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Indian Journal of Community Medicine

Proxy Information of Health Problems in School Children from Parents using Questionnaire and Interview Technique

Author(s): Vandana Kakrani, Sudesh Gandham, Geeta Bhat, Shrikar Pardeshi

Vol. 26, No. 1 (2001-01 - 2001-03)

Deptt. of Preventive and Social Medicine, B.J. Medical College, Pune.


Research question: What is the difference in the information obtained from the questionnaire, an interview and a clinical examination regarding the health problems of school students?

Objective: Identify and compare information from the questionnaire, an interview and a clinical examination regarding the health problems of school students.

Design: Cross-sectional.

Setting: A convent school for boys in Pune.

Participants: First and fifth standard students.

Study variables: Health problems, history of operations.

Statistical analysis: Standard error of difference between two proportions, McNemars chi-square test.

Results: After comparing the responses in 361 subjects, there was a significant discordance in the overall information obtained from the questionnaire and interview technique. However, a concordance was observed between information on major health problems and history of operations. Majority of the refractive errors, dental problems and malnutrition were detected only on clinical examination. Parents tend to mention skin problems and behavioural problems only during the face to face interviews.

Conclusions: A questionnaire sent home to be filled by parents successfully brings forth information regarding major health problems and history of operations. A carefully conducted clinical examination can detect problems such as refractive errors, dental problems and malnutrition. Training the school teachers to observe for specific problems missed by these techniques i.e. skin problems and behavioural problems and to focus on these issues during each parent-teacher interaction would complement the school health check-up and make it more successful.

Keywords: Proxy information, Health problems, School children


The responsibility for the health of the child rests with the home, the community and the school. The school health services consist of a broad range of activities including examination and procedures necessary to determine the health status of each child1.

Apart from the limited time and resources the medical examination carried out by physicians of the local health departments are limited in scope because the pupil examined is unknown to the physicians2. One of the parental functions in school health services is the parent's willingness to supply information concerning the pupil's illness, injuries, operations, possible physical difficulties, health habits and emotional health problems. This information should be placed in the pupil's health history.

While it is accepted that persons reporting their own experiences respond more fully than those by proxy, certain groups may be considered unreliable or inadequate informants in their own right3,4. Children form one such group5. As most health care is carried out by parents, they are usually assumed to be the best proxy informants of childhood illness. This is especially true of children attending the primary and elementary school.

The parents' co-operation will add to the success of the school health check-up. Ideally the parents should be present at these medical examination sessions. Questions can be asked by or directed to the parents and direct relevant advice given to them2. This, however, may not be feasible in all circumstances. Another emerging trend is to send a questionnaire through the pupil to be filled by their parents. More commonly the parents play no role in the school health check-ups.

Material and Methods:

The study was carried out in a convent school for boys in Pune in the month of July 1999. The first and fifth standard students of the school were included in the study. The study was carried out in four phases:

In phase one, a questionnaire was sent to the parents through their ward. The questionnaire sought information regarding relevant past history, operations in the past, any major handicap and present complaints.

A week later, in phase two, a health check-up of the students was organised. The parents were requested to be present during the health check-up. The health check-up included history taking, general and systemic examination as well as dental, ophthalmic and E.N.T. check-up.

The parents who accompanied their wards were interviewed regarding the health status of their wards in the third phase.

In the last phase the information from the three sources was reviewed, appropriate diagnosis was made and referrals, investigations and treatment carried out as necessary.

An attempt was then made to compare the information obtained from the questionnaire sent to the parents, interview of the parents and findings of the clinical examination.

The school authorities should be aware of certain health conditions of the children which may require immediate or emergency treatment, result in restrictions on physical activity or require supervision in rehabilitation etc. These include major problems such as bronchial asthma, convulsions, congenital heart disease, hearing impairment and refractive errors. It is of utmost importance that parents communicate the vital information regarding these health problems to the school authorities. These major health problems were considered as a separate category during analysis. Similarly, past history of operations was analysed separately. The class teachers were interviewed to assess their awareness regarding these health problems.

The statistical analysis was done using standard error of difference between two proportions and McNemars chi square test.


There were 192 students in the three divisions of the class five and 179 students in the three divisions of class one. Thus a total of 371 students were present in the two classes. Amongst these, all parents answered the questionnaire except one parent of a class five student. On the day of the health check-up, 10 children of class five were not accompanied by their parents and hence could not be interviewed.

The analysis of the information of 182 students of class five and 179 students of class one is presented here. The mean age of class one students was 6 years and class five students was 10 years.

Amongst the parents 238(66%) of the fathers and 209(58%) of the mothers were educated above the secondary school level. 202(56%) of the fathers were either in government or private service and 256(71%) of mothers were house-wives.

Table I: Information regarding health problems of the class one and five students.

Health Problems First standard Fifth standard
Questionnaire Interview *O/E (n=179) Questionnaire Interview *O/E (n=182)
Respiratory system 1 1 1 2 2 0
Cardiovascular system 1 1 1 2 2 2
Central nervous system 1 1 0 1 1 0
History of operations 2 6 NA 3 11 NA
Eye problems 2 4 47 7 11 45
Ear Nose Throat 0 7 14 0 12 16
Skin 0 3 3 0 2 3
Dental 0 35 102 1 43 128
Malnutrition 0 19 30 0 20 32
Behaviour problems 0 17 NA 0 4 NA
Swelling in the neck 0 2 2 0 2 2
Others 7 8 10 6 9 10

*O/E - On clinical examination.

The health status of the students obtained from different sources is given in Table I. There was a significant difference between the information obtained from the questionnaire and interview techniques (p<0.05). More number of parents tend to mention their complaints at the time of face to face interview (204 i.e. 56.5%) as compared to a questionnaire sent home (52 i.e. 14.4%).

Table II: Concordance of information from questionnaire and interview.

First standard Fifth standard
Questionnaire Interview (complaints) Questionnaire Interview (Complaints)
Complaints Present Absent Total Complaints Present Absent Total
Present 16 0 16 Present 36 0 36
Absent 60 103 163 Absent 92 54 146
Total 76 103 179 Total 128 54 182
Mc Nemar's X2= 58.01, d.f.=1, p<0.05 Mc Nemar's X2=90, d.f.=1, p<0.05

When data was compared using McNemar's test, there was a significant lack of concordance between the information obtained using the two techniques i.e. questionnaire and interview technique (Table II).

Table III: Concordance of information of major problems obtained from questionnaire and interview.

First standard Fifth standard
Questionnaire Interview (complaints) Questionnaire Interview (Complaints)
Complaints Present Absent Total Complaints Present Absent Total
Present 5 2 5 Present 7 0 7
Absent 2 172 174 Absent 4 171 175
Total 7 172 179 Total 11 171 182
Mc Nemar's X2= 0.5, d.f.=1, p>0.05 Mc Nemar's X2=1, d.f.=1, p>0.05

A comparison of data on important health problems, which the school authorities should be aware of, was done. There was a concordance between the information obtained from the questionnaire and the interview. the parents tend to successfully communicate information on these problems to the school authorities (Table III).

Table IV: Concordance regarding history of major operations in the past-questionnaire and interview technique.
First standard Fifth standard
Questionnaire Interview (complaints) Questionnaire Interview (Complaints)
Complaints Present Absent Total Complaints Present Absent Total
Present 6 0 16 Present 11 0 11
Absent 2 171 163 Absent 3 168 171
Total 8 171 179 Total 14 168 182
Mc Nemar's X2= 0.5, d.f.=1, p>0.05 Mc Nemar's X2=1.33, d.f.=1, p>0.05

In only 12 (30%) cases, the teachers were aware of the vital information regarding health of students and operations they had undergone. A similar concordance was seen when the information on past history of operation was compared (TableIV).

Table V: Findings on interview of parents and clinical examination of the students for ophthalmic problems, dental problems and malnutrition.

Health problems First standard Fifth Standard
Interview *O/E P Interview *O/E P
No. (%) No. (%) No. (%) No. (%)
Eye problems 4 (2.23) 47 (26.25) >0.05 6 (3.3) 45 (24.72) >0.05
Dental problems 35 (19.55) 102 (56.98) >0.05 43 (23.6) 128 (70.3) >0.05
Malnutrition 19 (10.6) 30 (16.76) >0.05 20 (10.9) 32 (17.6) >0.05

*O/E - On clinical examination.

A majority of the ophthalmic problems, dental problems and cases of malnutrition were detected only after clinical examination. These were not reported by the parents either in the questionnaire or the interview (Table V).

The parents reported about the complaints of skin rash with itching (8), swelling in the neck (4) and throatache (7) in their children. In 21 cases, parents reported behavioural problems. Of these 15 were complaints of bedwetting and others were nail biting (4) and thumb-sucking (2). This information was important in drawing attention to relevant health problems.


The questionnaire, which was sent home with the child to be filled by the parents, brought out relevant information on major illnesses and operations. This method, therefore, can be used to successfully communicate the information of the relevant diseases to the school authorities.

The presence of parents during the health check-up helps in drawing attention of the examining doctors to habit problems, skin infections etc. which may need counselling, health education and treatment. These problems are usually not mentioned in the questionnaire sent home.

Certain conditions like refractive errors, dental caries and malnutrition are detected only on careful examination of the child. The presence of parents during the check-up helps in interacting with them on these issues which need careful discussion, intervention and change in lifestyle.

Definitions and reporting of change or illness are not imitable, but vary in several ways. The more salient an illness the more accurately will it be reported. Serious disorders are better reported in contrast to those that are less persistent or illdefined6. Decision to report or inform an illness will depend upon many factors. These could be age of the child, frequency and intensity of symptoms, degree of functional impairment it causes, amount of distress it causes to the children, parents and teachers as well as the past experiences in discussing the problems with their physicians.

In a study, parents tended to over-report longstanding illness but not limiting longstanding illness in comparison to the self reports by their 15 year old children4. In a study which compared reports from school children aged 11 and their parents, the latter reported similar levels of (limiting) longstanding illness and parent-child agreement was greatest for the presence of longstanding illness and conditions of asthma, diabetes and skin problems. The agreement was lower for recent symptoms categorized as malaise. The study concluded that illness reporting depends on various factors including saliency, social disability and definitions of normality7.

Dental caries was a very common problem, which many of the parents failed to mention in their questionnaire and the interview. It is important to increase their knowledge and awareness on this subject using appropriate channels of education. The parents reported bedwetting amongst their children in 15 cases. Other habit problems like thumb sucking, nail biting are described as tension discharging phenomena8. Working with parents and teachers to help them improve their understanding of developmental issues and using improved methods of training may prove to be important solutions9.

Ideally the parents of the pupil should be present during the school health check-up. They assist the physician in making the correct diagnosis by providing relevant information and appropriate advice can be given to them.

If this is not feasible, a questionnaire sent home through pupils would at least succeed in communicating information regarding important health problems to the school authorities. Some of the problems such as dental caries, refractive errors etc. can be detected by clinical examination. The teachers can be trained to observe and identify specific problems likely to be missed by both techniques. They can focus on these specific problems during each parent teacher interaction. These and other such modifications will make the school health check-ups more successful.


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  3. Nelson LM, Longstreth WT, Koepsell T, Belle G. Proxy respondents in epidemiologic research. In: Armenian H, Leon G, Myron ML, Stephen BT, editors. Epidemiologic Reviews. Vol. 12; 1990. p.71-86.
  4. Ecob R, Macintyre S, West P. Reporting by parents about longstanding illness of their adolescent children. Soc Sci Med 1993; 36: 1017-22.
  5. Cunningham BS, Maclean V. Dealing with children's illness: Mothers' dilemmas. In: Wyke S, Hewison J, editors. Child Health Matters, Miton Keyes. Open University Press; 1993. p.29-39.
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  8. Nelson WE, Behrman RE, Kliegman RM, Arvin AM. Nelson Textbook of Paediatrics, 15th ed. London: W.B. Saunders Company; 1995. p.77-98.
  9. Solnet A, Provence S, Schowalter J. Psychological development. In: Rudolph A, Hoffman J, editors. Paediatrics. 18th ed. USA: Appleton and Lange; 1987. p.58-9.
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