no attempt was made to ensure that the non-screened cohort was similar to that which was screened. Also, the authors do not describe socioeconomic comparisons between the two groups, or other variables such as accessibility to health-care resources, which might have influenced the outcome. There have been no randomised controlled trials attempting to answer questions about the benefits of preschool screening. Except for the study of Kohler and Stigmar,none of the four cohort studies 1-4 set out to answer the question that is posed in our investigation. Thus, we set out to answer the
question: Is a cohort of preschool children which undergoes vision and hearing screening tests better off than a matched comparison cohort which’has not had such screening? SUBJECTS AND METHODS
Subjects The two cohorts examined were: (1) a group of children screened before entry into kindergarten in Halton County, Ontario, and (2) a group of children not screened before school entry, in HamiltonWentworth region. The two areas chosen to represent these two counties were, for geographic convenience, Burlington and Hamilton City. Preschool screening in Burlington had been public health policy for years; in Hamilton, the policy was to defer screening until after school entry. A potential bias was the possibility of discrepancy in socioeconomic status in Burlington and Hamilton. To eliminate this problem, parents’ education levels were taken as a measure of socioeconomic status since education probably plays a larger part in the recognition of health problems and the seeking of health care than does the income level, particularly in an area where over 95% of the population is covered by government health insurance. The socioeconomic level of children attending each school was assumed to be similar to that of the area from which the school population was drawn. To ensure that the distribution of socioeconomic levels in our two cohorts was similar school catchment boundaries were translated onto a map which displayed census tracts. For each school the socioeconomic level was estimated by determining what proportion of each census tract contributed children to that school and then weighting the parental education distribution accordingly. For the total distribution, all census tracts in the designated areas were added together. 17 schools in Hamilton and 18 schools in Burlington were chosen to provide over 730 children in each group. There are no significant racial or ethnic differences in the 2 com-
mittees, and accessibility
opticians,
and
to ophthalmologists, otolaryngologists, audiologists is similar.
Sample Size It was agreed that a 50% lower rate of uncorrected problems in the screened group would be considered to be a clinically significant difference. Where the prevalence of both hearing and visual defects was assumed to be 5%, and the a level to be 0 - 05 and the 0 level to be of 0 - 2, a sample size of 696 would have been required to show a 50% difference between the groups. Allowing for a number of children who would not fit the criteria for the group, it was estimated that 730 children in each group should be examined.
Assessments The two cohorts of schoolchildren underwent systematic hearing and vision assessment in their kindergarten year. The Burlington children had been screened 6-12 months earlier and the Hamilton children were scheduled to be screened after our assessment. The preschool vision and hearing screening tests on the Burlington children were done by public health nurses who used the "Illiterate E" and verbal auditory screening test for children (VASC) audiometer ; their criteria for pass/fail were the same as those we subsequently used. Children who failed a second screen were referred to their family doctor who either confirmed the findings themselves or referred the children for specialist care. No records were kept of whether parents or doctors complied with the follow-up care, but the Public Health Department judged compliance to be high. In order to minimise a bias that could be caused by seasonal variations and associated respiratory infections and allergies leading to serous otitis media and hearing loss, the nurse-tester who did the assessments for our study alternated weekly between the previously screened and unscreened cohorts. The nurse-tester was a registered nurse with work experience and interest in paediatrics. She was trained in both vision and hearing screening methods by an audiologist and an optometrist. The nursetester’s results were regularly compared with those ofa senior paedi-
1015 atric clinic
nurse-tester.
Differences between the
two were
negli-
gible.
TABLE II-DIFFERENCES IN VISION STATUS BETWEEN UNSCREENED AND SCREENED COHORTS TESTED 6-12 MONTHS AFTER SCREENING
A Madsen pure-tone audiometer was used with ’Audiocup’ (Madsen) noise-excluder shells on the headset. The audiometer was calibrated every three months in case daily transport by car from disturb its accuracy, but it remained in order throughout. The Illiterate E screening instrument was used with the ’Good-Lite’ eye chart at a distance of 10 feet (3 metres).
school
to
school
might
perfect operating
Criteria for
Hearing and
Vision’
Hearing.-A child failed the screening test if he could not hear at 25 decibels two of four speech frequencies: 500, 1000, 2000, and 4000 in one or both ears. Inability to hear at 30 decibels or more was classified as a moderate to severe defect. Vision. -Children with glasses were tested with their glasses. The final line in which the child could read 5 of the 6 letters was regarded as his visual acuity. Vision of 20/30 in both eyes was considered normal ; 20/40 in either or both eyes was mild impairment; and 20/50 or more in either or both eyes was moderate impairment. RESULTS
Demographic Data To balance the distribution of socioeconomic status between Burlington- and Hamilton, the areas recognised as the north and east ends of Hamilton City were removed from the study. This results in similar distributions of socioeconomic status between the two cities (table 1). For practical purposes, Hamilton City minus the north and east sections and Burlington City excluding the rural sections were chosen as the target areas. Sex and age distributions of the two populations were similar. In Hamilton, the ratio of boys to girls was 1’17, and in Burlington it was 1’04. The mean age for the Hamilton group was 66 - 4 months and that for the Burlington group was 65,6 6 months. Vision 10% in the Burlington group and 1507o in the Hamilton group had visual impairment, a higher prevalence than the predicted 5%. These prevalence figures reflect vision problems for all children including those wearing glasses at the time of testing. The 50% difference between the group screened before entry to school and the unscreened group was
statistically significant (p=<0’01)
VA =visual
acuity
*p=<0-01
z
Hearing The prevalence of hearing defects was 16’ 8% for Hamilton and 14’1% for Burlington. This difference was not statistically significant, but. both percentages were higher than predicted. There was a marked seasonal variation in prevalence of hearing defects, with twice as many test failures in both cities in November and December as in April and May (see accompanying figure). DISCUSSION was associated with 50% fewer vision and 79% fewer moderate to severe vision overall problems problems 6-12 months after the screen. 58% more children in the already screened group were wearing glasses. Hearing screening was not associated with fewer hearing problems. Vision screening works because the screening procedure is adequate, compliance of patients in follow up is satisfactory, and the interventions (glasses, patching, strabismus surgery) are efficacious. There are several possible reasons why hearing screening is not useful. The first is the screening procedure itself. Although impedance audiometry is a more sensitive test for assessing middle-ear fluid than is pure-tone audiometry,5 it may be too sensitive; the number of children who have abnormal tympanograms but who pass pure-tone audiometry (i.e., who hear normally) is too high for tympanometry to be used
Vision
screening
(table n).
TABLE I-EDUCATIONAL LEVELS IN MODIFIED HAMILTON AREAS AND BURLINGTON
Results of assessment of hearing in relation Failure is inability frequencies..
to
hear
at
to
month of hearing test.
25 dB sounds of at least two of four
speech
1016
routine screening at the pre-school level. As a measure of telling us what we want to know-i.e., whether children can hear the spoken word-the VASC audiometer for pre-school children (used in the Burlington screening programme) and the pure-tone audiometer (used in the present study) are more appropriate. Tympanometry is mentioned because it is in great vogue as a screening tool in North America. We did not as
it because it is too sensitive. The next possibility is lack of compliance with recommended therapeutic measures, but there is no reason why parents should comply with regard to vision problems (screened children have significantly fewer vision problems than unscreened, and 58% more screened children wear glasses) and yet not comply with regard to hearing problems. The third and likeliest possibility is that medical and surgical therapies for the commonest cause of hearing deficit, namely, serous otitis media, are not effective. Olson et al.’7 found that children with serous otitis media did not improve when treated medically, and Brown et al. found no improvement in hearing beyond the initial 3 months in ears in which tubes had been inserted. Similarly, there is no conclusive evidence9that tonsillectomy and adenoidectomy materially affect serous otitis media. Hearing is important in language and development but deficits in hearing are thought to be more important in this regard in the first 2 years of life than at the immediate preschool age." In addition, one must balance the potential benefits of knowing a child has difficulty in hearing (appropriate classroom placement, &c.) against the risks of labelling a child with a transient self-limited hearing loss as being hard of hearing. Indeed, it is important to look at side-effects of
use
Community Health TEACHERS AND PUPILS AS HEALTH WORKERS M. V.
JOSEPH
Department of Pœdiatrics, Hospital, Kangazha,
M. G. D. M.
India
ALTHOUGH schools are an obvious target for health promotion, their potential is often neglected in developing countries. Health workers are scarce and expensive, and existing programmes tend to concentrate on curative care. Lately, however, there has been a recognition that schoolteachers and even pupils can become effective health educators. 1,2 In Kerala we have taken this concept further by training teachers and pupils to engage in curative, preventive, and promotive care. As a primary step we reviewed the health problems in a few selected schools.3 Simple ailments such as deficiency states and skin disease accounted for 85% of the morbidity—conditions amenable to prevention and treatment at school level. THE PROGRAMME
Our target
area was
rural, situated in Central Kerala.
were selected within 20 km of a hospital; the average number of pupils was 1000. In this community the literacy rate is 95% and schoolteachers are held in high esteem. The programme was implemented in four phases, each consisting of one school year.
Thirty schools
"The Menace of Mass Screenscreening as a recent editorial ing" has suggested."’I We thank Dr I. Cunningham and Dr J. Chamberlain, Medical Officers of and their staffs for their help; the Boards of Education for their cooperation; Dr David Sackett for reviewing the paper; and Linda Teiml and Anne Glover for typing the manuscript.
Health,
This work was funded by the Ontario Ministry of Health (grant no. DM375), and it has been presented at the Annual Meeting of the Ambulatory
Pediatric Association, San Antonio, Texas,
on
April 28,
1980.
Requests for reprints should be addressed to W. F., Department of Paediatrics, McMaster University Medical Center, Hamilton, Ontario L8N 3Z5, Canada. ’
REFERENCES L, Stigmar G. Visual disorders in 7 year old children with and without previous screening. Acta Paed Scand 1978; 67: 373-77. Kaplan GJ, Fleshman JK, Bender TR, Baum C, Clark PS. Long term effects of otitis media in a ten year cohort study of Alaskan Eskimo children. Pediatrics 1973; 52:
1. Kohler
vision
2.
577-85. 3. Kohler
L, Svenmngsen NW, Lindquist B. Early detection of preschool health problems-role of perinatal risk factors Acta Paed Scand 1979; 68: 229-37. 4. Tibbenham AD, Peckham CS, Gardiner PA. Vision screening in children tested at 7, 11, and 16 years. Br Med J 1978; i: 1312-14. 5. Doyle PJ, Morwood D. Middle ear disease in native Indian children in British Columbia-incidence of disease and an evaluation of screening methods. J
Otolaryngol 1976; 5: 103-15. 6. Paradise JL, Smith CG. Impedance screening for preschool children. Ann Otol Rhinol Laryngol 1979; 88: 56-65. 7. Olson AL, Klein SW, Charney E, et al. Prevention and therapy of serous otitis media by
8. 9. 10. 11.
oral decongestant: A double blind study in pediatric practice. Pediatrics 1978, 61: 679-84. Brown MJK, Richards SH, Ambergaokar AG. Grommets and glue ear: A five-year follow-up of a controlled trial. J Roy Soc Med 1978; 71: 353-56. Shaikh W, Vayda E, Feldman W. A systematic review of the literature on evaluative studies of tonsillectomy and adenoidectomy. Pediatrics 1976; 57: 401-07 Holm VA, Kunze LH. Effect of chronic otitis media on language and development Pediatrics 1969; 43: 833-39. Editorial. The menace of mass screening. Am J Pub Hlth 1977; 67: 601-02.
Phase
I- Training of Teachers
The teacher attended a short course at the base hospital, then established a school health unit equipped with simple medicines and first-aid facilities. Continued training and administration was the responsibility of the base hospital and a visiting health worker formed the link between school health unit and hospital. Teachers had four days’ intensive training, ending in a practical test at one of the schools: they were required to identify scabies, skin sepsis, trachoma, vitamin-A deficiency, nutritional anaemia, and dental caries. The training was modified according to the problems of particular areas-thus, some teachers had instruction in the recognition of, say, leprosy or malaria. In addition, all had to acquire the following skills: (1) screening for growth failure; (2) screening of vision and hearing; (3) first-aid and symptomatic treatment; (4) identification of common, infectious disease and application of their quarantine regulations; and (5) imparting health education. In our experience this training is adequate, provided that continuing training is offered and the work is supervised
periodically. To start a school unit, a stock of medicines and simple equipment such as a weighing machine and vision chart are acquired. A register is maintained in which the teacher carefully notes the cases, the symptoms, the treatment offered, and follow-up results, need for referral, and so on. A special register is maintained for children who need follow-up treatment. The teacher administers simple medicines according to standing instructions. The programme is now being extended to other schools: a school with an established unit and a trained teacher functions as the new training centre.
Phase 2-Pupils
as
Participants and Beneficiaries
Between 6 and 10 pupils from each school were put through an initial training. They were trained to perform the following functions: (1) assist the teacher in record-keeping; (2) appraise pupils’ health with daily reporting to the teacher; (3) assist teacher in dispensing; (4) promote immunisation among pupils; (5) organise