Hong Kong Journal of Paediatrics [HK J Paediatr (New Series) 2025;30:61-68]

Family Tokat Gaziosmanpasa University, Faculty of Medicine, Department of Family Medicine, Turkey
G Oktay MD
EE Ceylan MD
U Unlu MD
NY Celtek MD

Tokat Gaziosmanpasa University, Faculty of Medicine, Department of Biostatistics, Turkey
YE Kuyucu PhD

Correspondence to: Assistant Prof. G Oktay
Email: drgoktay@hotmail.com

Received August 9, 2023

Purpose: In our study, we aimed to determine the health problems of secondary school students in our province. Methods: Secondary school students were evaluated anthropometric measurements, blood pressures, vision, hearing and scoliosis scans. Findings: A total of 3342 students were evaluated. 4.4% of the students had short stature, 22.8% were overweight-obese, and a suspicion of hypertension was found in 32.3%. In addition, 13.3% of the students had visual impairment, 5.4% had hearing impairment, and 0.8% had suspected scoliosis. It was determined that the frequency of abdominal obesity and hypertension increased as the body mass index increased. Conclusions: Our health screening results show that vision problems, overweight-obesity and hypertension are the leading health problems in children. In addition, in the relationship between body mass index and hypertension and abdominal obesity; This suggests that prevention of obesity will contribute to the reduction of the frequency of comorbid conditions.

Introduction

Health screenings are crucial within the scope of preventive health services. It also has an important place in school health services. Early diagnosis and treatment of diseases can be possible with screening. In Turkey, the Ministry of Health provides hearing screening for newborns and first grade children with the Newborn Metabolic and Endocrine Disease Screening Program.¹ In addition, various screenings carried out by family physicians, such as vision screening, autism spectrum disorder screening, and iron deficiency anaemia screening are also carried out effectively.² However we see that the subject has been discussed by various researchers and contributed to the literature.^3,4

Regarding health screenings in schools; vision, hearing, obesity and oral and dental health screenings can be given as examples. In the literature, it is possible to see studies made on students at various stages of education life.^5-7 Secondary school period; consists of puberty students entering the transition period from childhood to adulthood. Identifying the problems in this period of physical and psychological changes; it is very important in terms of raising healthy generations. In this process, in which secondary gender characters are acquired, a rapid growth period is entered. Girls are usually at the end of secondary school (when the bone age is 15-16); boys reach the final height one or two years later than girls.² It is important to assess short stature in secondary school children.⁸ Because one of the criteria used to evaluate growth is height and growth rate. However, it is not just height. It is also very important to carefully evaluate other parameters used to evaluate growth, such as body weight in children of all age groups. After all, detailed physical examination is important at all ages.

Obesity is an important problem with increasing frequency in school-age children.⁹ In the Obesity and Diabetes Clinic guide published in 2017 for primary health care workers, it is stated that one out of every five children over the age of five in our country is overweight or obese.¹⁰ Obesity can cause an increase in blood pressure through various mechanisms. While the Ministry of Health states that after the age of three, blood pressure should be measured once a year in children; states that blood pressure should be evaluated earlier in children with risk factors such as obesity.¹¹

Another common problems in adolescents are orthopaedic problems, especially scoliosis. Adolescent idiopathic scoliosis is the form that occurs in adolescence and constitutes a large part of idiopathic scoliosis. According to the results of the prevalence study conducted in our country, its frequency was found to be 2.3%. Another striking result of the same study is that more than half of the families did not know about scoliosis and stated that they had heard of scoliosis for the first time.¹²

Other health problems that should be considered in adolescents are vision-hearing problems that affect education and communication. Infections-traumas or different risk factors pose a risk for permanent or temporary hearing loss. In addition, refractive errors are common in school-age children.¹³ Early detection of vision-hearing problems is important in terms of healthy development, education and professional life of children.

School health services-health screenings are trying to reveal the health needs of school-age children. In this context, studies conducted on both primary school students and students studying in different classes are important for child health. This study is a cross-sectional study using health screening data of secondary school students in our province. The reason why our study was conducted with secondary school students instead of primary school students is to draw attention to adolescent health. With this study, it is aimed to determine the health problems of secondary school students and to contribute to the literature.

Methods

Our study is a cross-sectional study using the data of the health screening conducted within the scope of the Health Movement in Education Project, which was carried out in cooperation with the Tokat Provincial Directorate of National Education and our Tokat Gaziosmanpasa University Department of Family Medicine.¹⁴ Students studying in secondary schools affiliated to the Tokat Provincial Directorate of National Education between the education years of 2022-2023 constitute the universe of the study; sample was not selected. However, three schools whose data were previously evaluated by Unlu et al, one of the faculty members of our department, were excluded from the study.¹⁵ In this study, health screening results of students studying in three different schools were compared according to socioeconomic status. The data in the study were removed to avoid any ethical violations. In addition, children whose families did not give their consent and who were not at school that day were excluded from the study. After the health screening, necessary information and referrals to the relevant specialist were provided.

Health screening was carried out in appropriate areas that were previously prepared by the school administration. Anthropometric measurements (weight, height measurements, arm circumference, waist circumference and hip circumference) of the children were evaluated within the scope of health screening. Waist/hip ratio and Body mass index (BMI): It was calculated according to the formula of body weight (kg) / height (m²). Weight, height, waist circumference and BMI percentile values. It was calculated according to the reference values of the children of our country in accordance with age and gender.^16,17 For the percentile BMI, those below five were considered underweight, those between 85-95 were considered overweight, and those between 95 and above were considered obese.¹⁸ Abdominal obesity, on the other hand, had a waist circumference of 90 percentiles and above were evaluated.¹⁹ Those whose height was below the 3rd percentile were considered short.⁸

The students' blood pressures were measured once using an age-appropriate blood pressure monitor. The results were evaluated according to the European Society of Hypertension classification of hypertension in children and adolescents, shown in Table 1. Accordingly, if the systolic and/or diastolic blood pressure was at or above the 95th percentile according to age, gender and height, it was considered hypertension.²⁰ Scoliosis was evaluated using Adams' forward bending test.

Visual and hearing screenings of the students were performed. Using the Snellen chart for vision scanning; at appropriate distance and both eyes were evaluated separately. Accordance with the definition of amblyopia in one eye in clinical practice, a visual acuity of 0.8 and below was considered as visual impairment.²¹ Senti Desktop type SID 100433 model hearing aid was used for the hearing test. Not being able to respond to a sound of 30 db and above in four different frequency bands (500, 1000, 2000, 4000 Hertz bands) for both ears was considered as hearing impairment.²²

Descriptive statistics were made in order to give information about the general characteristics of the individuals examined in the study. Data for quantitative variables were mean and standard deviation (n±sd); data belonging to qualitative variables were defined with frequency and percentage (n%). The hypotheses for the study were One Way Analysis of Variance (Anova) for quantitative values; For qualitative values, it was evaluated with Chi-Square Tests. Post-Hoc tests (Tukey HSD, Tamhane's T2 ) were used for multiple comparisons. When p values were calculated less than 0.05, it was considered statistically significant. Ready-made statistical software was used in the calculations (IBM SPSS Statistics 22, SPSS inc., an IBM Co., Somers, NY).

Results

Within the scope of our study, the screening results of 3342 students in total were evaluated. The mean age of the students was 11.95±1.15 years (min:9 - max:16) and 51.5% of them were girls. Anthropometric measurements of the students were made and their percentiles were calculated. According to the anthropometric measurement results of the students, the percentile distributions of weight, height, waist circumference are shown in Table 2. Among the anthropometric measurement results, the mean arm circumference, waist circumference, hip circumference, and waist/hip ratio were calculated as 23.43±3.69 cm, 71.35±10.98 cm, 85.53±10.70 cm, 0.83±0.06, respectively.

According to the BMI percentile, 11.1% of students were obese. According to the percentile values of waist circumference, abdominal obesity was detected in 1339 (40.1%) students. 32.3% of the students have hypertension (Figure 1).

According to the results of vision and hearing evaluation, 356 students were using glasses. Glasses wearers were examined with glasses. However, 12 students who did not have their glasses with them for various reasons were examined without glasses. The rate of visual impairment in all students who underwent a visual examination was 13.3% (444 people). In the group wearing glasses, it was found to be 17.7% (61 people). Hearing impairment was detected in 5.4% of the students (180 students). In addition, 3 students were using hearing aids. In the evaluation of scoliosis, scoliosis was suspected in 26 (0.8%) students. In addition, One student was using a corset with the diagnosis of scoliosis.

The BMI and waist/hip ratio, as well as mean arm circumference, waist circumference and hip circumference were compared. It was determined that the mean values of waist/hip ratio, waist circumference, arm circumference and hip circumference increased as BMI increased (Table 3).

The relationship between BMI and abdominal obesity and hypertension was evaluated. While 95.7% of obese students have abdominal obesity; 90.3% of those underweight did not have abdominal obesity. As BMI increased, the frequency of abdominal obesity increased and a statistically significant difference was found (Table 4). In addition, as BMI increases, the frequency of hypertension also increases; It was determined that 59.9% of the obese students and 45.2% of the overweight students had hypertension cut-off values (Table 5).

Discussion

Health screenings in schools are important for the protection of children's health and the development of healthy generations. Although the rate of elderly population in our country is increasing, according to the 2022 data of the Turkish Statistical Institute, 26.5% of our population is child population; Adolescents between the ages of 10-14 constitute 28.5% of this rate.²³ It was determined that approximately one out of every five students was overweight or obese and one out of every three students had hypertension cut-off values. In addition, 4.4% of the students had short stature, 13.3% had visual impairment, 5.4% had hearing impairment, and 0.8% had suspected scoliosis.

Secondary school students consist of students in the puberty period by age group. Puberty is a period in which men experience a height increase of approximately 8-9 cm per year, starts between the ages of 9-14. In girls, it starts between the ages of 8-13 and there is a height increase of approximately 7-8 cm per year.^2,24 In our country, the average age of onset of puberty is reported as 9.8-10.1 years in girls and 11.8 years in boys.²⁵ For this reason, it is possible to see children who look physically different from each other in the same class. In this period when a rapid increase in height is observed; evaluation of short stature is important. However, it is also important to carefully evaluate not only height but also other parameters used to evaluate growth, such as weight, and physical examination in children of all age groups. Only in this way, pathological conditions such as short stature and early puberty can be distinguished. In studies conducted in different provinces of our country on short stature in children; different age groups were discussed and the results ranged between (6.9%-10.5%).^26-29 The rate of short stature in our study was 4.4%, which is similar to the literature. It is possible to see the most common normal variants of short stature. However, early diagnosis is important to distinguish pathological causes. In this sense, thanks to the information systems they use, family physicians. They can contribute to early diagnosis by following the growth curves more closely.

Obesity is an important public health problem in children as well as adults. According to the information obtained from the World Health Organization database, the rate of obesity and overweight in children and adolescents aged 5-19 years in 2016 increased more than four times according to 1975 data.³⁰ According to the results of the Turkey Childhood Obesity Survey, approximately one out of every four students is overweight (14.6%) or obese (9.9%).³¹ In our study, the rate of overweight and obese students was similar and approximately eleven percent. Similar results were obtained in the study conducted with 3171 students aged 6-18 years in Konya.³² In different studies, it was conducted with 529 students aged 8-10 in Kayseri in 2017-2018, and in the study, the overweight rate was 15.3% and the obese rate was 8.7%. In addition, it was stated in the study that the level of physical activity in children was generally moderate.³³ The increase in obesity in children also poses a risk in terms of comorbid conditions such as hypertension and type 2 diabetes mellitus¹⁰ Therefore, early detection of obesity is important. The United States Preventive Services Task Force recommends screening for obesity in children aged six and over (Grade B), and the Turkish Society of Endocrinology and Metabolism recommends BMI measurement at least once a year in adolescents.^18,34 For this purpose, healthy child-adolescent follow-ups and follow-ups by family physicians are recommended. It is thought that school screenings will make a great contribution to obesity screening. Our study focused on secondary school students and aimed to draw attention to adolescent health.

It is stated that BMI is the gold standard among anthropometric measurements in the evaluation of obesity and overweight.³⁵ In addition, waist circumference and waist/hip ratio are among the methods used to determine abdominal obesity.³⁶ Forty percent of the students in our study had abdominal obesity. In a study conducted ten years ago on secondary school students studying in different settlements in terms of socioeconomic level in our city, it was determined that approximately one out of five children (22.7%) had a waist circumference of the 95th percentile and above, and the obesity rate was 6.5%. In the same study, waist circumference of almost all obese students (98.2%) was 95 percentile and above. As BMI increased, the prevalence of central obesity was found to increase.³⁷ Similarly, in our study, 95.7% of obese students had abdominal obesity. In addition, in our study, it was determined that the mean values of waist/hip ratio, waist circumference, arm circumference and hip circumference increased as BMI increased. The results of the study in children who applied to the Okmeydanı Training and Research Hospital Pediatrics outpatient clinic due to overweight are similar to our study. It was stated that there was an increase in waist circumference, arm circumference and hip circumference with an increase in BMI, and there was a significant positive correlation.³⁸ Although BMI is often used in practice to evaluate obesity, different anthropometric measurements are also used in studies. For example, it is stated that waist/hip ratio and waist/height ratio can predict body fat distribution.¹⁸ There are also studies stating that upper arm circumference is also important tools in the evaluation of obesity.³⁹

Another increased health risk in children and adolescents is hypertension. Evidence over the past two decades indicates that its frequency has increased. When we look at the causes, primary hypertension is the most common cause in children older than 12 years of age, but secondary causes should be excluded.⁴⁰ The prevalence of hypertension in children in the world was reported as 4% in a meta-analysis and systemic review that included 47 studies. In the same study, it was stated that a positive correlation was observed between BMI and the prevalence of childhood hypertension.⁴¹ It is seen that the results of studies on childhood hypertension in our country vary between 5.5%-24.5%.^42-45 The proportion of children who had the same values was 32.3%. It is thought that the number of participants, the rate of obese children and the frequency of blood pressure measurement in the studies are effective on this difference in the results. The positive correlation between obesity and hypertension, which is among the modifiable risk factors for primary hypertension in children, has been shown in various studies.^41,43 In our study, more than half of the obese students had hypertension breakpoints. In this sense, it is thought that the prevention of obesity will contribute to the decrease in the frequency of hypertension. Early diagnosis will be possible by measuring blood pressure and questioning other risk factors, which are a part of healthy child and adolescent follow-up.

Some of the health risks addressed in school screenings are vision, hearing problems and scoliosis. Early detection of vision problems is very important for the success of treatment. In addition, with the changing world, children's spending less time outside and increased screen exposure may negatively affect their eye health. Studies supporting this are also available in the literature.^46,47 There are regional studies on refractive errors in children in our country; The results vary between 8%-10.5%.^7,48,49 In our study, the rate of visual impairment and hearing impairment in students was 13.3% and 5.4%. Hearing screening was performed on 812 fifth grade students in Malatya within the scope of the study, and 24 (3%) students failed the screening.⁶ Early recognition of hearing impairment contributes to the language, social and cognitive development of children. For this purpose, the Newborn Hearing Screening program has been started all over Turkey since 2008, and primary school 1st grades were added to the screening in 2015.⁵⁰ Thus, it contributed to the detection of hearing loss that occurs in the postnatal period. Another important health problem in adolescents is adolescent idiopathic scoliosis. In the prevalence study conducted in our country in the 2016-2017 academic year, its frequency was found to be 2.3%.⁶ In our study, scoliosis was suspected in 26 (0.8%) students, and one student was using a corset. In the health screening conducted in Tekirdağ three years ago, 1913 students were screened and scoliosis was found in 363 (18.98%) students.⁵¹ It is aimed to prevent the increase in curvature by early recognition of scoliosis, which causes physical and psychological problems. Therefore, it is thought that school screenings will contribute to early diagnosis.

Our health screening results show that vision problems, overweight-obesity and hypertension are the leading health problems in children. In addition, in the relationship between body mass index and hypertension and abdominal obesity suggests that prevention of obesity will contribute to the reduction of the frequency of comorbid conditions. In addition, short stature, scoliosis and hearing problems are problems that should not be overlooked. Robust child-adolescent follow-ups and health screenings in schools are great opportunities for early diagnosis. In this sense, family physicians have great responsibilities. Follow-ups in primary care are important both for early diagnosis and primary prevention. Because with the counselling services, eating habits can be corrected or physical inactivity can be prevented.

Limitations of the Study

Once measurement was made and there were no repeated measurements and no follow-up process are the most important limitations of our study. Additionally, students who were not at school that day could not participate in the health screening and their personal history was not questioned.

Ethical Approval

The study was carried out with the permission of Clinical Researches Ethics Committee of Tokat Gaziosmanpasa University School of Medicine (Meeting Date: 9.6.2022, Project No: 22-KAEK-127).

Declaration of Interest

The authors declare the study received no funding. The authors declare that there is no conflict of interest.

References

2. Republic of Türkiye Ministry of health. General Directorate of Public Health. Department of child and adolescent health. Bebek, Çocuk, Ergen İzlem Protokolleri Ankara 2018. [Online]. Available at https://hsgm.saglik.gov.tr/tr/dokumanlar-cocukergen/kitaplar.html. [Accessed 08.08.2023]

3. Ugras AA, Yilmaz M, Sungur I, et al. Prevalence of scoliosis and cost-effectiveness of screening in schools in Turkey. J Back Musculoskelet Rehabil 2010;23:45-8.

4. El-Missiry A, Soltan M, Hadi MA, Sabry W. Screening for depression in a sample of Egyptian secondary school female students. J Affect Disord 2012;13:e61-8.

5. Ayrancı Ü. A Study On Dental Caries In A Group Of Primary School Students. Sürekli Tıp Eğitimi Dergisi 2005;14:50-4.

6. Yılmaz Ö, Yakıncı C, Karataş E. Malatya il merkezi okul çağı çocuklarda işitme taramaları. Çocuk Sağlığı ve Hastalıkları Dergisi 2018;61:59-66.

7. Kalyoncu C, Metintas S, Balız S, Arıkan İ. Eğitim araştırma bölgesinde ilköğretim öğrencilerinde sağlık düzeyleri ve okul tarama muayeneleri sonuçlarının değerlendirilmesi. TAF Prev Med Bull 2011;10:511-8.

8. Bundak R. Büyümenin değerlendirilmesi ve boy kısalığına yaklaşım. Oğuz F. (eds). Genel pediatri-pediatrinin temel taşları. Ankara: Ema Tıp Kitapevi; 2022:s853.

10. Republic of Türkiye Ministry of health. General Directorate of Public Health. Department of healthy nutrition and active life. Birinci Basamak Sağlık kurumları için Obezite ve Diyabet Klinik Rehberi. [Online]. Available at https://hsgmdestek.saglik.gov.tr/tr/beslenmehareket-yayinlar1/rehberler. [Accessed 08.08.2023]

12. Republic of Türkiye Ministry of Health. Health Services General Directorate Türkiye Adölesan İdiyopatik Skolyoz Prevelans Araştırması Sonuç Raporu Ankara 2018. [Online]. Available at https://www.tftr.org.tr/uploads/skolyoz.pdf. [Accessed 01.04.23]

13. Republic of Türkiye Ministry of health. General Directorate of Public Health. Department of child and adolescent health. [Online]. Available at https://hsgm.saglik.gov.tr/tr/cocukergen-tp-liste. [Accessed 21.12.22]

15. Ünlü U, Çeltek NY, Ceylan EE, Demir O. Research of socioeconomic status and school-based health screening results of study with children after two years of COVID-19 pandemic. Journal of Health Sciences and Medicine 2022;5:1002-8 .

16. Neyzi O, Günöz H, Furman A, et al. Türk çocuklarında vücut ağırlığı, boy uzunluğu, baş çevresi ve vücut kitle indeksi referans değerleri. Çocuk Sağlığı ve Hastalıkları Dergisi 2008;51:1-14.

17. Hatipoglu N, Ozturk A, Mazicioglu MM, Kurtoglu S, Seyhan S, Lokoglu F. Waist circumference percentiles for 7- to 17-year-old Turkish children and adolescents. Eur J Pediatr 2008;167;383-9.

20. Lurbe E, Agabiti-Rosei E, Cruickshank JK, et al. 2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents. J Hypertens 2016;34:1887-920.

21. Şahin T, Buyru Özkurt Y. Çocuklarda Ambliyopi ve Ülkemizdeki Görme Tarama Programı. Ortadoğu Tıp Dergisi 2017;9:79-87.

22. Kırman A, Sarı HY. İşitme Engelli Çocuk ve Adölesanların Sağlık Durumları. Güncel Pediatri Dergisi 2011;9:85-92.

25. Yıldız M, Darendeliler F. Ergende puberte sorunlarının güncel yönetimi. Oğuz F. (eds). Genel pediatri-pediatrinin temel taşları. Ankara: Ema Tıp Kitapevi 2022:s867-82.

26. Tütüncü İ. Kastamonu İl Merkezinde 13 İlköğretim Okulunda 5-15 Yaş Grubu Öğrencilerde Fazla Kiloluluk ve Obezite Prevalansı. Acıbadem Üniversitesi Sağlık Bilimleri Dergisi 2014;5:141-51.

27. Küçük Ö, Biçer S, Uğraş M. Evaluation of the association between obesity and short stature among children living in Yozgat city. Med Bull Sisli Etfal Hosp 2012;46:203-7.

28. Ece A, Ceylan A, Gürkan F, et al. The Prevalence of Short Stature, Underweight and Obesity in Schoolchildren in Diyarbakir, Turkey. Van Med J 2004;11:128-36.

29. Kayıran PG, Taymaz T, Kayıran SM, Memioğlu N, Taymaz B, Gürakan B. The frequency of overweight, obesity and short stature among primary school students in three different regions of Turkey. Med Bull Sisli Etfal Hosp 2011;45:13-8.

31. "Turkey Childhood (Primary School, 2nd Grade Students) Obesity Surveillance Initiative COSI-TUR 2016" Ministry of Health - General Directorate of Public Health, Ministry of National Education, World Health Organization Regional Office for Europe, Ministry of Health Publication No: 1125 Ankara 2019.

32. Yazar A, Kılıçaslan M, Akın F, Arslan Ş. Konya ilinde 6-18 yaş arası çocuklarda obezite sıklığı. Bozok Tıp Dergisi 2019;9:123-9.

33. Yazıcı-Gülay M, Korkmaz Z, Kaya Erten Z, Gürbüz Z. Çocukların fiziksel aktivite, obezite düzeylerinin incelenmesi: Kayseri ili örneği. Genel Sağlık Bilimleri Dergisi 2021;3:228-38.

35. Tekin F, Özkoçak V. Comparing Anthropometric Measurements in Determining Obesity in Children: A Systematic Review. Adnan Menderes Üniversitesi Sağlık Bilimleri Fakültesi Dergisi 2022;6:52-64.

36. Öztürk AP, Baş F. Çocukta Metabolik Sendromun Yönetimi. Oğuz F. (eds). Genel pediatri-pediatrinin temel taşları. Ankara: Ema Tıp Kitapevi 2022:s853.

37. Demir Acar M, Bayat M, Demir O, Çiçek B, Erdem E. Farklı sosyoekonomik düzeydeki ergenlerde santral obezitenin bel/boy oranı ile değerlendirilmesi. Türkiye Klinikleri Pediatri Dergisi 2019;28:55-62.

38. Yücel BB, Toprak D. Evaluation of Anthropometric and Biochemical Parameters in Obese Children Between 6-16 Years. Ankara Medical Journal 2016;16:27-40.

39. Rerksuppaphol S, Rerksuppaphol L. Mid-Upper-Arm Circumference and Arm-to-Height Ratio to Identify Obesity in School-Age Children. Clin Med Res 2017;15:53-8.

41. Song P, Zhang Y, Yu J, et al. Global prevalence of hypertension in children: a systematic review and meta-analysis. JAMA Pediatr 2019:173:1154-63.

42. Sarıkan İ, Öngel K. Isparta'daki okul çocuklarında hipertansiyon prevalansı ve risk faktörlerinin araştırılması. SDÜ Tıp Fakültesi Dergisi 2020;27:541-5.

43. Şanlı C, Alpcan A. Kırıkkale ilinde 7-15 yaş grubu çocuklarda arteryel kan basıncının değerlendirilmesi. Turkısh Journal of Clinics and Laboratory 2015;6:8-13.

44. Önsüz FM, Demir F. Prevalence of hypertension and its association with obesity among school children aged 6-15 living in Sakarya Province in Turkey. Turkish Journal of Medical Sciences 2015;45:907-12.

45. Akdoğan SA, Başpınar MM, Basat O. Okul çağı çocuklarında obezite, hipertansiyon ve abemi sıklığı: Bir aile sağlığı merkezinden retrospektif kesitsel bir çalışma. Türkiye Aile Hekimliği Dergisi 2021;25:69-75.

46. Alvarez-Peregrina C, Sánchez-Tena MÁ, Martinez-Perez C, Villa-Collar C. The Relationship Between Screen and Outdoor Time With Rates of Myopia in Spanish Children. Front Public Health. 2020;8:560378.

47. Foreman J, Salim AT, Praveen A, et al. Association between digital smart device use and myopia: a systematic review and meta-analysis. The Lancet. Digital Health 2021;3:e806-18.

48. Dığrak E, Öztürk Eyimaya A, Zengin H, Tezel A. İki devlet okulundaki öğrencilerin sağlık tarama sonuçlarının değerlendirilmesi. Turkısh Journal of Family Medicine and Primary Care 2020;14:289-98.

49. Yıldırım B, Adana F, Kırağ N, Yeşilfidan D, Kaplan O. Aydın ili bir merkez ilkokulunda göz tarama sonuçları. İzmir Dr. Behçet Uz Çocuk Hast. Dergisi 2018;8:132-8.

51. Irmak AY, Çelikkalp Ü. Okul temelli ergen sağlığı tarama sonuçları. Turkısh Journal of Family Medicine and Primary Care 2022;16:255-64.