Current IssuesJanuary 2006
| Current Issues | No.46 January 2006 |
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Abstract
The sedentarity of youth is a major public health issue. Much hope
has been placed on school physical education (PE) as a source of regular
physical activity and to promote an active lifestyle. A trans-disciplinary group counted the number of medical certificates in secondary school (11,339 students), modified the existing excuse formula and generated a debate about PE. In 2000-2001, 15% of students (1,688) presented medical certificates. 48% were for more than 3 months to 1 year, of which 75% were girls. The proportion of medical certificates varied from school to school (2.3 to 15%). A new formula permitting to establish partial incapacity, brought a 40% reduction in total EX in 2002-2003. In conclusion, a debate about PE as well as a new excuse formula permitted to reduce the number and duration of medical excuses. Introduction
Medical certificates (excuses) for physical education (PE), are part
of the daily activity of most physicians dealing with school age youth.
Apart from protecting injured or ill children, they can be source of
conflict and misunderstanding both for teachers and physicians. Teachers
sometimes believe the excuses are unfounded and physicians sometimes
believe physical education is un-adapted for the child.
There are in fact, very few medical reasons to excuse a youngster from PE, other than acute illness or certain chronic conditions. However we have over the last years seen a steady increase in the number of medical certificates, especially in the teen age group (age 10-15) and in young adults (15-20). Over the last 30 years, the socio-educative environment seems to have
lead to a progressive decrease in the practice of structured sport and
daily physical activity. This has largely contributed to the increase
in overweight and obese children. In this context, many health strategies
aiming to increase physical activity, count on the influence of schools
to promote physical activity and a healthy active lifestyle. In this
respect, it is essential that health professionals and PE teachers collaborate
to promote physical activity both in schools and in everyday life (1). Method:
A working group was constituted, consisting of the head teachers from
primary and secondary school PE and a health professional, involved
with physical activity.
The group proceeded in four phases:
The study was carried out from 2001-2002 and from 2002-2003, among
the secondary school children from the Canton of Geneva and consisted
of 11,339 students. Girls and boys were equally distributed.
The medical certificates were collected by the school PE teachers and centralised. No evaluation was carried out in primary school (<11 years), because of the small number of certificates. The certificates were then divided in to four subgroups depending on duration: from one week to one month, from one month to 3 months, from 3 months to 6 months and for the whole school year. This permitted to better evaluate mid (3-6 months) and long term (>6 months) certificates. Comparisons were done using the Chi squared statistic. Results:
1688 certificates were collected during the period from 2001 to 2002.
This corresponds to 15% of the studied population, assuming each child
only presented one certificate.
The proportion of certificates according to their duration is shown
on fig1. One notices that the most frequent certificate is the short
term certificate followed by a yearly excuse.
Figure 1 : Proportion of certificates as
a function of duration
 The proportion of girls presenting a certificate was greater in all
duration subgroups (fig 2); 48% of certificates were for more than 3
months; of these 75% concerned girls. The proportion of certificates
also increased with age, the oldest age group being the most frequently
excused.
Figure 2 : Distribution of certificates as
a function of age and sex.
 We also noticed a very large inter-school variation in the number of
certificates (fig 3).
Figure 3 : Percentage of students giving
certificates as a function of the school they go to.
 Development of an adapted certificate:
Based on these results, a reflection was carried out with the Geneva
physicians, The Youth Health Department (SSJ) and the physical education
teachers to develop a new medical certificate, permitting to better
adapt the certificate to each child's capacities (partial excuses) and
limit their duration.
The certificates are presented as a small booklet which contains the current recommendations for physical activity in children given by expert groups (2) and the WHO (3). It also contains the school rules for the acceptation of certificates (maximal delay, duration, consequences) and detachable certificates to be filled in by the physician (fig 4). The certificate contains personal information and information on the degree of inaptitude; Level 1: Can do everything except certain activities (defined by the physician), level 2: Can run for 10 min. and or participate in team games, level 3: Can walk 20 to 30 minutes and or do stretching exercises, level 4: Can not participate in any physical education activities. Figure 4 : The inside of the booklet; recommendations
and detachable leaflets
 This booklet was distributed to paediatricians and general practitioners
in the Canton and represents the new official document. Evaluation of the pilot phase
Table 1 shows the evolution of certificates before and after the introduction
of the new certificate. There was a significant decrease in the total
number of certificates per year, which went from 1688 to 966, corresponding
to a 40% decrease. The decrease in whole year certificates was even
more marked and went from 470 to 243, which corresponds to a 50% decrease.
Table 1. Number of medical certificates in boys and girls during the
two periods. Chi squared test.
Discussion
The process helped health professionals and PE teachers realise the
importance of physical activity for health and the importance of participating
in school physical education. Certificates have for a long time been
a source of misunderstanding between teachers and health professionals.
This process permitted the two groups to meet and discuss about their
mutual problems and questions.
It is sometimes difficult for the doctor to refuse to give a certificate even if objective evidence is absent. It is however an occasion to talk about the importance of physical activity. With the new certificate, it is easier to make a more personalised inaptitude, meaning that the student might be unable to do some of the exercises and be advised to do certain others that the PE teacher can adapt. The evaluation permitted to objectively get an overview of the large
number of certificates and the differences between schools and sexes.
Considering the few medical justification to avoid sport among young healthy people, the total number of excuses is considerable. We however have no "normal" number of excuses to compare to. This might be the occasion to encourage other countries/areas to do similar statistics permitting international comparisons. Very little literature exists in the field, the only articles found
dated from the 1970's (4). Among these, one article deals with "The
perpetuation of phantom handicaps in school age children". This
is indeed a subject of interest and could certainly be one of the side
effects of a lenient prescription of physical education certificates.
As to the inter school variations, the only hypothesis that was brought
by the PE teachers was that it could be linked to the overall level
of absenteeism in the school. A more school specific research would
be necessary to answer this question.
The large amount of certificates certainly has important repercussions
on the physical activity of this age group. The causes are probably
multiple: real health problems; low motivation to participate in PE
(especially girls); the fact that you can leave school if you don’t
participate; unattractive PE lessons and finally un-adapted lessons
compared to the potential of certain children. In this respect, a strong
focus on performance can constitute an obstacle for certain children.
A reorientation towards personal, progressive progress and more individually
adapted PE might encourage the less performant to participate more (6).
Significant differences were observed between boys and girls, which
seems to reflect the differences described in the literature (7). It
is however , difficult to explain that girls should be less apt to participate
in PE than boys.
The new certificate was well accepted by health professionals and is
quite widely used. It has permitted to decrease overall and especially
long term certificates, even though it is improbable that the certificate
alone made all the difference. The process definitely permitted an open
debate between professionals and has encouraged doctors to prescribe
shorter term inaptitude.
We have now started a process aiming at offering an adapted PE class,
during lunch time or after school, to children that can not participate
in regular PE classes. This would permit to ensure that all children
get adapted and regular physical activity. References
1. Office Féderale du Sport, OFSP, SGPG, SGP, SGSM. Santé
et pratique du sport pendant l'adolescence: quelques faits. Prise de
position scientifique. Revue Suisse de Médecine et de traumatologie
du sport 1999;175-9. **
2. Biddle S., Cavill N., Sallis J. Policy framework for young people
and health-enhancing physical activity. In Young and Active? Young people
and health-enhancing activity - evidence and implications. London: Health
Education Authority, 1998;3-16.**
3. World Health Organisation. Diet and physical
activity: a public health priority. http://www.who.int/dietphysicalactivity/en/
. 2005. Ref Type: Internet Communication **
4. Murdock CG. Excuse from physical education. J.Sch Health 1967;387-90. 5. Keeve JP. Perpetuating phantom handicaps in school age children. Except Child 1967;539-44.
6. Housseau B. Médecins scolaires: accompagner les adolescents
vers la reprise de l'activité physique. La santé de l'homme
2005;25-6.
7. Michaud PA, Narring F, Cauderay M, Cavadini C. Sports activity, physical
activity and fitness of 9- to 19-year-old teenagers in the canton of
Vaud (Switzerland). Schweiz.Med.Wochenschr. 1999;691-9.* *P. Mahler, *P. Bouvier, P. Kurer, JJ Cuenoud, M. Houlmann*
Centre de Médecine d'Exercice Service de Santé de la JeunesseCP 3682 1211 Genève 3 Switzerland Tel: 0223276157 Fax:0223276171 per.mahler@etat.ge.ch  http://www.icsspe.org/portal/index.php?w=1&z=5 |