Abstract
Objective
To assess the national inequality of school readiness and autism among 6-year-old Iranian children before school entry using a national health assessment survey.
Methods
In a cross-sectional nationwide survey, all Iranian children entering public and private elementary schools were asked to participate in a mandatory national screening program in Iran in 2009 in two levels of screening and diagnostic levels.
Findings
The study population consisted of 955388 children (48.5% girls and 76.1% urban residents). Of the whole children, 3.1% of the 6-year-old children had impaired vision. In addition, 1.2, 1.8, 1.4, 7.6, 0.08, 10, 10.9, 56.7, 0.7, 0.8 and 0.6 percent had color blindness, hearing impaired, speech disorder, school readiness, autism, height to age retardation, body mass index extremes, decayed teeth, disease with special needs, spinal disorders, and hypertension, respectively. The distribution of these disorders was unequally distributed across provinces.
Conclusion
Our results confirmed that there is an inequality in distribution of school readiness and autism in 6-year-old children across Iranian provinces. The observed burden of these distributions among young children needs a comprehensive national policy with evidence-based province programs to identify the reason for different inequality among provinces.
Keywords: National Health Assessment Survey, School Readiness, Autism, Children, Inequality, Iran
Introduction
Representative and valid information at the population level is essential for health planning and priority setting for interventions to control diseases, and for population-based evaluation of health programs[1]. National representative studies may help to have a view on these health concerns at national and regional levels. These national health surveys might prepare reliable information for policy making1–9].
Autism prevalence is not the same in different countries, for example the prevalence of autism-spectrum disorders (ASDs) in the UK is 1 percent[10] but 8.0 per 1000 (among 4-year-old) and 7.0 per 1000 among 8-year-olds in South Carolina[11]. Children with ASDs have at least as many comorbidities as individuals with typical development may show, but sometimes with different presentations[12]. Those children who show disproportionate difficulty with the pragmatic as compared to the structural aspects of language are described as having pragmatic language impairment (PLI) or social communication disorder (SCD); among them, some who have PLI also show mild social impairments associated with high-functioning autism or ASD[13]. The impairments in social cognition and social skill that characterize autism spectrum disorder extend in milder forms to the broad autism phenotype in the general population and suggest a framework for understanding how social broad autism phenotype traits may manifest in diminished social ability[14]. In addition, children with average development, both with and without autism, had lower adaptive skills than expected for their developmental level[15]. On the other hand, mothers of children with autism report higher levels of depression than mothers of children with other developmental disabilities[16]. Research has shown that a 20-week parent education program including skills training for parents of young children with autistic disorder provides significant improvements in child adaptive behavior and symptoms of autism for low-functioning children[17]. Therefore, it is important to find these children as soon as possible, especially at pre-school ages.
Although, there are some Iranian health surveys available, most of which have been limited to one city and thus their results could not be generalizable to the whole country[18–20]; however, there are also some national studies which have considered all Iranian provinces[21–23]. Some of these studied only adult people[24–27] or only on special diseases such as childhood dental problems[28] or overweight and obesity[21, 22, 29]. Moreover, developing countries including Iran are facing with epidemiologic transition in disease and nutritional patterns [30], which in turn would raise the necessity for conducting a representative and comprehensive national health survey. Since Iran is a big country, taking into account the great diversity in socioeconomic and demographic factors in different provinces, it is expected to observe a substantial inequality in disease and disorder distribution across Iranian provinces. The aim of this study was to assess the potential national inequality of school readiness and autism in 6-year-old Iranian children before school entry across Iranian provinces using national health assessment survey.
Subjects and Methods
The data were collected as a nationwide screening program. This program is regularly performed by the Ministry of Health and Medical Education and the Ministry of Education and Training among all children entering elementary schools. The number of health employees who helped to conduct this survey was 5582 health workers through Iran in health centers. All Iranian children entering elementary school were studied. As elementary education in Iran is mandatory; thus the study population comprised all children entering public and private elementary schools. During summer 2009 (for three months), in 823 centers and 712 cities and regions, 955388 Iranian children entering elementary schools have been assessed physically and mentally by 5582 skilled health care staff.
The assessment had two levels: introductory (screening) and diagnostic levels. In the first level, probable diseases and disorders have been screened (in 13 different aspects) and potential patients were sent to verify their possible problems in the second level. The diagnosed patients then were referred to specialists for further treatment and some advices were given to their parents. Ethical committee of Iranian Health Ministry has approved this survey with regard to ethical considerations. The national Data and Safety Monitoring Board closely supervised the quality control and quality assurance of each survey. At first, the data-checking process was conducted at the provinces every week and then at national level monthly. The analysis has been done after editing.
Overall health assessment, primary assessment (impaired vision, color blindness, hearing impaired and autism), school readiness assessment include current problems with potential reasons (low score, no corporation, higher age, insufficient language understanding, sensorimotor disorders and others), expert evaluation result (normal, unapt, confidential refer to school, be trainable, test/temporary, re-evaluation, refer to special school), combinations of disabilities (refer to normal/special school or re-evaluation) include visual-hearing, visual-school readiness, hearing-school readiness, and visual-hearing-school readiness disorders, autism's expert evaluation normal, confidential refer to normal/special school and autistic), mental illnesses (diagnosed or suspected) include severe mental disorder, mild mental disorder, epilepsy, mental retardation and other mental illnesses, and psychology results include separation anxiety disorder, mood disorder, hyperactivity and attention deficit disorder, epilepsy, conduct disorder and obsession disorder were the considered health problems which were taken into account by general practitioner.
The children have been referred to specialists to give the readiness score available. The specialists have taken into account overall assessment scores by sex, preschool education, father's and mother's education (illiterate, reading and writing, primary school, high school, diploma, associate degree, BSc, MSc, and above), father's occupation (unemployed, dead, employed and retired), mother's occupation (dead, housekeeper, retired and employed), number of family members (from 2 to 9 and more), parity number (from 1 to 8 and more) and residency.
The data were analyzed using the Statistical Package for Social Sciences (SPSS) software package version 18.0 (SPSS Inc., Chicago, IL, USA).
Findings
Main characteristics of national health assessment survey on Iranian 6-year old children before entering school in 2009 are shown in Table 1. Of 955388 Iranian children aged 6 years, 50.8% were boys, 76.1% lived in urban area, 24.5% didn't have health insurance, 28.6% spoke two languages (Farsi and Turkish/Kurdish) at home, 11.5% did not complete their vaccination, 2.8% of children needed extra/specific examinations, 15.4% were referred to specialists and 0.5% had to go to special schools.
Table 1.
Main characteristics of national health assessment survey on Iranian 6-year-old children before entering school in 2009
| Characteristics | Number (%) | |
|---|---|---|
| Health employees | 5582(-) | |
| Children | Girl | 463076 (48.5) |
| Boy | 484891 (50.8) | |
| Residence | Urban | 727309 (76.1) |
| Rural | 210997 (22.1) | |
| Health insurance | Yes | 714955 (74.8) |
| No | 233755 (24.5) | |
| Home Language* | One | 673812 (70.5) |
| Two | 273708 (28.6) | |
| Having previous education | 722977 (75.7) | |
| Vaccination | Complete | 817995 (85.6) |
| Incomplete | 110234 (11.5) | |
| Extra/specific examination | Not necessary | 757950 (79.3) |
| Necessary | 26702 (2.8) | |
| Unknown | 170736 (17.9) | |
| Referred to specialists | 146790 (15.4) | |
| Referred to special schools | 4661 (0.5) |
Two languages (Farsi and Turkish/Kurdish)
Table 2 demonstrates the main characteristics of school readiness and autism of these children. Of these children, 39859 (4.2%) had a disease or disorder. In addition, 3.1, 1.2, 1.8, 1.4 and 0.08 percent showed impaired vision, color blindness, impaired hearing, speech problems and autism, respectively. Of them, 72605 (7.6%) children had problems with their school readiness assessment, mainly due to low score (46556 or 4.9%). Based on expert's opinion, 23104 (2.42%) were unapt. There were different combinations of disabilities some of which have been sent to normal or special schools. Autism was diagnosed in 226 (0.07%) children. For diagnosed mental illnesses, 2189 (0.2%) of children had severe mental illnesses. This figure was 1110 (0.1%) for suspected mental illnesses. Psychology result showed that separation anxiety disorder is the main disorder among others with 3836 (0.4%).
Table 2.
Main characteristics of school readiness and autism among Iranian 6-year-old children before entering school in national health assessment survey in 2009
| Disease/ Disorder | Number (%) | ||
|---|---|---|---|
| Overall primarily assessment | Healthy | 809593 (84.7) | |
| With disease/disorder | 39859 (4.2) | ||
| Unknown | 105936 (11.1) | ||
| Primary assessment | Impaired vision | 29874 (3.1) | |
| Color blindness | 11243 (1.2) | ||
| Impaired hearing | 16821 (1.8) | ||
| Speech problems | 13586 (1.4) | ||
| Autism | 788 (0.08) | ||
| School readiness assessment | Having problems | 72605 (7.6) | |
| Potential reasons | Low score | 46556 (4.9) | |
| No corporation | 6339 (0.7) | ||
| Higher age | 10308 (1.1) | ||
| Insufficient language understanding | 1360 (0.1) | ||
| Sensorimotor disorder | 835 (0.1) | ||
| Others | 3463 (0.4) | ||
| Expert evaluation result | Normal | 22061 (2.31) | |
| Unapt | 23104 (2.42) | ||
| Confidential refer to school | 13356 (1.40) | ||
| Is trainable | 3048 (0.32) | ||
| Test/temporary | 1007 (0.11) | ||
| Re-evaluation | 588 (0.06) | ||
| Referred to special school | 156 (0.02) | ||
| Disability combination | Visual-hearing disorder | Referred to normal school | 975 (7.7) |
| Referred to special school | 73 (0.6) | ||
| Visual-school readiness disorder | Referred to normal school | 4642 (36.6) | |
| Referred to special school | 1146 (9.0) | ||
| Re-evaluation | 337 (2.7) | ||
| Hearing-school readiness disorder | Referred to normal school | 2333 (18.3) | |
| Referred to special school | 450 (3.5) | ||
| Re-evaluation | 92 (0.7) | ||
| Visual-hearing-school readiness disorder | Referred to normal school | 1062 (8.4) | |
| Referred to special school | 1087 (8.6) | ||
| Re-evaluation | 397 (3.1) | ||
| Autism's expert evaluation | Normal | 177 (0.02) | |
| Confidential refer to normal school | 236 (0.01) | ||
| Temporarily sent to special school | 70 (0.02) | ||
| Autistic | 226 (0.07) | ||
| Mental illnesses (Diagnosed) | Severe mental disorder | 2189 (0.2) | |
| Mild mental disorder | 797 (0.1) | ||
| Epilepsy | 203 (<0.1) | ||
| Intellectual disability | 655 (0.1) | ||
| Other mental illnesses | 4258 (0.4) | ||
| Mental illnesses (Suspected) | Severe mental disorder | 1110 (0.1) | |
| Mild mental disorder | 433 (< 0.1) | ||
| Epilepsy | 219 (<0.1) | ||
| Intellectual disability | 99 (< 0.1) | ||
| Other mental illnesses | 3328 (0.3) | ||
| Psychology result | Separation anxiety disorder | 3836 (0.4) | |
| Mood disorder | 762 (0.1) | ||
| Hyperactivity and attention deficit disorder | 1123 (0.1) | ||
| Epilepsy | 162 (< 0.1) | ||
| Conduct disorder | 502 (0.1) | ||
| Obsession disorder | 469 (< 0.1) |
Table 3 demonstrates the relationship between school readiness and other characteristics among Iranian population of 6-year olds entering primary school. The mean score of school readiness was higher among girls, children with preschool education, children with fathers and mothers ofhigher education, less crowded families, less parity number and urban children (P<0.0001).
Table 3.
The relationship between school readiness and other characteristics among Iranian 6-year-old children before entering school in national health assessment survey in 2009
| Characteristic vs school readiness | Mean | P-value | |
|---|---|---|---|
| Sex | Girl | 35.38 | <0.0001 |
| Boy | 35.10 | ||
| Preschool education | Yes | 35.70 | <0.0001 |
| No | 33.64 | ||
| Father's education | Illiterate | 32.53 | <0.0001 |
| Reading and writing | 32.86 | ||
| Primary school | 33.74 | ||
| High school | 34.97 | ||
| Diploma | 36.31 | ||
| Associate degree | 36.85 | ||
| BSc | 37.63 | ||
| MSc and above | 38.51 | ||
| Illiterate | 32.72 | ||
| Mother's education | Reading and writing | 33.16 | <0.0001 |
| Primary school | 33.86 | ||
| High school | 35.16 | ||
| Diploma | 36.59 | ||
| Associate degree | 37.37 | ||
| BSc | 37.97 | ||
| MSc. and above | 39.13 | ||
| Father's occupation | Unemployed | 33.30 | <0.0001 |
| Dead | 34.67 | ||
| Employed | 35.33 | ||
| Retired | 35.68 | ||
| Mother's occupation | Dead | 34.29 | <0.0001 |
| Housekeeper | 35.01 | ||
| Retired | 37.06 | ||
| Employed | 37.53 | ||
| Number of family members | 9 and more | 32.80 | <0.0001 (others) 0.8 (2, 4) |
| 8 | 33.23 | ||
| 7 | 33.53 | ||
| 6 | 34.00 | ||
| 5 | 34.70 | ||
| 2 | 35.43 | ||
| 4 | 35.51 | ||
| 3 | 36.18 | ||
| Parity number | 8 and more | 32.71 | <0.0001 |
| 7 | 32.94 | ||
| 6 | 33.21 | ||
| 5 | 33.66 | ||
| 4 | 34.06 | ||
| 3 | 34.70 | ||
| 2 | 35.40 | ||
| 1 | 35.67 | ||
| Residency | Urban | 35.90 | <0.0001 |
| Rural | 32.95 |
Discussion
To the best of our knowledge, the present study is one of the first Iranian reports providing information on inequality of school readiness and autism from the entire population of children at school entry. We confirmed substantial differences in the regional distribution of diseases and disorders across Iranian provinces[29, 31–34].
Since various socioeconomic groups are living in different provinces and therefore the observed differences among provinces on children disorders and diseases cannot be fully explained by the socioeconomic pattern of each province, and this study has not documented the socioeconomic determinants of growth in Iranian 6-year-old children at school entry. As an obvious assumption, it seems to be logical to say that the provinces with more prevalence of diseases/disorders were economically deprived; however, this prevalence was low in other provinces with a similar socioeconomic situation.
The irregularity in distribution of diseases/ disorders across Iranian provinces does not follow the socioeconomic distribution. It means that there is a considerable inequality in the distribution pattern of diseases/disorders. The first explanation for this inequality would be different nutritional and economical patterns among Iranian provinces; however, because in recent decades, Iran has had a remarkable improvement in maternal and child nutritional status[3], the role of other determinants such as the different pattern of micronutrient distribution across Iran might be more important; in other words, it might be due to recent global economic crisis which could affect the accessibility to enough and necessary amount of foods for Iranian families.
Another explanation for the observed inequality might be the ethnic differences. The populations of various Iranian provinces have their own ethnic distribution. However, these differences are more socioeconomic-related than ethnic differences, because even in provinces with a mixture of ethnic groups, the distribution of observed diseases/disorders is similar to the pattern of provinces with special ethnic groups.
The most important strength of our study is its nationwide coverage of all school-entry children. Another strength is reporting of disease/disorder patterns of children across Iranian provinces. There is also the benefit of using inference statistics; i.e. despite the descriptiveness of previous national health assessments on these children, this study also considered inferential statistics. However, the study had also some limitations. The main limitation of this study is its cross-sectional nature. In addition, due to very large sample size of the study population, it was not possible to document details of socioeconomic and lifestyle determinants of Iranian children entering school.
Conclusion
The high inequality in the distribution of school readiness and autism among 6-year old children across Iranian provinces is confirmed in this study. These results will raise the necessity of a comprehensive surveillance system and a centralized data registry for Iranian children. Given the variation of growth disorders across different Iranian provinces, information on local circumstances as well as dietary and physical activity patterns of children is essential for policy making at national level.
Acknowledgment
The present study was part of a national screening study supported by the Ministry of Health and Medical Education and the Ministry of Education and Training. The authors declare that they have no conflict of interest. All authors have read and confirmed the manuscript. The authors forward their sincere thanks to the large team working for the present study at national level.
Conflict of Interest
None
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