Coverage Of School Health Monitoring Systems In China: A Large National Cross-Sectional Survey – The Lancet

Background

There is growing interest in the role that schools can play in promoting student health. The aim of this study was to describe the coverage of school health monitoring systems for infectious diseases, non-communicable diseases, and school physical environments in China, and to explore differences by geography, regional wealth, and school type.

Methods

A cross-sectional study was performed using data from 2428 schools from 17 provinces in China in 2018. Data were collected using a questionnaire administered by the Ministry of Education through its monitoring system, and included infectious diseases (e.g., reporting system for student infectious diseases), non-communicable diseases (e.g., regular student health examinations), and school physical environments (e.g., monitoring of classroom light, microclimate and drinking water).

Findings

Overall, the coverage rate of full school health monitoring systems was 16·6%. The coverage rates of school health monitoring systems for infectious diseases, non-communicable diseases, and school physical environments were 71·2%, 68·5%, and 24·9%, respectively. Coverage was higher in schools from urban rather than rural areas, in schools from areas with greater wealth, and in senior secondary schools rather than junior secondary and primary schools.

Interpretation

Systems for monitoring infectious diseases in school students have been widely implemented in China. Systems for monitoring non-communicable diseases and physical environments need to be strengthened. Beyond greater attention in poorer and rural areas, increased investment in more comprehensive approaches to school health is indicated.

Funding

This study was supported by National Statistical Science Research Project (2021LY052 to YS) and China Scholarship Council (201906015028 to PH).

背景: 学校在促进学生健康方面可以发挥的作用越来越引起关注○ 本研究旨在描述传染病, 非传染性疾病和学校物理环境三方面的学校卫生监测制度在中国的覆盖情况, 并探讨其在不同区域, 地区经济发展水平和学校类型上的差异○

方法: 数据来源于2018年在中国17个省 (市, 区)2428所学校进行的一项横断面研究○ 使用中国教育部指导下设计的调查问卷, 通过其在17省的监测站体系, 收集了学校卫生监测制度的覆盖数据, 包括传染病 (如学生传染病报告制度), 非传染性疾病 (如学生定期体检)和学校物理环境 (如教室采光照明, 教室微小气候和生活饮用水的监测)三方面○

结果: 总体上, 全面的学校卫生监测制度覆盖率仅为16.6%○ 针对传染病, 非传染性疾病和学校物理环境的学校卫生监测制度的覆盖率分别为71.2%, 68.5%和24.9%○ 针对传染病, 非传染性疾病和学校物理环境方面的制度覆盖率表现较为一致, 均呈现城市高于乡村, 经济发达地区高于欠发达地区, 高中高于初中和小学的情况○

解释: 在中国, 针对在校学生的传染病监测制度已被广泛实施.针对非传染性疾病和物理环境的监测制度尚需要得到强化○ 除了对贫困地区和乡村地区给予更多关注外, 还需要在更全面的学校卫生措施上增加投资○

基金: 全国统计科学研究项目 (2021LY052 to YS)和国家留学基金 (201906015028 to PH)

Universal health coverage (UHC), endorsed by the World Health Assembly in 2005, is now a core tenet of the United Nations (UN) Sustainable Development Goals (SDG) 3.

UHC means that all individuals and communities receive the health services they need without suffering financial hardship. It includes the full spectrum of essential, quality health services, from health promotion to prevention, treatment, rehabilitation, and palliative care across the life course.

Older children and adolescents are commonly viewed as healthy and perhaps for that reason have been relatively neglected in health service delivery.

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However, more than 1·2 million children and adolescents aged 10-19 years old died worldwide in 2015, largely from preventable causes, with much less improvement over recent decades than in younger children.

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There is also growing understanding that an investment focus on the first 1000 days of human development is necessary but insufficient, with provision of support to guide health and development across the next 7000 days also required for children and adolescents to achieve their full adult potential. This is particularly around three phases: the middle childhood growth and consolidation phase (5–9 years), the adolescent growth spurt (10–14 years), and the adolescent phase of growth and consolidation (15–19 years).

Children and adolescents spend a large proportion of their waking hours at school and there is growing awareness of the role of schools as sites for enhancing health and wellbeing as well as educational achievements.

In 1995, the World Health Organization (WHO) launched its Global School Health Initiative with the purpose of encouraging the adoption of the health-promoting school approach worldwide. In 2021, the first global standards for health-promoting schools were developed by WHO and the United Nations Educational Scientific and Cultural Organization (UNESCO), which span eight domains: government policies and resources, school policies and resources, school governance and leadership, school and community partnerships, school curriculum, school social–emotional environment, school health services, and attention to how schools’ physical environments can promote health and wellbeing.

These approaches extend beyond treatment and management of health conditions, to address prevention and health promotion.

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While inter-sectoral collaboration is required to make every school a health-promoting school, inadequate coordination between health and education sectors has been frequently reported.

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In China, inter-sectoral collaboration around school health is largely concentrated around health services and the physical environment of schools.

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Policy that supports monitoring and rapid responses to infectious diseases has been a health priority in China since the outbreak of severe acute respiratory syndrome (SARS) in 2003 and the sudden emergence of a novel corona virus in 2019.

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Over this time, China has also developed approaches to preventing infectious diseases through school health services

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and policies and regulations around controlling infectious diseases are well established in primary and secondary schools throughout the country.

Yet China’s rapid epidemiological transition has resulted in a health profile in children and adolescents that now extends beyond infectious diseases to include a set of similarly serious threats including chronic diseases such as obesity and mental health disorders, as well as risks for adult non-communicable diseases, such as hypertension.

For example, data from the Chinese National Survey on Students’ Constitution and Health (CNSSCH) showed that the prevalence of overweight among Chinese children and adolescents aged 7 to 17 years increased from 4·3% in 1995 to 18·4% in 2014.

A systematic review also showed that the prevalence estimates of depressive symptoms among Chinese children and adolescents increased from 18·4% before 2000 to 26·3% after 2016.

Accordingly, the priorities for school-based preventive health services have expanded to strengthen the early detection and prevention of both infectious and non-communicable diseases, monitor the health status of students and improve student learning and living environments.

However, little is known about the current coverage of these services or the quality of monitoring across the country, which is essential for understanding their effectiveness. The current study aimed to investigate the coverage of school health monitoring systems for infectious diseases, non-communicable diseases, and school physical environments, and to explore differences between regions, by urban-rural areas and by school type, across 17 Chinese provinces. Our overarching goal was to identify how well school health services are reorienting their focus to both addressing the continuing challenge of infectious diseases while also tackling new problems related to chronic diseases and environmental health risks.

Since the SARS outbreak in 2003, the Chinese government has invested heavily in infectious disease control and prevention, with demonstrated improvements in disease surveillance.

This may explain why we found few differences in the coverage of infectious disease prevention and monitoring systems between urban and rural locations, regional SES groups, and primary and secondary schools, which is consistent with the widespread implementation of school-based monitoring systems around infectious diseases. Among the components of infectious disease monitoring in schools, the one exception to high coverage was around a system to review student enrolment inoculation cards (a certificate inspection system) which was evident in only 76·4% of schools, well lower than for other components. However, primary schools had over double the coverage than in senior secondary schools (96·4% vs 47·3%). According to China’s immunization guidelines, children should be vaccinated with all national immunization programme (NIP) vaccines before the age of seven.

Schools are required to check the vaccination certificates of students when they enter the school and students with incomplete vaccination status are asked to rectify this and re-represent their certificates for inspection. Research based on the National Immunization Programme Information System (NIPIS) showed that the reported immunization coverage rates for 22 doses of NIP vaccines for children were all more than 98% across China in 2015.

Because most students have completed the immunization programme before they enter primary schools, the inoculation card inspection is no longer considered a major element of preventing infectious diseases beyond primary schools. This might change were Human Papilloma Virus vaccination to become part of the NIP. At present, some areas in China have tried to incorporate HPV vaccine into the immunization programme.

Compared with school health monitoring systems for infectious diseases, coverage for non-communicable diseases was lower, with greater differences evident between urban-rural locations as well as by school SES. While the health burden in Chinese young people has rapidly shifted towards non-communicable diseases,

this lack of monitoring suggests a lag in the establishment and implementation of relevant nationwide systems and monitoring. In our survey, the monitoring for non-communicable diseases mainly focused on student health examinations, but relevant monitoring systems for non-communicable diseases in schools would ideally include evidence of school policy (e.g., that supports students being able to access medication while at school), school curriculum (e.g., around socio-emotional learning), teacher professional development (e.g., around health-promoting schools) and access to school-based health services. In China, the relatively high rate of boarding schools suggests this is particularly pertinent, as school health services will be much more significant in boarding schools given the absence of parents. Around non-communicable disease monitoring, the greatest gap was for a feedback system to parents of the results of student health examination, which suggests that more work is required to promote partnerships between schools and families around student health, consistent with health-promoting schools. Schools in China are required to conduct a regular health examination for students every year.

We found that more than one in ten schools did not meet this requirement; there was poorer performance among schools from rural areas and lower SES areas where the proportion not meeting the requirement was closer to one in seven. Student health examinations require professional medical personnel, standard-compliant equipment and facilities, links to referral services and government financial support.

It is not certain which factors are most contributing to the relatively poorer performance in some regions. This is important as while little is known about the overall benefits of these health examinations in China, any benefits would be anticipated to be greater in more disadvantaged regions due to the combination of greater health needs and less access to quality health services. We also found that annual school health examinations were more commonly undertaken in senior secondary schools than junior secondary and primary schools. Considering that many non-communicable diseases are influenced by lifestyle and daily behaviours, early detection has great significance for early intervention to effectively prevent and control the progression of non-communicable diseases.

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Within school health systems, monitoring of physical environments was less common than monitoring of infectious diseases and non-communicable diseases. There were also much more pronounced differences by region (urban-rural), SES and province. In fact, classroom environments, including the intensity of lighting, is linked to risks for myopia,

a highly prevalent health issue in Chinese children and adolescents. In August 2018, a comprehensive national children’s myopia management plan was jointly issued by the eight central government bodies including the Ministry of Education.

Beyond the quality of lighting, there is also evidence that poor indoor environmental quality (e.g., poor ventilation or excess moisture) can adversely affect the health and academic performance of school-children,

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which warrants further prominence in the context of the COVID-19 pandemic, as well as climate change. However, among the six domains of environmental health monitoring, the coverage of classroom microclimate monitoring was lowest (less than 40%), and the proportion in areas of lower SES was less than half than in wealthier areas. Investments are needed to reduce these regional disparities. We also found that monitoring of physical environment was better undertaken in senior secondary schools, rather than primary schools. The school physical environment supports the development of social–emotional environments that promote learning and student well-being,

which should also receive adequate attention from an earlier stage of schooling. Generally, the shift in health profiles in Chinese students towards non-communicable diseases, including common mental disorders, indicates that schools should include a wider focus on safety. This might include schools working to reduce the hidden spaces within physical environments in order to limit where bullying can occur and having school policies around responding to incidents of bullying. However, beyond safety, a wider focus within school environments warrants consideration. This includes approaches to promote student levels of physical activity at school, such as by having sufficient space for playgrounds and sportsgrounds, and by scheduling games and sports within the school curriculum. The only element within school physical environments that had coverage rates higher than 90% was monitoring of school canteen hygiene, which reflects the Chinese government’s emphasis on food safety.

Disappointingly, this item did not include attention to the nutritional quality of food that is available in schools, such as access to fresh fruit or foods and drinks that are low in salt, sugar and fat. At present, the government’s current attention on school food is from the perspective of health and safety, without including any standardised monitoring system or programme for the nutritional composition of school food.

The rapid transition in the weight and nutrition profile of China’s children and young people suggests this also warrants greater attention, including through establishing standardised monitoring.

A limitation of this study is that it took place in only 17 of China’s 34 provinces, and in selected districts within each province, as a result of it being based on the network of schools surveyed by the monitoring stations which at that time only covered 17 provinces. However, the sample was stratified by urban and rural areas and included all school types. In addition, since more excluded schools were from lower SES areas, the regional SES differences in the coverage of school health monitoring systems may be underestimated. A further limitation is the scope of the questionnaire, as many aspects that are now considered relevant to health-promoting schools were not monitored by this survey, such as policies on bullying, injury prevention, mental health and so on. The current monitoring systems for non-communicable diseases focus on student health examinations, without integrating these within a unified framework, such as health-promoting schools, which further limits the picture of non-communicable diseases monitoring in schools in China. In addition, many aspects of school health systems monitoring are unique to China, which limits comparison with other countries. However, a strength of this study is that it demonstrates that aspects of school health systems can indeed be taken to scale when supported by government investment in policy, implementation and monitoring systems, consistent with the recommendations within the new global standards for health-promoting schools.