A National School Health Campaign in Lebanon on Children Aged between 3 and 12 Years Old: Concordance Level between Parents’ Reports and Medical Visit Findings about Physical and Mental Health

**Background:** Parental health literacy is critical for child health, but parents may not be fully aware of their children's physical and mental health status. This study aimed to assess the concordance between parent reports and medical findings from a national school health campaign in Lebanon, covering both observable and non-observable health domains. The study was conducted by the Order of Malta Lebanon (OML) across 27 schools (16 public, 11 semi-private) in proximity to OML medical centers and Mobile Medical Units (MMUs).

**Methods:** A cross-sectional study was conducted from November to December 2022. In the first step (Nov 14-19, 2022), physicians performed physical exams and nurses conducted face-to-face mental health interviews with 7,184 students aged 3-12 years. In the second step (first 10 days of December 2022), trained medical students interviewed parents by phone (30-35 minutes) using a questionnaire matching the medical assessment items. The final analytical sample included 3,380 children whose parents consented and completed the interview. Overlapping variables between medical assessments and parent questionnaires were compared: physical health (vital signs, vision, hearing, oral health, skin, posture, vaccination, etc.) and mental health (sadness, anxiety, loneliness, bullying, behavioral problems). Mismatch was categorized as very extreme (>50%), extreme (30-50%), moderate (15-30%), or mild (<15%). Cohen's kappa was calculated for each item. Bivariate analyses (chi-square, Fisher exact, t-test, ANOVA) identified sociodemographic factors associated with mismatches.

**Key Results:** Very extreme mismatches (>50%) were found for: sadness (69.1%, kappa=0.008), incomplete vaccination (67.8%, kappa=0.011), withdrawal/loneliness (61.0%, kappa=0.007), BMI/nutrition (59.0%, kappa=0.03), anxiety (53.4%, kappa=0.034), and level of consciousness (52.5%, kappa=-0.001). Extreme mismatches (30-50%) included: passive smoking (47.3%, kappa=0.103), oral cavities (40.3%, kappa=0.228), enlarged tonsils (39.9%, kappa=0.044), and bullying (32.9%, kappa=0.078). Moderate mismatches were vision problems (20.5%) and ear infections (18.0%). Mild mismatches (<15%) included skin lesions (3%), hypercholesterolemia (0.8%), and posture (2.5%). Sociodemographic factors significantly associated with mismatches included: school type (public vs. private), governorate, child age, family income, parental education and occupation, and child's medical history. For example, sadness mismatch was higher in public schools (p=0.013), in the South governorate (77.2% vs. 54.5% in Beirut, p<0.001), and among children aged 3-6 years (p<0.001). Vaccination mismatch was higher in private schools, families earning >USD 900/month, and among employed parents with higher education (all p<0.001).

**Clinical Implications:** The study reveals critical gaps in parental awareness of children's health, particularly for non-observable conditions (mental health) and for vaccination and weight status. These mismatches indicate that parents often lack accurate knowledge about their children's health, which can delay diagnosis and treatment. The findings support the need for: (1) improved parent-physician communication, especially regarding vaccination schedules and weight status; (2) school-based health campaigns that actively involve parents; (3) targeted educational interventions for parents on recognizing mental health symptoms (sadness, anxiety, loneliness) and the importance of open communication; (4) enhanced oral health education, particularly for lower-income families; and (5) addressing stigma around mental health in rural areas. The study's large sample size and comprehensive coverage of multiple health domains provide robust evidence for public health strategies in Lebanon and similar settings.