The Journal of School Nursing2024, Vol. 40(5) 574–583© The Author(s) 2023Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405231163753journals.sagepub.com/home/jsn
Abstract
The burden of childhood visual impairment and disparities in access to pediatric vision care remain pressing issues in the United States. School-based vision programs (SBVPs) serve as one approach to advancing health equity. Operating at the intersection of schools and healthcare, SBVPs can increase access to pediatric vision services, improve academic performance, and facilitate referrals to community vision care providers. To maximize their impact, SBVPs must tailor their services to the individual needs and resources of local school communities. School nurses, who have strong ties to school health care services and the school community, are trusted partners in building SBVPs. This article aims to facilitate SBVP development, implementation, and sustainability processes by offering guidance for school nurses and other stakeholders who aim to build a SBVP, support local programs, or learn more about how SBVPs operate.
Keywordsscreening/risk identification, evidence-based practice, coordinated school health program, health disparities, program development/evaluation
There is an unmet need for pediatric vision care in the United States (Prevent Blindness, n.d.). Uncorrected refractive error is the most common cause of childhood visual impairment, affecting up to 15% of children (Schneider et al., 2010; Varma et al., 2008). Although more than three-quarters of states require school-age children to receive a vision screening, often overseen by school nurses in the school setting, there is wide variation in the grade levels screened (Prevent Blindness, n.d.). As state mandates were modified during the COVID-19 pandemic, even more children may have missed routine vision screenings in the last two years (Antonio-Aguirre et al., 2023). After a vision screening is performed, challenges exist in connecting students to follow-up community eye care, with reports that only half of the children found to have visual difficulties during a vision screening were able to receive follow-up care (Alvi et al., 2015). Disparities in pediatric vision care have been frequently documented. Children who are Black or Hispanic, have Medicaid, or live in high-poverty areas may have both decreased access to needed services and poorer vision outcomes (Guo et al., 2021; Killeen et al., 2022; Lee et al., 2018). In the face of these challenges, there is a need for more intensive and collaborative solutions to address children’s vision care needs. As described by the National Center for Children’s Vision and Eye Health at Prevent Blindness, successful pediatric vision screening requires multiple steps before, during, and following a vision screening event (NCCVEH, 2012). School-based vision programs (SBVPs) are one approach to delivering this sequence of eye care services directly in the school setting.
SBVPs work by partnering with both schools and eye care providers to offer vision care services within the school setting. These services typically include vision screenings, eye examinations for students referred based on screening results, provision of eyeglass prescription and/or eyeglasses, when indicated by the eye exam, and community referrals for students with more complex vision care needs. SBVPs have been shown to make a substantial impact on children’s lives, improving access to screening (Milante et al., 2021), reducing the burden of uncorrected refractive error (Alvi et al., 2015), and increasing eyeglass use in urban minority populations (Guo et al., 2021). Poor vision has been shown to negatively affect students’ learning (Collins et al., 2017; Maples, 2003), while the provision of eyeglasses through SBVPs has been shown to improve reading ability (Hark et al., 2020) and boost standardized test scores (Neitzel et al., 2021). Efforts to promote the routine wearing of prescribed eyeglasses may improve classroom behavior, increase academic engagement, and decrease disruption (Haag et al., 2022).
The establishment and operation of SBVPs are multifaceted and require coordination across multiple stakeholders, including those who have strong relationships with schools, given the importance of school engagement for eliciting program participation, building trust (Nahum et al., 2022; Vongsachang et al., 2020), and connecting children who need ongoing care to community providers (Alvi et al., 2015; Shakarchi & Collins, 2019). For those unfamiliar with the school setting, it can be challenging to develop a school-based program tailored to the specific eye care needs of a school community. School nurses, who have strong ties to school health care services and the school community, are uniquely positioned to support SBVP development and incorporate emerging evidence-based practice findings into SBVP operations.
While SBVPs are growing in popularity as an evidencebased intervention to increase access and reduce disparities in pediatric eye care, there are currently no resources or how-to guides to aid school nurses, school administrators, eye care providers, or other stakeholders who aim to build a SBVP. Here we offer considerations relevant to the building or strengthening of existing programs that may be of use for key stakeholders.
Considerations in the development or expansion of a SBVP are broadly divided into three phases: planning, implementation, and sustainability (Table 1). This report was reviewed by the Johns Hopkins Medicine Institutional Review Board and determined to be exempt.
Understanding the needs and resources in the local community will inform the goals, scope, and scale of a SBVP. Defining the program scope should include decisions about the services offered and the student population served. A needs analysis should include an understanding of (1) the current state and local vision screening requirements and practices, (2) local organizations and providers that currently offer screenings, eye exams, or eyeglasses, (3) existing personnel (e.g., school nurses) and equipment within schools to support vision screenings, (4) parental consent requirements for school-based programs and policies regarding sharing student information between schools and partner agencies, (5) barriers that children and their families currently encounter when connecting with eye care after a vision screening indicated visual difficulties, (6) the magnitude of uninsured or underinsured students in the community, and (7) local cultural influences regarding eyeglasses wear or vision care (Ezinne et al., 2020).
State vision screening mandates typically specify which grade levels, if any, receive required or recommended vision screening, as well as required screening components and documentation practices (Wahl et al., 2021). Beyond screenings, it is important to understand the current accessibility of eye care within the community. Prior work has demonstrated that children, especially from low-income families, have difficulty connecting with needed follow-up vision services for issues identified during vision screenings (Williams et al., 2013). Understanding barriers in access to and utilization of community-based eye care services will enable SBVPs to create proactive measures that mitigate their effects.
The SBVP should engage stakeholders, including local schools, health departments, ophthalmic and optometric providers, pediatricians, youth-focused community organizations, students, and families, among others. Understanding stakeholder perspectives, experiences, and resources will provide valuable insight into how best to design and operate a SBVP in a specific community. When applicable, measures should be taken to coordinate with other local organizations that may provide vision screenings, eye exams, or eyeglasses to maximize impact and reduce any duplication of services. Such organizations may also be important partners in the establishment or growth of a SBVP.
An SBVP should include a clear delineation of roles and responsibilities for all program partners, including who will facilitate the processes of vision screenings, obtaining caregiver consent, eye examinations, eyeglasses dispensing, operational support, data management, community outreach, school engagement, and coordination with community eye care providers for follow-up care.
In preparing a budget for a SBVP, stakeholders should identify initial funding needs and long-term sustainability considerations. The SBVP budget should include start-up costs and annual operating expenses, such as personnel, facilities, and technology (screening tools and data management platforms). SBVPs may explore state coverage options, including reimbursement for screenings, eye exams, and eyeglasses, which may vary by state. Additional funding sources to consider include grant support from philanthropic organizations, corporate entities, and federal funding agencies, among others.
SBVPs need staff to support core program operations, including vision screenings, eye exams, dispensing of eyeglasses, and administrative needs, including management of program logistics (e.g., collecting consent forms, scheduling screenings and eye exams, placing orders for eyeglasses and eyeglasses replacements, and billing, when applicable). In addition, staffing is needed for data management, information technology, compliance with relevant state or federal privacy laws, and care coordination/case management when students are referred for additional vision needs. Effective SBVP operations also require regular communication among school staff, which may include school nurses, administrators, teachers, social workers, and school counselors, as well as with local health departments. Other SBVP support needs include monitoring and promoting eyeglass use among students, offering educational programs about vision and eye health, and gathering feedback about program operations. These roles may be taken on by schools, dedicated SBVP staff, program partners, or a combination thereof.
The consent approach for SBVPs may differ and should be informed by stakeholder perspectives, local regulatory requirements, eye exam protocol (e.g., use of dilating drops), and consent practices adopted by other local school-based programs. Understanding these considerations is essential, as the inability to obtain consent for program participation has previously been reported as a major barrier to serving students through school-based health programs (Vongsachang et al., 2020). Consent for vision screening is more often done with an opt-out approach, similar to what is used for other school health screenings (Connors et al., 2022; Marshall et al., 2003), while the consent approach for eye exams can vary. Eye exam consent strategies include opt-out consent and opt-in consent, either distributed to all students or only to students who are referred after a vision screening. If a SBVP distributes consent forms to all students, the forms can be given out at the beginning of the school year alongside other school forms, which can simplify the process of completing and returning these documents. Other opportune times to distribute forms include events during which caregivers are on site at schools, including “back to school” nights and parent–teacher conferences. Opt-out consent for eye exams requires SBVP to consult school leadership to ensure legal approval and community acceptance of this approach. Consideration of the logistics of these consent approaches as well as the pros and cons of each strategy within a particular school or community can inform the best approach for each SBVP. School nurses contribute a valuable perspective given their familiarity with the school community and knowledge of consent strategies implemented by other local programs. With either opt-in or opt-out consent, SBVPs may consider utilizing electronic or text-based formats, in addition to paperbased consent, to improve the speed and ease of the consent process. Access to technology, including smartphones and computers, and availability of phone numbers and email addresses across the student and caregiver populations are, however, key considerations for the implementation of these methods. Child assent with a waiver of parental/guardian consent or emancipated minor consent may be applicable for some children based on state laws. However, this approach is not routinely used for SBVPs.
Regardless of approach and delivery method, the key goal of the consent process is to ensure that families understand the purpose of the SBVP and what it means for a student to participate. In the short-term, families’ understanding can build trust and improve the adoption of program recommendations, such as children wearing their prescribed eyeglasses. In the long-term, continued familial engagement may help improve awareness of the importance of good vision for overall health and academic achievement, as well as the need to connect with community providers for any routine long-term follow-up and complex care needs.
When developing a vision screening protocol, the SBVP team should consider personnel, training, and equipment needs. The protocol should specify who will schedule screenings, which grades will be screened, when and where screenings will be conducted, and how the SBVP screenings may interface with existing state requirements, as well as other local groups that provide screening services. The vision screening protocol should be informed by the best, current evidence about the assessments to be conducted, eye exam referral criteria, and the role of instrument-based screening (Logan & Gilmartin, 2004; NCCVEH, n.d.). As the evidence evolves, the screening protocols need to be updated accordingly. The advantages of instrument-based screening include its speed and independence of a child’s familiarity with letter optotypes, making it particularly useful for younger children (Donahue & Baker, 2016). Instrument-based screening is not yet a recommended standalone screening tool for school-age children. The SBVP protocol should establish processes to work with school nurses and school health staff to coordinate screening schedules that fit into the school days. The protocol should also develop processes to document screening results and report them in plain language to families, teachers, school nurses and school health staff, and local health departments, when applicable. Finally, the SBVP should create contingency plans to conduct vision screening for students who are absent from school on primary screening days.
Personnel providing eye exams must be state-licensed vision care providers and meet requirements for delivering care within schools (e.g., school district background checks, when applicable). The SBVP team may choose to have providers meet additional criteria, such as prior experience working with children. At a minimum, eye exams should be offered to children who meet referral criteria during vision screenings. Depending on the program scope, eligibility may be expanded to include teacher referrals, student/family requests, or students who are currently wearing outdated eyeglasses. Teacher referrals can be especially helpful to identify students in need of SBVP services outside of scheduled grades or screening times. While SBVPs can conduct school-based exams on the vast majority of students, there may be a subset of students with behavioral, developmental, or physical needs who should bypass a school-based exam due to the complexity of their condition and instead be connected with a community provider for a comprehensive eye exam (Donahue & Baker, 2016). Programs should consider creating a list of local providers to facilitate necessary connections to community care. Although beyond the scope of this paper, these lessons about connecting children to community providers are also relevant for schools that conduct vision screenings without support from a SBVP; it is important to leverage local resources to ensure that children in need of follow-up eye care can access community providers.
The eye exam protocol should specify the components of the exam, including eyeglass prescribing guidelines, space requirements for performing exams, and infection control considerations in light of COVID-19 and other current public health issues. The eye exam protocol should also establish a referral process for students who are unable to cooperate for a school-based eye exam, or have more complex eye care needs, such as strabismus, amblyopia, and other non-refractive ocular conditions that cannot typically be managed through a SBVP. There is marked variation across programs regarding the use of dilating drops, with some performing dilated exams on most or all students and some not using drops at all. Individual SBVPs should consider the pros and cons of whether to use dilating eye drops as part of the eye exams conducted at schools. This decision should be made in consultation with eye care providers so as to best meet the needs of the student population and to ensure accurate eyeglass prescriptions (Funarunart et al., 2009; Guo et al., 2022). SBVPs that do not dilate must take steps to minimize accommodation. Furthermore, prescribing guidelines should include acuity and refractive error thresholds to avoid prescribing eyeglasses unnecessarily. The protocol should specify whether students will be provided a prescription, eyeglasses, or both, and describe the process for communicating eye exam findings to families, teachers, and pediatricians. For programs that provide eyeglasses, families should be aware of any associated out-of-pocket costs or insurance billing. For programs that do not provide eyeglasses, efforts should be made to inform families about where affordable eyeglasses can be obtained.
Space requirements for SBVPs vary depending on the design of the program. SBVPs may vary from mobile clinics parked at schools to temporary eye exam facilities set up in schools with portable equipment. Program planning necessitates an understanding of equipment and spacing needs, including parking, electrical outlets, and building access for mobile clinics. It is also important to consider the number of students that can be served per day in a SBVP, which will vary based on the clinic and staff capacity and the burden of uncorrected refractive error needs within the school population.
Dispensing. For SBVPs that provide eyeglasses, the process of dispensing glasses is typically carried out directly at a child’s school. Less commonly, eyeglasses are mailed to a student’s home. When dispensing eyeglasses at school, there should be coordination between opticians (or the dispensing team), school nursing staff, and teachers. The SBVP should develop an eyeglasses distribution protocol, which describes the personnel involved in dispensing, any requisite training, equipment needs for fitting/adjustment, and the materials provided (eyeglasses, lens cleaning cloths, eyeglass cases, instructional material about wear and care of eyeglasses). If mailed home, methods for verifying addresses before mailing eyeglasses should be identified, especially in populations with high student mobility. To increase the impact of eyeglasses and account for student mobility, efforts should be made to minimize the interval between eye examination and eyeglasses distribution. Quality assurance measures for eyeglass ordering and dispensing should include a confirmation of the correct lens prescription, as well as follow-up measures with students and families to determine satisfaction with eyeglasses.
Monitoring. The SBVP can provide teachers with a list of students who were prescribed eyeglasses to help them monitor eyeglass use and encourage their students’ eyeglasses adherence (Huang et al., 2019). When feasible, a SBVP can integrate information about students who wear eyeglasses into electronic student academic record systems. This integration may be especially helpful in populations with high student mobility, as it can follow students across schools.
Replacements. Children will sometimes lose or break their glasses. SBVPs need a protocol for whether replacements will be provided and how they can be requested. Teachers and school staff need to be made aware of the replacement program, so they can help facilitate its utilization (Vongsachang et al., 2021). To reduce the likelihood of children going for long periods of time without eyeglasses, some programs may offer two pairs of eyeglasses initially and leave one pair with school staff, depending on school health staff resources.
SBVPs may be supported by a variety of sources, including philanthropy, state and local funding, billing insurance providers, or a combination of the above. When billing a student’s insurance is part of a SBVP’s operations, there should be explicit communication with families about billing procedures, including the use of any personally identifiable health information, any associated out-of-pocket costs, and the process for obtaining necessary insurance information in alignment with federal privacy laws. To support the goal of making pediatric eye care accessible to all students, SBVPs should aim to minimize out-of-pocket costs and to cover costs for any uninsured or underinsured students. For uninsured students, SBVPs should be aware of school resources that provide assistance to families in obtaining insurance coverage.
SBVPs require internal communication among the parties responsible for program operations and external communication between the SBVP, program stakeholders, and the community-at-large. Given that multiple organizations may need access to program data for reporting purposes, methods for secure inter-agency information sharing should be established. SBVPs may also consider seeking legal advice related to safe and permissible data-sharing practices. External communication strategies should work to ensure that students, families, and other stakeholders are aware of services offered, access to services, and eligibility criteria, if applicable. As limited awareness of SBVPs has been reported as a substantial barrier to participation (Vongsachang et al., 2020), SBVPs should consider the factors that may prevent communication from reaching students’ caregivers, including changes in home contact information or difficulty in identifying the parent or guardian. In addition, SBVP communications should be made available in different languages to account for non-English speaking households. School health staff are well-positioned to assist SBVPs in navigating communication barriers within the school community and adjusting outreach strategies accordingly. Eliciting ongoing feedback from SBVP partners, students, families, and the community is an important strategy to continuously improve the program and ensure its agility in responding to community needs. Wider outreach from SBVPs can report program impact, best-practices, and lessons learned to advocacy groups, policymakers, and funders locally, regionally, and nationally.
Education efforts should inform school staff, students, and families about SBVP logistics, eye health, the academic impact of poor vision, and the wear and care of eyeglasses. SBVPs may also consider developing educational programs (e.g., vision and eye health fairs) as an opportunity to increase all students’ exposure to the science of eyesight. In some cases, this science exposure can be done in partnership with community organizations focused on STEM mentorship for students.
SBVPs may utilize technology to support program operations, depending largely on SBVP resources and community access to the internet and devices. Technology used during the screening process could include instrument-based screening or electronic data entry and management. Consent for screenings and eye exams can be offered electronically or through text. The eye exam process and/or documentation may be performed using an electronic health record platform. Some programs may have telehealth platforms, enabling providers to connect virtually with students and families during an eye exam, though this option is not routinely available when eye exams are conducted at school. Technology may also be used to facilitate meetings between students’ caregivers and SBVP staff regarding questions about SBVP operations, eye exam results, community referrals, or prescribed eyeglasses.
SBVP data includes student enrollment data, vision screening results, consent for eye exams, eye exam results, and eyeglass dispensing, replacement, and monitoring data. SBVPs need an integrated system to manage electronic and paperbased data input across multiple entities. The SBVP data management protocol should address how data is stored and shared across partner organizations, and how exam results are communicated to students and families. In all processes of data management, the privacy of health information, secure data transfer and storage, and alignment with the Health Insurance Portability and Accountability Act (HIPAA) and Family Education Rights Privacy Act (FERPA) must be considered.
SBVPs should develop quality assurance practices and establish protocols for tracking processes and outcomes. Regular progress reports measuring program processes should document the number of students who received a vision screening, passed or did not pass screening, provided consent for an eye exam, received an eye exam, were prescribed eyeglasses, received replacement eyeglasses, or received a referral for additional care. Quality control measures should be implemented to ensure that program operations are executed with fidelity. Across program components, these quality control measures may include validation of screening and eye exam outcomes, periodic internal review of eye exam documentation, review of alignment between referral criteria and referrals sent, how many students wore eyeglasses as prescribed, and accuracy of lenses made by the optical lab. Finally, as SBVPs recognize the interrelatedness of health and learning, it is important to examine their impact on the health and academic outcomes of the students served.
Regarding SBVP quality improvement, gathering feedback from stakeholders such as students, families, and teachers can be a key tool to identify focus areas. Feedback may be elicited through organized focus groups and/or surveys. While focus groups are helpful for answering specific questions about SBVP operations and obtaining detailed feedback, surveys may be more convenient for stakeholders and can allow for more timely feedback about program operations.
In building a SBVP, careful consideration must be made in program planning, implementation, and sustainability to meet the goal of increasing access to pediatric eye care. In each phase, SBVPs require a strong partnership between school health staff, teachers, and vision care providers. Due to school nurses’ experience and relationships within the school community, they are important partners in supporting the success of SBVPs and ultimately advancing health equity for disadvantaged students.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Christina Marie Ambrosino https://orcid.org/0000-0002-0171-6815
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Christina M. Ambrosino, BS, a medical student at Johns Hopkins School of Medicine, Baltimore, Maryland, United States.
Jonathan Callan, MD, a resident doctor at the University of California, San Francisco, California, United States.
Tresa M. S. Wiggins, MSN, RN, CPNP-PC, a pediatric nurse practitioner in Baltimore, Maryland, United States.
Michael X. Repka, MD, MBA, is a professor of Ophthalmology and a professor of Pediatrics at the Johns Hopkins University School of Medicine, Baltimore, Maryland, United States.
Megan E. Collins, MD, MPH, is an ophthalmologist in Baltimore at Johns Hopkins School of Medicine, Maryland, United States.y
1 Wilmer Eye Institute Dana Center for Preventive Ophthalmology, Johns Hopkins School of Medicine, Baltimore, MD, USA
2 University of California San Francisco, San Francisco, CA, USA
3 Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
* This work was accepted as a poster for an American Association for Pediatric Ophthalmology and Strabismus annual meeting in 2020; it has not been published elsewhere.
Corresponding Author:Megan Collins, MD MPH, Wilmer Eye Institute Dana Center for Preventive Ophthalmology, Johns Hopkins School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA.Email: mcolli36@jhmi.edu
