All Issues

Annually, about half a million of school children are screened and their health status in 2019 is as follows:

(i) Myopia - Number of students with visual acuity (VA (Snellen) ≥ 6/12 or VA (LogMAR) ≥ 0.30) for male students is 4702 per 10,000 examined and for female students is 5131 per 10,000 examined (1).

(ii) Obesity - Number of students who are overweight (BMI-for-age ≥ 90th percentile) for males who are in Primary 1 is 1094 per 10,000 examined and for females who are in Primary 1 is 897 per 10,000 examined. And for males who are in Primary 5 is 1739 per 10,000 examined and for females for who are in Primary 5 is 1307 per 10,000 examined (2).

Since the mid-1980s, schools were grouped into zones and each zone would comprise teams of doctors and nurses who conducted screenings and immunisation in schools (3). To date, the screening coverage achieved by SHS is more than 98% and that for immunisation is more than 95%. Nearly half a million school children are screened annually.

In the past, the health problems detected were mainly dental caries, visual defects, anaemia, malnutrition, skin diseases and communicable diseases (4). With modernisation and economic development, the type of medical conditions of school children has evolved to one that reflects affluence and sedentary lifestyle. Since early 1980s, more children were detected with visual defects, obesity and dental caries (5).

Based on the new disease trends and with the core functions of the SHS remaining unchanged, its services are constantly being reviewed and enhanced to benefit all students. Besides primary and secondary school children, SHS now extends its services to all preschools and post-secondary institutions (Institutes of Technological Education and polytechnics). In order to better manage the students after screening, the Lifestyle Clinic was set up to address those with chronic conditions.

Over the years, SHS immunisation programme has developed in line with Singapore’s National Childhood Immunisation Programme (NCIP). Together with the NCIP, SHS has contributed towards the eradication of vaccine-related communicable diseases such as tuberculosis among school children and has greatly improved the public health in general (6).

Since 1921 to the present, SHS has contributed to the prevention of vaccine-related communicable diseases through immunisation (Table 1). In 2019, SHS has also offered human papillomavirus (HPV) as part of the school-based immunisation programme for all secondary one, four and five female students. The coverage of all immunisation remains high at more than 95% of the school population for relevant immunisation.

The prevalence of childhood obesity has increased from 10% in 2010 to 13% in 2017 (7). To control this trend, the Lifestyle Clinic, formerly known as the Nutrition Clinic, was set up in 2001. It has been educating children and their parents to take ownership of their health by promoting a healthy and active lifestyle.

Primary, secondary schools and junior colleges are encouraged to send their overweight and severely overweight students in groups to the Life-style Clinic for a medical assessment which includes blood pressure measurement and blood test to assess blood lipids and glucose level. Those identified in schools as severely underweight students are also referred to the Lifestyle Clinic for a medical assessment and dietary counselling. One-third of obese students screened were found to have either elevated blood pressure or abnormal fasting lipids and were referred to the Lifestyle Clinic for lifestyle coaching and monitoring and if necessary, referred to an endocrinologist. Students with normal blood tests results are referred to Student Health Advisors (SHA) and HPB’s school and community-based programmes. Since 2018, these medical assessments have also been offered onsite at schools.

In 2017, out of 1,129 students who participated in the lifestyle coaching programme, about 54% reduced their Body Mass Index-for-age to a healthier level (8).

Apart from the life coaching programme, in 2017, the “Healthier Meals in Schools Programme” was launched to introduce healthy eating in preschools, primary, secondary schools and junior colleges.

In 2019, 1,040 preschools have started serving healthier meals and 79,040 preschool children have benefitted from the programme (8). All the other primary and secondary schools also serve balanced and healthy meals.

Besides helping students to lose weight and improve their lifestyle, SHAs in schools also help smokers quit smoking and manage other chronic illnesses. These SHAs, stationed in schools, Institutes of Technological Education and polytechnics, offer lifestyle coaching and group counselling programmes such as the “school-based mental well-being programmes” aims to help to achieve the national target reduction of adult smoking in Singapore to 12 per cent by 2020 (11). National Population Health Survey of 2019 shows a drop in the population of smokers from 13.9% in 2010 to 10.6% in 2019 (12).

In 2017, 44% of the students who participated in the SHA programme achieved weight loss or maintained their weight and for smokers who participated in the coaching programme, 11% of the students reduced or quit smoking after the three months post intervention period (9).

Another health issue observed among students is myopia. The rate of myopia is among the highest in the world, in 2011, with 65 percent among primary six students having defective vision (8). The National Myopia Prevention Programme (NMPP) was introduced in 2001 to prevent myopia among primary school children. It was then extended to preschools in 2002 and provided vision screening and promoted good eye care habits. In 2017, a total of 354,188 school children in preschools, primary and secondary schools had their vision screened (8).

Since 2006, SHS has been offering vouchers to subsidise free lenses through participating optical shops to underprivileged school children with myopia, who are on the government’s Financial Assistance Scheme (FAS). In addition, over the years, SHS has been improving the accessibility of these services by partnering optometrists to provide refraction, prescription and the fitting of spectacles at schools. To date, through these “Roving Optical Shops”, around 2,600 children have redeemed their spectacles with the vouchers.

The promotion of good eye habits has contributed towards a reduction in the rate of myopia by 5% among primary school students, from 38% (in 2004) to 33% (in 2009) (10).

Prior to 2006, screening and immunisation data were recorded on cards. With technological advancement, these data were then captured on computer systems. The SHS computer systems have evolved from the mainframe system to the current online system, which allows entry, sharing and easy retrieval of health-screening and immunisation data.

To improve the interactive process with parents, in 2015, the Child Consent Portal (CCP) was introduced for parents to submit consent for their child’s immunisation online. Reminders are also sent to parents via mobile phones for students who are referred and default their appointments for follow-up consultation. In 2017, the eHealth-book (electronic health booklet) was launched to allow parents to view the health records of their children online at their convenience.

To increase efficiency in screening, electronic weighing scales are used by our screening teams to measure and capture children’s weight and height measurements directly into our computerised systems and calculate their Body Mass Index electronically. By using electronic weighing scales, nurses are allowed to focus on their core function of health screening and immunisation.

Over the years, SHS has improved its vaccine cold chain management by instituting a 24-hour monitoring system to ensure vaccines do not lose their immunogenicity/potency from the point of storage at warehouse chillers, transportation and delivery to schools.

The clinical quality and safety framework developed in the 1990s, reviewed regularly, monitors the clinical standards and processes to ensure safety and quality of the services. With the healthy child being our ultimate goal, SHS’s focus, comprises the following seven areas:

• • Standards setting of clinical operating procedures and guidelines
• • Skills assessment of all nursing staff
• • Monthly supervisory checks
• • Risk management to address identified areas and issues
• • Annual audit to identify potential gaps
• • Assess service delivery to ensure customers’ satisfaction
• • Service provider monitoring to ensure service level agreement and meeting of Key Performance Indicator (KPI) targets.