Awareness, Knowledge, And Perception of School Health Services among parents of school going children in Dakshina Kannada District, Karnataka.

Introduction

The school health program is an important component of community health. According to the modern concept, school health service is an economical and powerful means of raising community health, and more importantly, in the future generation.¹ Since 1900s school health program has been conceived to include three components, i.e. health education, health services and a healthy environment.^2,3 The school health program is important to provide emergency care for illness or injury while at school, to ensure that all students get appropriate referrals to health care providers, to monitor for and control the spread of communicable disease, to provide education and counselling in a variety of health and wellness themes, to serve as a medical resource in the development of policies and procedures in the School. ⁴ Evidence suggests that awareness among the mothers of preschool children regarding the Integrated Child Development Scheme (ICDS) services were found to be 84.2%.⁵

Globally it is seen that worm infestations are the greatest cause of disease among 5-14-year-old children, and vitamin A deficiency is the single greatest cause of preventable childhood blindness.⁶ Iodine deficiency is the single most common preventable cause of mental retardation and brain damage in children.⁷ Injury is the leading cause of death and disability among school-age youth,⁸ one out of two young people who start and continue to smoke will be killed by tobacco-related illness. Worldwide 5% of all deaths of young people between the ages of 15 and 29 are attributable to alcohol use where in some countries, up to 60% of all new HIV infections occur among 15- 24 year old and all of the above health problems can be prevented or significantly reduced through effective school health and youth health programs.⁴

In India, School health services are provided under the National Health Mission (NHM), which has been necessitated and launched in fulfilling the vision of NHM to provide effective health care to the population throughout the country.⁹ It also focuses on the effective integration of health concerns through decentralized management at districtlevel with the determinant of health like sanitation, hygiene, nutrition, safe drinking water, gender and social concern.¹⁰ The school health program intends to cover 12, 88,750 Government and private aided schools covering around 22 Crore students all over India.¹¹ The focus is to address the health needs of the children including both physical and mental, to provide nutritional interventions, to promote physical activities, counselling and provision of fixed day immunization coupled with education, weekly Iron and Folic acid supplementation (WIFS) along with biannual deworming.¹²

In Karnataka, school health services are provided under the name of "Suvarna Arogya Chaitanya program" since 2006-07. It is conducted every year, usually in August. During the year 2008-09, 1415, children were treated for various ailments. In the year 2009-10, 1623 children were treated. In the year 2010-11, 821 children were treated for various ailments including medical, surgical and specialty cases.¹³ This study is aimed to assess the awareness, Knowledge and perception among parents on school health services provided to the School going children in selected primary and secondary schools of Dakshina Kannada district, Karnataka and to find the association between parental perception with related demographic variables.

Materials and methods:

Study was conducted in Dakshina Kannada district of Karnataka. It is a coastal district in the state of Karnataka in India. Considering the design effect of 1.5, with the addition of a 95% confidence interval and a 5% margin of error. Cluster sampling technique was used to select the sampling unit, and random sampling techniques were used for selecting the samples. Two Taluks, namely Bantwal and Mangalore, were selected out of five Taluks from Dakshina Kannada district, using a convenient sampling technique. First, 20% of the total villages from Bantwal and Mangalore Taluk were selected randomly. From each village, one school was selected randomly, and from each selected School, 10 students were further selected randomly with the help of attendance register. The addresses of the selected students were obtained from the school documents. Prior permission was taken from the respective school authorities. From all the eligible respondents in households, only one was selected randomly for the interview. But in the absence of an eligible respondent in a given household, a substitution was made by an individual in the next household. Data collection was done by Interview schedule using a semistructured, newly developed questionnaire. Face validation was done by the experts and further validation done by pilot testing. The basic demographic and socioeconomic statuses were collected. Further, the questions related to awareness and Knowledge and perception on school health services were categorized and under each category set of questions with responses were placed. Based on the response, the scores were given and then the percentage was calculated and analysed. Ethical clearance was given by the Institutional Ethics Committee of K.S. Hegde Medical Academy.

Parents, primarily mothers and in the absence of mother the child's father was interviewed, whose child is of School going Age between 6 to 16 years and who studies in a Government or a Government-aided School. Parents who weren't willing to participate in the study, Parents, whose children go to private schools, Parents, who have their domiciliary status within last one year, Children, who are shifted from private schools to Government and aided schools and vice versa are excluded.

Results

Socio-Demographic Information:

A total number of samples were 340, and four were non-respondents in this study who did not show a willingness to participate in the study. Hence, after the data cleaning, Information of 336 samples was analyzed. And the socio-demographic characteristics are mentioned below.

Table 1, shows that most of the respondents were between 30- 49 years and mean Age found to be 39 years. Majority were in the age group of 30-39 years, 162 (48.2 %) and 150 (44.6 %) were in the age group of 40-49 years. Among 336 samples, 5 respondents were males, and others were females. Majority of the respondents were Hindus (73.8%) followed by Muslims. Most of the participants completed their primary and higher primary education. A majority (72.3%) of the respondents were home makers, and others were employed. Among the reference children, 56.8% are females, and 43.2% are males, and among them, 63.1% were going to government schools 36.9% to Government aided schools. For the further analysis categories from the above table were combined and analyzed. The combined demographical variable categories are given below.

Figure 1 shows that most of the parents are aware of the various health services provided in the schools. Majority 96.1% are aware of about the provision of mid-day meal in the School. Awareness on First aid, physical education, treatment of minor ailments and deworming is also good 83.3%, 84.8%, 86.9% and 88.4% respectively. Compared to all other services, awareness on referral card and counselling services showed less 58.6 % and 59.2% respectively.

Table 2 shows that 89.9% of parents have adequate awareness regarding the school health services, 55.8% has good Knowledge regarding various school health services and only 31% perceive school health services as not good or not useful. These are all combined scores which computed to analyze final outcome variables 'awareness, Knowledge and perception on various school health services.

There was no significant association between awareness and demographic characteristics like Age, religion occupation, education and income. Hence it was not taken for the further multivariate analysis.

Multivariate analysis

Multiple logistic regression models were constructed using Perception and Knowledge as a binary dependent variable. The first model was based on the influence of demographic variables on parental Knowledge regarding school health services, and the second model was based on the influence of demographic variables on parental perception regarding school health services.

Table 4 shows that parental Knowledge is not influenced by any of the demographic variables such as Age, religion, occupation, education and income.

Table 5 shows that Age, religion and income turned out to be statistically insignificant in influencing parental perception. However, parents with 5-9 years of formal education had 1.859 higher odds of perceiving school health services as good or useful (95% CI: (1.116-3.096), than those who had education up to 4years of formal education. Employed parents have 1.915 folds good perception than homemakers (95% CI: 1.053-3.480)

Discussion

Parental awareness on school health services: There is limited Information on parental awareness regarding school health program. A cross-sectional study in Sanliurfa, Turkey, suggests high (84.7%) parental awareness regarding school health program9. The current study also suggests similar results with high (89.9%) parental awareness. This may be due to higher parental concern regarding education and health of their children.

Parental awareness, Knowledge and perception on the mid-day meal program:

A cross-sectional study by Goyal and Vasantha in Agra (2014) suggests a majority of the parents do not have basic Knowledge about National Program for Nutritional Supplement to primary education (NP-NSPE) and its aims and benefits, quality, menu prescribed by the Government.¹⁴ Another study conducted by Claudia et al. (2004) shows disparities in perceptions among the groups,¹⁵ another study by Laurel et al. (2002) shows 79% of parents "intended to encourage their children to participate in the School lunch program.¹⁶ In the present study, it is found that 96.1% of parents are aware of mid-day meal services provided in the school, only 88.6% of children participate in the mid-day meal program.

Parental perception of De-worming:

Booker et al. (2001) conducted a study to assess Community perception of school-based delivery of anti-helminthic in Ghana and Tanzania which suggests thatalthough all parents knew that their children received tablets at School, only 57% know beforehand that these tablets are specifically for treating schistosomiasis or intestinal nematodes.¹⁷ The present study shows that 77 % students have received deworming tablets from the School, only 52 % parents know correctly about the frequency of deworming of children in the schools and only 63 % parents perceive that it is good because it prevents anaemia and 20 % parents are not sure whether deworming is good, our study shows better perception compared to the results of studies mentioned above.

Parental Knowledge on immunization:

In a study conducted by Donna et al. (2014) in Ontario, Canadashows that those parents supportive of School-based influenza immunization (SBII), think that this added pressure could be beneficial, resulting in increased vaccine uptake in children.¹⁸ Many parents think that if SBII was well developed, timed appropriately during the school year and safely implemented. Allison et al. (2011) had conducted a study on a limited awareness of vaccines recommended for adolescents and results from two National consumer health surveys in the United States. Results show that 84% agreed or strongly agreed that vaccines are one way they can protect their child's health, 33% reported general concern about vaccine safety, 70% agreed or strongly agreed that parental recommendations about healthcare and vaccines were important to their child.Many parents and adolescents surveyed are not aware of all vaccine recommendations for adolescents and did not support adolescents receiving vaccinations independent of parental Knowledge or consent.¹⁹ Another study conducted by Tracy et al. (2007) suggests that 81.6% aware of smoking policies, 86.7% aware of alcohol policies, and 88.8% aware of illicit-drug policies versus 72.1%, 70.3%, and 71.9%, respectively and the percentage of parents aware of specific drug policies at their child’s school was higher in Washington than in Victoria.²⁰ Only 9.7% parents have corrected Knowledge regarding specific Age and the name of the vaccine as mentioned in the National immunization schedule, and there are no studies conducted to assess Knowledge on immunization of School going children as per the National immunization schedule, similar results were shown by the current study.

Parental perception of health education and healthy School:

The present study shows that the parental perception and opinion about the healthy school components which include yoga practice, adolescent health education and health cabinets formed in the schools are perceived as good and useful by many parents, 77.2%, 97.1%, 88.1%, 98.1% of parents perceive the regular practice of yoga, adolescent health education and health cabinets, physical education in School as good and useful respectively, and the qualitative study findings shown by Hesketh et al. (2005) which reveals that parental perception regarding the timing and content of childhood obesity prevention through healthy eating and activities was good.²¹ Another study was conducted by Marjorita et al. (2012) shows that group of parents consider main responsibilities of School should include educating a child in content areas such as functioning in a group 29.5%, anatomy and physiology of the human body 28.9%, human growth and development 25% and proper working postures 22.8%.²² Most of the contents of the child's health education were perceived as the mutual responsibility of home and school by parents.

The present study indicates parental awareness, Knowledge and perception of various school health services. All the school health services provided from the School were acceptable by the parents, but there was a difference in the perception of individual components. Majority of the parents were having adequate but incomplete awareness on all the health services provided in the schools, more than half were having good Knowledge regarding the school health services, and more than three-fifth parents perceived school health services are not good and not useful. Study shows that though there is good awareness among parents regarding the school health services, there is a lack of Knowledge regarding these services and many parents perceive these services as not good and not useful. Though this study shows high parental awareness, and more than half parents having good Knowledge regarding school health services, there is no statistical significance. There is a significant difference in the association of perception with occupation and education. However, the study shows significant differences to Religion, Education and occupation of the parents.

The strengths of the current study:

This is a community-based study which gives more understanding of community with various socioeconomic backgrounds. Since the respondents were interviewed at their own house, they were comfortable in answering questions. Hence, more of true responses were captured in the study. This is one of the first studies conducted in the region as there were very limited literatures even for the country as a whole. The questionnaire was developed according to the guidelines of on school health programs issued by the Ministry of Health and Family Welfare. So, this study is able to capture various health services provided by the Government.

Limitation of the current study: There was limited literature on school health services in Karnataka and India; hence, the comparison is one of the limitations of this study. Structured items and lack of qualitative component might have limited capturing of a wide variety and rich Information. Reliance on self-reported data is another limitation.

Conclusion

The study results showed more than 50% of parents have adequate awareness, good Knowledge of the school health services, and they perceive these services to be good or useful. But there is a significant difference among the homemakers and parents with lesser education below the 5th standard. These results of the study recommend for the inclusion of parents in school health programs, to provide Information, education, communication (IEC) regarding school health services and its benefits, thereby increasing awareness and Knowledge on school health services. Involving local government authorities in the planning and implementation of school health services will open a better way to increase awareness among the parents in a particular locality. As it was found lack of parental Knowledge regarding the immunization and its frequencies, micronutrient supplements and deworming, involving health professionals in providing health education will benefit both teachers and parents. Providing proper IEC on school health programs to the parents and thereby increasing the utilization of the school health services by the children and getting maximum benefits out of it will serve the purpose and make school health program worthwhile for the contribution of the society. As there is limited literature on parental awareness, Knowledge and perception on school health services, further research will be useful