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Continuing the studies on periodic medical examinations in schools,

Yankauer and his co-workers now deal with the health behavior and
attitudes of a sample of school children and their mothers. They
emphasize the need for flexibility in the entire school health
program, taking into account the needs of individual
schools and the populations they serve.



Alfred Yankauer, M.D., M.P.H., F.A.P.H.A.; G. Richard Wendt, Ph.D.; Herbert Eichler, M.S.;
Charles L. Fry, M.S.; and Ruth A. Lawrence, M.D.

THIS is the fourth report of a study In the course of each periodic medical
to evaluate periodic school medical appraisal, parental concerns were fully
examinations in the first four grades of explored and the values of preventive
elementary school. Previous reports health services were pointed up by the
have described this study in detail and public health nurse and pediatrician
analyzed the case-finding and follow-up working as a team.
aspects of four careful annual medical One of the stated purposes of periodic
appraisals performed on a 15 per cent school medical examinations is educa-
sample of children who were first grade tional in nature. As phrased by Wheat-
pupils in Rochester, N. Y., schools dur- ley some years ago, this purpose is to
ing the school year 1952-1953.1 All ap- "create in the child and the parents
praisals were performed by the same understanding and desire for preventive
pediatrician (R.A.L.). They included medical services."2 As expressed by
a detailed medical history from the par- Sellery, the physician should attempt
ent which was the joint responsibility "to make the examination a positive
of a public health nurse and pedia- educational experience for the child and
trician, as well as a physical examination his parents, where present, which will
of the child, procedures requiring an result in changed behavior."3 As stated
average of 30-40 minutes to complete. by the Joint Committee on Health Prob-
At the initial examination 81 per cent lems in Education of the NEA and
of the parents were present, and this AMA these examinations should "con-
figure was maintained or bettered at tribute to pupils' understanding of the
subsequent examinations. Ninety-three health professions and of ways to protect
per cent of the parents were present at and improve health. Pupils develop
two or more examinations. Parents feelings of respect toward physicians
unable to attend an examination com- and nurses if their school experiences
pleted a detailed health questionnaire. with these individuals are pleasant and

1532 VOL. 51. NO. 10. A.J.P.H.


satisfying."4 Many similar statements with this study. These control group
may be found in the literature on school children had been examined by their
medical services. private physician or a school physician
The careful annual medical examina- on entrance to school and again in the
tion of 617 children for a period of four fourth grade as part of the routine school
years (through fourth grade) provided medical service program of the Rochester
an unusual opportunity to evaluate the City Health Bureau (now Monroe
educational effects of such an experience. County Health Department). Some chil-
The two hypotheses to be tested were dren in both the experimental and con-
that four intensive annual school medi- trol groups had had contact with the
cal examinations from the first through regular school physician or nurse be-
fourth grades resulted in (1) changed cause of special problems. In so far as
family behavior in the direction of possible, equal numbers of experimental
securing more adequate total health and control subjects were drawn from
care for children, and (2) changed the same school.
family attitudes toward health profes- Mothers were interviewed in their
sions and health concerns in the direc- homes, and most of the interviews were
tion of more positive attitudes. collected during the winter and spring
of 1957. The remainder were collected
Material and Methods the following school year. In general,
the interview occurred from 8 to 18
The study to be reported was carried months after the last periodic school
out through the Department of Psy- medical examination of the children in
chology of the University of Rochester the experimental group and from 20 to
by individuals who had no prior associa- 30 months after the fourth-grade medi-
tion with the examiners or planners of cal examination of children in the con-
the other aspects of this study or with trol group. Interviewing was conducted
the families themselves. primarily during the day. To avoid
The experimental sample was drawn exempting working mothers from the
from among the 617 mothers of children study, interviewers were instructed to
on whom four annual study examina- check back during the evening on all
tions had been recorded. These chil- mothers not available during the day.
dren had all been in the first grade at There was no precontacting of mothers.
the beginning of the initial study. At The interviewer presented himself as
the time the collection of these data was one making a survey of health needs
begun, they were in the fifth grade. and problems and did not refer to school
The control sample was drawn from medical services until general health atti-
the mothers of children attending the tudes and behavior had been probed. At
same schools as the experimental chil- no time was the study itself referred to
dren. As the experimental children con- directly. Thirty different questions
stituted virtually the entire fifth grade, were asked in the interview.
the control children were drawn from A total of 596 interviews was at-
the sixth grade. As the experimental tempted. Interviewers failed to get in-
children had been in attendance at the terviews with 71 mothers originally
same school for a minimum of four selected for the experimental sample and
years, the same stipulation was applied 82 mothers originally selected for the
to the control children. None of the control sample. Inability to contact the
mothers or children in the control mother was the principal cause of inter-
group had had contact with the pediatri- view failure. Refusal accounted for
cian or public health nurse associated only 6 per cent of the failures.

OCTOBER, 1961 1533

Table 1-Distribution of Family Socioeconomic Status in Experimental and Control

Warner Index of Status Characteristics Scores

Group 10-19 20-29 30-39 40-49 50-59 60-69 70-79 N Mean Sigma

Experimental 0 14 27 48 80 52 5; 226 50.19 11.64

Control 1 12 29 49 79 45 2 217 49.67 11.34

Total 1 26 56 97 159 97 7 443

In all, there were 226 completed in- pletion items were scored independently
terviews with mothers in the experi- by three judges who classified responses
mental sample and 217 with mothers in to five of the eight completion items as
the control sample. All families were showing positive affect, negative affect,
scored for socioeconomic status by the mixed affect, or no affect. The judge's
Warner Index of Status Characteristics.5 classifications were identical 95 per cent
The distribution of the status charac- of the time. The data were then ana-
teristic scores in experimental and con- lyzed by comparing results in the experi-
trol groups is shown in Table 1. mental and control samples.*
Interview data were analyzed in two
ways: by comparing responses of the Results
experimental and control samples; and
by comparing responses of the highest Mothers of children in both groups
and lowest socioeconomic thirds of the reported the same frequencies of medi-
total sample. cal visits (for both illness and "check-
The attitudes of the children them- up") and dental visits to community
selves were probed through a short writ- doctors and dentists. Although chil-
ten questionnaire administered in the dren in the control group were reported
late spring of 1957, by the classroom to have had more medical "check-ups"
teacher to all children in the grades from within the year preceding the interview,
which the sample was drawn. The this was probably a reflection of the
teachers were asked to distribute the special school examinations given them
question sheet without referring to any since there were no significant differ-
study or test and merely state that the ences in the proportion of children re-
health department was trying to find out ported to have had "check-ups" within
how the children felt about doctors and the six months preceding the interview
health problems. The questionnaire it- (Table 2). Of more significance is the
self consisted of a series of eight sentence fact that 78 per cent of the mothers in
completion items such as: "When I go the control group reported that their
to see a doctor I feel ..............," child had received a medical "check-up"
"Doctors are .............-," and two within one year of the interview. None
direct questions asking how often doc- of these check-ups could have been re-
tors and dentists should be seen for ceived as part of the routine school
"check-ups." Of the 443 children whose medical program.
parents were interviewed, 87.5 per cent * Copies of the instruments used with both

returned completed questionnaires which mothers and children and a tabulation of

responses to all questions are available on
could be analyzed. The sentence com- request to the senior author.

1 534 VOL. 51. NO. 10. A.J.P.H.


Table 2-Reported Interval Between Interview and Last Medical "Check-

Up" in Experimental and Control Groups

Per cent Reporting "Check-Up" Within:

6 Months 7-12 Over 12
Group N or Less Months Months Total

Experimental 226 48 43 9 100

Control 217 44 34 23 101
Total 443 46 38 16 100

X2 (Total distribution) = 16.51

P= 0.01
P (6 months or less) =12.5 (n.s.)

A slight difference of borderline sta- flicting. No significant difference in re-

tistical significance in the number of sponse to the question, "How often do
polio shots received was reported (Table you feel children of (your child's) age
3). In view of the fact that polio im- should see a doctor (or dentist) for a
munization was stressed each year at check-up?" was apparent. However, in
the special periodic medical examina- response to the question (asked at an-
tion, it is not surprising that some dif- other point in the interview), "What
ferences between the two groups should do you feel is the longest time that
be reported. A similar relationship did should go by before (your child) should
not hold with respect to dental check- see a doctor (or dentist) ?," 8.5 per cent
ups (although this was also stressed at of the experimental group answers were
the special periodic medical examina- more favorably slanted than the control
tion). As shown in Table 4, no differ- group answers, a difference of border-
ences between experimental and control line statistical significance.
groups are apparent, but a highly sig- The remainder of the interview dealt
nificant differential by social class is with the mothers' knowledge of and
evident. Significant differences in medi- attitudes toward the school health serv-
cal and dental behavior by social class ice itself. No differences between ex-
existed in every area of behavior
probed. They were strongest in the area
of dental care. Table 3-Reported Number of Polio
The attitudes of mothers and of chil- Shots Received by Children in Experi-
dren (as reported by their mothers) mental and Control Groups
toward medical and dental health super-
vision and toward physicians in general Number of Polio
were probed in several areas. General Shots Reported
feelings about physicians, family doc- Group 1 2 3 Total
tors, and specialists were on the whole
positive and did not differ significantly Experimental 15 37 174 226
between experimental and control Control 25 49 143 217
groups. There was some slight evidence Total 40 86 317 443
of a difference in opinion as to the ideal
frequency of dental and medical "check- X2 =7.03
ups" in children, but the data are con- P =0.03

OCTOBER, 1961 1 53S

Table 4-Reported Number of Dental "Check-Ups" Received in Past Five
Years by Children in Experimental and Control Groups and in High and
Low Socioeconomic Thirds

Number of Dental Check-Ups

Group 1-2 34 5 or More None Total

Experimental 21 19 174 12 226

Control 23 23 162 9 217
Total 44 42 336 21 443
High S-E status 4 6 136 2 148
Low S-E status 26 18 92 12 148
Total 30 24 228 14 296

p =<0.01

perimental and control groups were ap- or some comparable response while only
parent except for some slight indication three in the entire sample responded
that mothers in the experimental group with negative affect. Almost half the
had a more favorable impression of children wrote that they felt "secure"
school doctors than those in the control or "calm because I know he will help"
group (Table 5). That some confusion when they saw a doctor (Table 8).
and inconsistency existed about school There were no differences between the
health services in the minds of all the groups in these responses.
mothers queried is indicated by a sum- In response to completion items about
mation of responses of the total sample women doctors and school doctors, more
to a series of statements summarized in control group children wrote that they
Table 6. The majority of these re- had never seen one or confused women
spondents seemed to derive some feel-
ings of security from having a doctor in
school who examined their children, but
in the light of their responses to other Table 5-Response to Question: "Do you
Feel a School Doctor Would Give Your
items, it is difficult to explain the reasons Child as Good a Check-Up as Your Own
for such feelings. Doctor Would?," in Experimental and
The questionnaire responses of chil- Control Groups
dren in the experimental sample did
not differ significantly from those of the Per Per
control sample except in one respect. cent cent
In both groups the vast majority of chil- Group Number Yes No Total
dren stated that medical and dental Experimental 226 57 43 100
check-ups should be done once or twice Control 217 46 54 100
a year (Table 7). The sentence com-
pletions reflected favorable and trust- Total 443 52 48 100
ing attitudes toward doctors. Close to
90 per cent of the children wrote that X2=5.36
doctors "helped us" or "made us well" P =0.02

1536 VOL. 51, NO. 103 A.J.P.H.


doctors with nurses. In completing the difficult to evaluate. This difficulty stems
statement, "The school nurse ...............," from the crudeness of present working
control group children tended more to tools of measurement. However, it is
respond with a factual statement of her only by applying existing tools that they
name or duties, while 84 per cent of the can be improved and refined. Con-
experimental group children responded clusions drawn from the data presented
with positive affect (as against 72 per previously must be qualified. Although
cent of the control group children). the interview and questionnaire re-
Thus the questionnaires could be said sponses in experimental and control
to discriminate slightly between the two groups were not differentiable in gen-
groups but only by virtue of the items eral, a dogmatic assertion that periodic
which pertained directly to the four school medical examinations have no
annual school medical examinations educational value would not be justified.
themselves. It seems reasonable to state, however,
that any effect of such a program upon
Discussion the health attitudes or behavior of par-
ents and children as a group phe-
The attainment of educational objec- nomenon is neither marked nor easily
tives, particularly when they involve identifiable. The annual interview with
motivation and behavior, are notoriously parents and the unusually careful health

Table 6-Response of Total Sample to a Series of Statements About

School Health Services
Response (N = 443)
Per cent Per cent
Statement Agree Disagree Total

1. School health service's primary job

is to prevent spread of disease in
schools. 76 24 100
2. Medical check-ups should be given
to all grammar school children by
school doctor. 77 23 100
3. School doctors do their best, but
have so many to take care of that
they cannot give a really good medi-
cal check-up, i.e., one that can tell
much of anything.* 68 32 100
4. School medical examinations are im-
portant mostly for children of par-
ents who are not concerned enough
about health 70 30 10)
5. Many people feel health is a per-
sonal and family responsibility and
that medical check-ups should be
given by private doctors, not the
school health service. 33 67 100
* Response to this statement revealed a difference between experimental and control groups of
similar magnitude and significance to a prior question (see Table 5). There were no differences
between the two groups in response to the other four statements.

OCTOBER. 1961 1537

Table 7-Percentage Distribution of Ex- ing used by Friedson and Silver to ex-
perimental and Control Group Children plain the paradoxical use of outside
Responses to Questions on Ideal Fre- medical services by medical group en-
quency of Medical and Dental "Check-
Ups" rollees in the Montefiore Family Health
Maintenance Demonstration.6 The ques-
Experimental Control tions themselves pose ambiguous situa-
Frequency of Group Group tions in which anxiety, simple con-
"Check-Up" (N = 174) (N =209) venience, and the extra insurance of
another opinion could play a decisive
Medical 100 100 role in decision making and thus con-
Semiannual 71 65 travene straightforward logical answers.
Annual 22 30
Biannual 1 3 Three other aspects of these data de-
"When sick" 4 2 serve comment. The fact that a high
Not answered 2 proportion of urban school children
(whether receiving periodic school medi-
Dental 100 100 cal examinations or not-see Table 2)
Semiannual 88 85
Annual 7 10 had received a recent medical "check-
Biannual 1 1 up"7 was not unanticipated. Although
"When needed" 3 3 previously unreported, this has been a
Not answered 1 1 constant feature of the data collected in
Rochester. It is paralleled by similar
findings from an unreported longi-
tudinal study in Albany, N. Y.;7 data
examination which these children re- collected in two rural areas in Cali-
ceived lends added weight to such a fornia;8 and experiences in a suburban
statement. It should also be pointed out county in Maryland.9 It serves to em-
that acceptance of polio vaccination (as phasize the fact that the contacts of
well as other preventive health meas- school children with doctors and nurses
ures) can be promoted among school (in health as well as in disease) are far
children by means other than a medical greater outside of school walls than
examination. within them, whether they receive regu-
The perception of school health and
physician services by mothers in our
sample was confused. Thus they ex-
pressed a desire to have a school physi- Table 8-Percentage Distribution of Ex-
cian examine their child in spite of the perimental and Control Group Children
fact that the family physician had al- Responses to Completion of Sentence:
"When I go to see a doctor I feel.... "
ready done so and the belief that the
school physician was too overworked to Experimental Control
"tell much of anything" (Table 6). Nature of Group Group
Again to the following question, "If the Response (N=174) (N =209)
school nurse or doctor got in touch with
you and told you something was wrong With positive affect 49 48
with your child and your own doctor With negative affect 22 24
disagreed, what would you do?," half With mixed affect 2 3
Factual only (no
the respondents stated they would be- affect) 24 24
lieve their own doctor and half said Not answered or
they would consult another doctor. illegible 2 1
These responses can probably be ac-
counted for by the same sort of reason- Total 99 100

1 538 VOL. 51. NO. 10. A.J.P.H.


lar annual school examinations or not. frequency of periodic medical examina-

This implies that if a medical examina- tions) on a state-wide basis. Even
tion of a school child is expected to within a single city clear indications for
"create . . . desire for preventive medi- varying the health program from school
cal services," "result in changed be- to school are bound to exist.
havior," or "contribute to pupil's under- Although interview responses did not
standing . . . of ways to protect and discriminate between experimental and
improve health" (hypotheses which control groups, they did discriminate
badly need to be tested), the medical sharply between the health behavior of
examinations done outside of school high and low socioeconomic groups.
may be the ones on which to concentrate This serves to further reinforce the need
school and classroom attention. for tailoring all features of a school
This inference is reinforced by the health program to the individual school.
data which reflected a somewhat more Residential segregation of socially, eco-
favorable attitude toward school doctors nomically, and ethnically stratified
and nurses in the experimental group on groups is an unpleasant and unfortunate
the part of both mothers and children. by-product of urban-metropolitan area
Since the school service extended to the living. Previous reports in this series
experimental group was unusually inten- failed to demonstrate significant differ-
sive and involved the services of a ences in the actual health of children in
woman doctor, the differences them- schools of differing socioeconomic neigh-
selves are not surprising. However, borhoods in Rochester. However, many
there is no evidence that the experiences studies too numerous to cite, reinforce
and feelings generated by this special our finding that less desirable behavior
program were generalized to health and attitudes toward preventive services
services or health personnel in extra- are found more commonly among under-
mural contexts or resulted in changed privileged social class groups.
behavior. It may be that a health ex- In conclusion it should be emphasized
amination in a school situation by a doc- that these study findings and implica-
tor who has no relationship with the tions should not be applied to any type
family or child during illness should not of mass rapid screening program of
be expected to "develop feelings of re- school children. Vision and hearing
spect toward physicians" in general, and screening tests, for example, lend them-
so on, simply because the school physi- selves well to health education technics
cian is perceived only as a part of the because of their specificity and their in-
school itself and not associated with a volvement of an entire class over a short
broader perception of health and health time span. Neither are these findings
personnel. In any case our data have applicable to intensive counseling serv-
clearly failed to support the hypotheses ices rendered by the school physican
tested. and nurse to the relatively small num-
Since there may be regional and local bers of selected families with special
differences in health behavior and the problems. With them, as reported pre-
extent of regular medical supervision, it viously, a single successful result speaks
becomes important to know the existing for itself.""' Above all, they are not
state of affairs and to design a program applicable to school medical and health
that will allow for and capitalize upon services for older age groups where the
it. Such a flexible and realistic ap- advent of adolescence with its unique
proach to a school health program is health problems and psychology may
greatly handicapped by state laws which call for very different programs and ap-
mandate program details (including the proaches.

OCTOBER, 1961 1 539

This study and the three previous re- restated. It appears more important to
ports in this series reflect upon the in- tailor all features of a school health pro-
discriminate overuse of physicians and gram (including the frequency of
nurses in elementary schools during the periodic medical examinations) to the
so-called "middle-years" of childhood needs of individual schools and the com-
to examine complete grades of children munities they serve than to follow a set
at frequent intervals. At the least, the and standardized pattern of frequent ex-
findings make it imperative for those aminations whose case-finding and edu-
who favor such a program to produce cational values are dubious.
objective data of its case-finding and
educational values so as to justify their ACKNOWLEDGMENT-The help of the follow-
opinions. ing individuals and agencies in planning and
carrying out these studies is gratefully ac-
knowledged: Dr. Margaret Rathbun; Lillian
Summary Ballou, R.N.; the Monroe County Department
of Health; the Rochester Board of Education;
1. A sample of mothers whose chil- and the Diocese of Rochester.
dren had received four special annual
school examinations in the first four REFERENCES
grades of elementary school and a 1. Yankauer, A., and Lawrence, R. A. A Study of
sample of mothers from the same Periodic School Medical Examinations: I. Methodology
and Initial Findings. A.J.P.H. 45:71-78 (Jan.), 1955.
schools, whose children had received no II. The Annual Increment of New "Defects." Ibid.
46:1553-1562 (Dec.), 1956. III. The Remediability of
such service, were interviewed. The Certain Categories of Defects. (With L. Ballou.)
interview probed various facets of the Ibid. 47:1421-1429 (Nov.), 1957.
2. Wheatley, G. M. The Physician and School Medical
health behavior and attitudes of the Services. New England J. Med. 236:305-310 (Feb. 27),
mothers and their children. 1947.
3. Sellery, C. M. Role of the School Physician in
2. The children of the mothers inter- Today's Schools. A.J.P.H. 42:813-817 (July), 1952.
viewed were given a questionnaire in- 4. Wilson, C. C. (Ed.). School Health Services. Report
of the Joint Committee on Health Problems in Edu-
tended to elicit feelings and informa- cation of the National Education Association and the
tion about health personnel and services. American Medical Association with the cooperation of
contributors and consultants. Washington, D. C.: Na-
3. No significant differences between tional Education Association, 1953.
the responses of mothers or children in 5. Warner, W. T.; Meeker, M.; and Eells, K. Social
Class in America. Chicago, Ill.: Science Research
the two groups were apparent, but sig- Associates, 1949.
nificant differences in many maternal 6. Friedson, E., and Silver, G. A. Social Science in
Family Medical Care. Pub. Health Rep. 75:489-493
responses by socioeconomic group ex- (June), 1960.
isted for the entire sample. 7. An Evaluation of Case-Finding Methods in Elementary
Schools. A Longitudinal Study. New York State De-
4. The implications of these findings partment of Health. (Study in process.)
and previous reports in this series are 8. Poole, B. D.; Montgomery, T. A.; et al. School
Health Studies in Two Rural California Counties.
discussed. The argument against fre- (To be published.)
quent periodic school medical examina- 9. Mitchell, H. H., and Peeples, W. J. Newer Concepts
of School Health Services. J.A.M.A. 171:2060-2064
tions in the middle childhood years is (Dec. 12), 1959.

Dr. Yankauer, formerly with the New York State Department of Health,
Albany, N. Y., is now regional adviser in maternal and child health, Pan
American Sanitary Bureau, Regional Office of the World Health Organization,
Washington, D. C. Dr. Wendt is professor of psychology; Dr. Lawrence is
instructor of pediatrics, School of Medicine and Dentistry; and Mr. Eichler
and Mr. Fry were graduate students in psychology at the time of this study;
all of the University of Rochester, Rochester, N. Y.
This paper was presented before the School Health Section of the American
Public Health Association at the Eighty-Eighth Annual Meeting in San
Francisco, Calif., November 1, 1960.

1540 VOL. 51, NO. 10, A.J.P.H.