Evidence Based Practice and Policy
The Effect of an On-Site Vision Examination on Adherence to Vision Screening Recommendations
The Journal of School Nursing 2015, Vol. 31(2) 84-90 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1059840514524599 jsn.sagepub.com
Raymond Chu, OD, MS1, Kristine Huang, OD, MPH1, Carmen Barnhardt, OD, MS1, and Angela Chen, OD, MS1
Abstract Vision screenings are intended to efficiently identify students with possible visual impairment and initiate a referral for diagnosis and treatment. In many cases, at-risk students do not access the recommended care or experience delays in receiving care. The purpose of this article is to report the effect on adherence to vision screening recommendations by providing the eye examination at the students’ school and at no cost. Of the 1,306 students screened, 382 (29.2%) were identified with possible visual impairment. Parental consent for examination was obtained for 198 (51.8%) students. Our vision screening and examination program yielded similar adherence to follow-up as stand-alone vision screening programs. Future program considerations should address perceptual barriers that may be contributing to parental nonadherence to vision screening recommendations. Keywords school-based clinics, health education, quantitative research, school nurse education
The objectives of a school vision screening program are to identify students with possible visual impairment, to notify the parents/guardians that their child needs further examination by an eye care professional, and to establish follow-up procedures to ensure students receive appropriate care (Ong & Davis-Alldritt, 2005). Unfortunately, many parents/guardians do not follow through with vision screening recommendations. The Baltimore Pediatric Eye Disease Study found that 5.1% of the study subjects would have benefited from glasses, but only 1.3% of the subjects actually received glasses (Giordano et al., 2009). Parental focus group discussions have identified the following as reasons for delayed care or nonadherence to seeking professional care: lack of awareness of the impact of visual impairment, cost of care/glasses, and limited access (e.g., limitations in available appointments; Yawn, Kurland, Butterfield, & Johnson, 1998). The purpose of this study was to examine whether addressing two specific barriers, cost and limited access to an eye care professional, would improve parental adherence to vision screening recommendations.
(2005) reported the prevalence of visual impairment and blindness among children 200% of the poverty level (Centers for Disease Control and Prevention, 2005). Sullivan (2006) reported 23.3% of uninsured children have delayed or unmet vision needs and are 5 times more likely than insured children to have unmet vision needs. Kemper, Bruckman, and Freed (2006) also reported uninsured African American or Hispanic children have lower odds of having glasses than insured African American or Hispanic children. Concern about the cost of care or the lack of insurance coverage is often considered the primary reason that parents/guardians do not seek vision care for their children; however, delays in care were also attributed to limited accessibility of care. Parents of dual income families feared potential loss of wages from time away from work and needing to travel long distances to seek care (Kemper, Bruckman, & Freed, 2006). Community health centers provide affordable and accessible medical care to low income, Medicaid participants and uninsured community members. Shin and Finnegan (2009) randomly surveyed 300 federally qualified health centers and found nearly 7 out of every 10 centers did not provide on-site vision services. Even if appointments could be made in a timely fashion, families often felt discriminated against and unwelcome while in the medical practices (Devoe et al., 2007).
Method Design Through a grant provided by the Kids Vision for Life Foundation, staff optometrists and interns from the Southern California College of Optometry at Marshall B. Ketchum University screened a total of 1,306 students and examined 198 students at two Title I schools (publicly funded schools with a large portion of the surrounding attendance area are low-income families) in the Santa Ana Unified School District from November to December 2012. The vision screening included an evaluation of distance and near visual acuity using a Snellen visual acuity chart. A LEA symbols chart was used if a student did not know the letters on a Snellen visual acuity chart. LEA symbols consist of four simple symbols (heart, square, circle, and house) that the student can identify verbally or by matching using a matching card. Refractive error was assessed with retinoscopy, a doctor-performed technique used to determine the amount of farsightedness, nearsightedness, and/or astigmatism. Binocular vision anomalies, including strabismus, were assessed with the unilateral and alternating cover test, version test, and near point of convergence testing. The unilateral
Table 1. Failure Criteria for the Modified Clinical Technique. Visual acuity 20/40 or worse Two lines or greater difference in acuity between either eye Cover test Any strabismus Esophoria ≥ 5D at distance or 6D at near Exophoria ≥ 5D at distance or 10D at near Hyperphoria ≥ 2D at distance or near Retinoscopy Hyperopia ≥ þ1.50 DS Myopia ≥ 0.50 DS Astigmatism ≥ 1.00 DC Anisometropia ≥ þ1.00 DS Note. Adapted from ‘‘Vision screening for elementary schools: The Orinda study,’’ by H. Blum, H. Peters, and J. Bettman, 1959.
cover test is used to detect the presence of strabismus and the alternating cover test is used to identify nonstrabismic binocular vision disorders (misalignment of the eyes). Version testing examines the function of the eye muscles, and near point of convergence testing screens for the most common nonstrabismic binocular vision disorder, convergence insufficiency (Rouse, Hyman, Hussein, & Convergence Insufficiency and Reading Study Group, 1997). Convergence insufficiency often leads to signs and symptoms such as eyestrain, headaches, fatigue, and avoidance of near tasks or the appearance of being easily distracted during reading or near tasks (Borsting et al., 2003; Rouse et al., 2009). In addition, color vision screening was performed. Students meeting any of the predetermined failure criteria were recommended for a comprehensive eye examination (Table 1; Blum, Peters, & Bettman, 1959). The results of the vision screening were recorded by the school nurse in the student’s health record database and a bilingual (English and Spanish) written report indicating whether the student passed or failed the vision screening was sent home (Figure 1). The report also indicated which components of the vision screening the student failed. Students marked as failing the screening were asked to obtain parent/guardian consent for an eye examination. In the event that the consent form was not returned, school personnel attempted to call the student’s parent/guardian. A comprehensive eye examination was performed on all students who failed the vision screening and who had returned signed consent forms. The eye examination included an assessment of visual acuity, eye alignment, binocular vision function (e.g., depth perception testing), refractive error, and ocular health. In some cases, a cycloplegic refraction using two drops of 1% cyclopentolate was performed to determine a child’s refractive error without the influence of accommodative focus. A report explaining the vision findings and recommendations, including whether glasses or additional care was needed, was sent home to the parents/ guardians at the conclusion of the examination. Following the eye examination, an optician from the Southern California College of Optometry visited each
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2575 Yorba Linda Blvd. Fullerton CA 92831. 714.992.7870. www.sccoeyecare.com
Child’s Name: ___________________________________________________________, After a series of brief tests, considered a vision screening, the doctor has found: Despue´s de realizar las pruebas ba´sicas de visio´n, el opto´metra considera: c
Normal visual acuity / Agudeza visual es normal
After a series of brief tests, considered a vision screening, the doctor would like you to see an Optometrist/Medical Doctor for the following concerns: Despue´s de realizar las pruebas ba´sicas de visio´n, el Doctor le recomienda que usted visite un Opto´metra / Me´dico para una mayor evaluacio´n de las siguientes condiciones: c
Reduced visual acuity /Discapacidad visual
c
Abnormal eye teaming / Dificultades del uso de ambos ojos a la vez
c
Other (Otro) _____________________________________________ A vision screening does NOT replace a periodic professional vision and eye health examination performed in your doctor’s office – please see your Optometrist yearly! Esta prueba ba´sica de la visio´n NO remplaza el examen completo de los ojos y la visio´n que se lleva acabo en la oficina de su doctor. Por favor visite a su Opto´metra cada an˜o!
..................................................................................................................................................................................................................................................... Your child will receive a comprehensive eye examination during school hours. By signing below, you as the parent or legal guardian authorize the treatment/care for this child under the general supervision of a staff optometrist. This consent is given pursuant to the provisions of section 25.8 of the Civil Code of California. Su hijo recibira´ un examen completo de la vista durante el horario escolar. Al firmar abajo, usted, como padre o guardia´n legal, autoriza el tratamiento/cuidado de este nin˜o bajo la supervisio´n de un opto´metra. Este consentimiento se da conforme a las disposiciones del artı´culo 25.8 del Co´digo Civil de California. Cuando llene la forma, por favor devue´lvala a la enfermera de la escuela antes de la cita de su hijo(a). Parent/Guardian Signature
Date
Firma de Padre o Guardia´n
Fecha
_________________________________________
_________________________________________
Please return this form to the school nurse before your child’s appointment. Cuando llene la forma, por favor devue´lvala a la enfermera de la escuela antes de la cita de su hijo(a). Figure 1. Bilingual (English and Spanish) patient vision screening report and parent/guardian consent form (Flesch–Kincaid Grade Level 12.0).
school to help students with frame selection, ordering of lenses, and delivery of the glasses.
Population School A had an enrollment of 675 students from Kindergarten through fifth grade (data from 2012 to 2013; Ed-Data Website, 2013). The student body consisted of 97.3%
Hispanic or Latino students and 88.6% (data from 2011 to 2012) of students received free or reduced price meals. School B had an enrollment of 707 students from Kindergarten through fifth grade (data from 2012 to 2013; Ed-Data Website, 2013). The student body consisted of 98.7% Hispanic or Latino children (data from 2012 to 2013) and 87.9% of students (data from 2011 to 2012) received free/reduced price meals. In California, a child’s family income must fall
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Table 2. Number of Children Screened.
School A School B
Total
Pass
% Pass
Failure
% Failure
675 631
435 489
64.4 77.5
240 142
35.6 22.5
below 130% of the federal poverty guidelines to qualify for free meals or below 185% to qualify for reduced-cost meals.
Human Subjects Approval Statement An application including study synopsis was submitted to the Institutional Review Board and the Health Information Privacy Board at Marshall B. Ketchum University. The study was exempted from approval, as the protocol was not subject to ‘‘Common Rule,’’ Food and Drug Administration (FDA) regulations, or to California human subject regulations. As there were no personal identifying information about students nor the school, Health Insurance Portability and Accountability Act approval was not necessary as well.
Results A total of 675 students were screened at School A, with 435 students (64.4%) passing all portions of the screening and 240 students (35.6%) failing one or more portions of the screening (Table 2). At School B, 631 students were screened, with 489 students (77.5%) passing all portions of the screening and 142 students (22.5%) failing one or more portions of the screening (Table 2). Among the students who failed the vision screening, the most common reason for failure was reduced visual acuity and/or refractive error (Tables 3 and 4). Parental consent was returned by 48.3% of the screening failures at School A and 57.7% at School B (Table 5). A w2 analysis was performed to evaluate any association between the likelihood of returning the parental consent form and the cause for screening failure. No statistically significant relationship was found between students who returned their consent forms and those who did not and the cause for vision screening failure at either school (p ¼ .153 for School A, p ¼ .811 for School B). Among the students examined, 63 of the 116 students (54.3%) at School A and 64 of the 82 students (78%) at School B required a spectacle prescription (Table 6). Referral for additional services because of conditions such as amblyopia, strabismus, convergence insufficiency, or other eye disease was needed for 13 students (11.2%) at School A and 2 students (3%) at School B (Table 6).
Discussion Although vision screening programs are often advocated, the effectiveness of these programs in reducing visual impairment has yet to be validated largely due to the lack of
adherence to vision screening recommendations (Mathers, Keyes, & Wright, 2010; Powell & Hatt, 2009; Powell, Wedner, & Richardson, 2005). Programs, such as ours, can improve access by providing eye examinations and glasses at no cost to the family and with the convenience of the examinations being performed on-site; however, there remains a higher than expected rate of nonadherence, as about 50% of those requiring an examination did not return the parental consent form. The Vision First Program offered free eye examinations to students in the Cleveland Metropolitan School District and also found about 50% of parents signed the consent form for examination (Traboulsi et al., 2008). The Baltimore Vision Screening Project found that, despite offering free on-site examination and glasses, only 30% of subjects who failed the vision screening returned the following year with glasses (Preslan & Novak, 1998). Manny et al. (2012) found a similar result with no difference in adherence to glasses wear among subjects who received a vision screening and examination (28%) and subjects who received a vision screening and referral recommendation (27%). Health literacy plays an important role in the adherence to vision screening and vision examination recommendations (Nielsen-Bohlman, Panzer, & Kindig, 2004). In the Los Angeles Latino Eye Study, knowledge of a disease was found to be associated with an increased likelihood of seeking care (Unzueta et al., 2004). Interviews with parents/guardians found that a significant percentage of nonadherence to vision screening recommendations was due to not believing the screening results and being unaware of the impact that visual impairment can have (Kimel, 2006; Mark & Mark, 1999; Sharma, Congdon, Patel, & Gilbert, 2012). Tjiam et al. (2011) reported that poor literacy may have been the reason for the bulk of their unsuccessful referrals following a vision screening. Additionally, most printed patient-centered educational materials on vision are not written to an appropriate literacy level for most individuals (Muir & Lee, 2010). Traboulsi and colleagues (2008) recommended utilizing a social worker to increase the number of parental consents in the Vision First Program. Incorporating social workers or community health workers (CHWs) as part of the health care delivery team has been associated with improved health outcomes and gained increased utilization in the management of chronic conditions, such as diabetes (Ayala, Vaz, Earp, Elder, & Cherrington, 2010; Elder, Ayala, Parra-Medina, & Talavera, 2009; Viswanathan et al., 2009). CHWs are trusted members of the community who often serve in low socioeconomic communities that have limited access to health care and limited fluency in English. The role of the CHW can include helping people understand their health condition, linking community members to health care services, translating, and informal counseling (U.S. Department of Labor, 2010). School nurses are already charged with establishing procedures to ensure students receive appropriate follow-up with an eye care professional (Ong & Davis-Alldritt, 2005). Contacting parents to ensure appropriate follow-up has been made
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Table 3. Reason for Screening Failure at School A. Total
Number of Returned Consent Forms
% Returned
Number of Not Returned Consent Forms
% Not Returned
p Value
Refractive error (based on VA and/or retinoscopy, see Table 1) Binocular vision disorders (based on cover testing) Multiple fails
208
98
47.1
110
52.9
19
13
68.4
6
31.6
13
5
38.5
8
61.5
Total
240
116
48.3
124
51.7
.153
Total
Number of Returned Consent Forms
% Returned
Number of Not Returned Consent Forms
% Not Returned
p Value
Refractive error (based on VA and/or retinoscopy, see Table 1) Binocular vision disorders (based on cover testing) Multiple fails
119
70
58.8
49
41.2
9
5
55.6
4
44.4
14
7
50
7
50
Total
142
82
Note. VA ¼ visual acuity.
Table 4. Reason for Screening Failure at School B.
57.7
60
42.3
.811
Note. VA ¼ visual acuity.
Table 5. Number of Signed Consent Forms Returned.
School A School B
Total
Number Returned
% Returned
Number Not Returned
% Not Returned
240 142
116 82
48.3 57.7
124 60
51.7 42.3
Table 6. Examination Outcomes.
School A School B
Total
Number of Glasses Dispensed
% Glasses Dispensed
Number of Referred
116 82
63 64
54.3 78.1
13 2
can be implemented by a CHW in order to expand the school nurses’ role in delivering community-based programs focused on educating parents/guardians on the limitations of vision screening, the impact visual impairment has on learning, and addressing common barriers to wearing glasses in order to address the perceptual barriers that result in parental nonadherence to vision screening recommendations. Furthermore, collaboration between school nurses and teachers can improve the sensitivity of school vision screening programs and adherence to prescribed glasses. Krumholtz (2004) reported improved knowledge, attitudes, and behaviors in the teacher’s ability to identify children at risk for visual impairment after delivering an in-service lecture on vision and its role in learning. Involving teachers in monitoring and
% Number of No Treatment/ Referred Referral 11.2 2.4
40 16
% No Treatment/ Referral 34.5 19.5
encouraging their students to use their glasses resulted in dramatic increases in student adherence to their prescribed glasses (Ethan, Basch, Platt, Bogen, & Zybert, 2010; Kodjebacheva, Maliski, Yu, Oelrich, & Coleman, 2014). These program considerations in conjunction with vision screening and examination programs may improve vision outcomes that impact a student’s quality of life and academic potential.
Implications for School Nursing The aim of this program was to improve adherence to vision screening recommendations by removing the barriers of lack of financial resources and the need to travel to an eye care professional. We propose that future program considerations
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should expand the school nurses’ role in providing eye and vision education; coordination of care between teachers, parents/guardians, and eye care professionals; and if a comprehensive vision program is utilized, coordinating the delivery of the parental consent form for vision examination to coincide with the school’s highest rate of return of signed forms.
Limitations The main limitation was the small sample size at the two schools, which may limit generalizability. We presume that parental lack of awareness of the impact of visual impairment is a major barrier; however, we did not formally assess this in the group that failed to return their parental consent form. In addition, it is possible that adherence to screening recommendation was higher, as families may have elected to entrust their vision care with providers in the community. Postanalysis of the parental consent form determined that the Flesch–Kincaid grade level was 12.0, which may have impacted the number of returned consent forms due to a high reading level demand. However, the consent form was available in both English and Spanish (Figure 1). Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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Author Biographies Raymond Chu, OD, MS, is an associate professor at the Marshall B. Ketchum University. Kristine Huang, OD, MPH, is an assistant professor at the Marshall B. Ketchum University. Carmen Barnhardt, OD, MS, is an associate professor at the Marshall B. Ketchum University. Angela Chen, OD, MS, is an assistant professor at the Marshall B. Ketchum University.
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The Effect of an On-Site Vision Examination on Adherence to Vision Screening Recommendations
The Journal of School Nursing 2015, Vol. 31(2) 84-90 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1059840514524599 jsn.sagepub.com
Raymond Chu, OD, MS1, Kristine Huang, OD, MPH1, Carmen Barnhardt, OD, MS1, and Angela Chen, OD, MS1
Abstract Vision screenings are intended to efficiently identify students with possible visual impairment and initiate a referral for diagnosis and treatment. In many cases, at-risk students do not access the recommended care or experience delays in receiving care. The purpose of this article is to report the effect on adherence to vision screening recommendations by providing the eye examination at the students’ school and at no cost. Of the 1,306 students screened, 382 (29.2%) were identified with possible visual impairment. Parental consent for examination was obtained for 198 (51.8%) students. Our vision screening and examination program yielded similar adherence to follow-up as stand-alone vision screening programs. Future program considerations should address perceptual barriers that may be contributing to parental nonadherence to vision screening recommendations. Keywords school-based clinics, health education, quantitative research, school nurse education
The objectives of a school vision screening program are to identify students with possible visual impairment, to notify the parents/guardians that their child needs further examination by an eye care professional, and to establish follow-up procedures to ensure students receive appropriate care (Ong & Davis-Alldritt, 2005). Unfortunately, many parents/guardians do not follow through with vision screening recommendations. The Baltimore Pediatric Eye Disease Study found that 5.1% of the study subjects would have benefited from glasses, but only 1.3% of the subjects actually received glasses (Giordano et al., 2009). Parental focus group discussions have identified the following as reasons for delayed care or nonadherence to seeking professional care: lack of awareness of the impact of visual impairment, cost of care/glasses, and limited access (e.g., limitations in available appointments; Yawn, Kurland, Butterfield, & Johnson, 1998). The purpose of this study was to examine whether addressing two specific barriers, cost and limited access to an eye care professional, would improve parental adherence to vision screening recommendations.
(2005) reported the prevalence of visual impairment and blindness among children 200% of the poverty level (Centers for Disease Control and Prevention, 2005). Sullivan (2006) reported 23.3% of uninsured children have delayed or unmet vision needs and are 5 times more likely than insured children to have unmet vision needs. Kemper, Bruckman, and Freed (2006) also reported uninsured African American or Hispanic children have lower odds of having glasses than insured African American or Hispanic children. Concern about the cost of care or the lack of insurance coverage is often considered the primary reason that parents/guardians do not seek vision care for their children; however, delays in care were also attributed to limited accessibility of care. Parents of dual income families feared potential loss of wages from time away from work and needing to travel long distances to seek care (Kemper, Bruckman, & Freed, 2006). Community health centers provide affordable and accessible medical care to low income, Medicaid participants and uninsured community members. Shin and Finnegan (2009) randomly surveyed 300 federally qualified health centers and found nearly 7 out of every 10 centers did not provide on-site vision services. Even if appointments could be made in a timely fashion, families often felt discriminated against and unwelcome while in the medical practices (Devoe et al., 2007).
Method Design Through a grant provided by the Kids Vision for Life Foundation, staff optometrists and interns from the Southern California College of Optometry at Marshall B. Ketchum University screened a total of 1,306 students and examined 198 students at two Title I schools (publicly funded schools with a large portion of the surrounding attendance area are low-income families) in the Santa Ana Unified School District from November to December 2012. The vision screening included an evaluation of distance and near visual acuity using a Snellen visual acuity chart. A LEA symbols chart was used if a student did not know the letters on a Snellen visual acuity chart. LEA symbols consist of four simple symbols (heart, square, circle, and house) that the student can identify verbally or by matching using a matching card. Refractive error was assessed with retinoscopy, a doctor-performed technique used to determine the amount of farsightedness, nearsightedness, and/or astigmatism. Binocular vision anomalies, including strabismus, were assessed with the unilateral and alternating cover test, version test, and near point of convergence testing. The unilateral
Table 1. Failure Criteria for the Modified Clinical Technique. Visual acuity 20/40 or worse Two lines or greater difference in acuity between either eye Cover test Any strabismus Esophoria ≥ 5D at distance or 6D at near Exophoria ≥ 5D at distance or 10D at near Hyperphoria ≥ 2D at distance or near Retinoscopy Hyperopia ≥ þ1.50 DS Myopia ≥ 0.50 DS Astigmatism ≥ 1.00 DC Anisometropia ≥ þ1.00 DS Note. Adapted from ‘‘Vision screening for elementary schools: The Orinda study,’’ by H. Blum, H. Peters, and J. Bettman, 1959.
cover test is used to detect the presence of strabismus and the alternating cover test is used to identify nonstrabismic binocular vision disorders (misalignment of the eyes). Version testing examines the function of the eye muscles, and near point of convergence testing screens for the most common nonstrabismic binocular vision disorder, convergence insufficiency (Rouse, Hyman, Hussein, & Convergence Insufficiency and Reading Study Group, 1997). Convergence insufficiency often leads to signs and symptoms such as eyestrain, headaches, fatigue, and avoidance of near tasks or the appearance of being easily distracted during reading or near tasks (Borsting et al., 2003; Rouse et al., 2009). In addition, color vision screening was performed. Students meeting any of the predetermined failure criteria were recommended for a comprehensive eye examination (Table 1; Blum, Peters, & Bettman, 1959). The results of the vision screening were recorded by the school nurse in the student’s health record database and a bilingual (English and Spanish) written report indicating whether the student passed or failed the vision screening was sent home (Figure 1). The report also indicated which components of the vision screening the student failed. Students marked as failing the screening were asked to obtain parent/guardian consent for an eye examination. In the event that the consent form was not returned, school personnel attempted to call the student’s parent/guardian. A comprehensive eye examination was performed on all students who failed the vision screening and who had returned signed consent forms. The eye examination included an assessment of visual acuity, eye alignment, binocular vision function (e.g., depth perception testing), refractive error, and ocular health. In some cases, a cycloplegic refraction using two drops of 1% cyclopentolate was performed to determine a child’s refractive error without the influence of accommodative focus. A report explaining the vision findings and recommendations, including whether glasses or additional care was needed, was sent home to the parents/ guardians at the conclusion of the examination. Following the eye examination, an optician from the Southern California College of Optometry visited each
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2575 Yorba Linda Blvd. Fullerton CA 92831. 714.992.7870. www.sccoeyecare.com
Child’s Name: ___________________________________________________________, After a series of brief tests, considered a vision screening, the doctor has found: Despue´s de realizar las pruebas ba´sicas de visio´n, el opto´metra considera: c
Normal visual acuity / Agudeza visual es normal
After a series of brief tests, considered a vision screening, the doctor would like you to see an Optometrist/Medical Doctor for the following concerns: Despue´s de realizar las pruebas ba´sicas de visio´n, el Doctor le recomienda que usted visite un Opto´metra / Me´dico para una mayor evaluacio´n de las siguientes condiciones: c
Reduced visual acuity /Discapacidad visual
c
Abnormal eye teaming / Dificultades del uso de ambos ojos a la vez
c
Other (Otro) _____________________________________________ A vision screening does NOT replace a periodic professional vision and eye health examination performed in your doctor’s office – please see your Optometrist yearly! Esta prueba ba´sica de la visio´n NO remplaza el examen completo de los ojos y la visio´n que se lleva acabo en la oficina de su doctor. Por favor visite a su Opto´metra cada an˜o!
..................................................................................................................................................................................................................................................... Your child will receive a comprehensive eye examination during school hours. By signing below, you as the parent or legal guardian authorize the treatment/care for this child under the general supervision of a staff optometrist. This consent is given pursuant to the provisions of section 25.8 of the Civil Code of California. Su hijo recibira´ un examen completo de la vista durante el horario escolar. Al firmar abajo, usted, como padre o guardia´n legal, autoriza el tratamiento/cuidado de este nin˜o bajo la supervisio´n de un opto´metra. Este consentimiento se da conforme a las disposiciones del artı´culo 25.8 del Co´digo Civil de California. Cuando llene la forma, por favor devue´lvala a la enfermera de la escuela antes de la cita de su hijo(a). Parent/Guardian Signature
Date
Firma de Padre o Guardia´n
Fecha
_________________________________________
_________________________________________
Please return this form to the school nurse before your child’s appointment. Cuando llene la forma, por favor devue´lvala a la enfermera de la escuela antes de la cita de su hijo(a). Figure 1. Bilingual (English and Spanish) patient vision screening report and parent/guardian consent form (Flesch–Kincaid Grade Level 12.0).
school to help students with frame selection, ordering of lenses, and delivery of the glasses.
Population School A had an enrollment of 675 students from Kindergarten through fifth grade (data from 2012 to 2013; Ed-Data Website, 2013). The student body consisted of 97.3%
Hispanic or Latino students and 88.6% (data from 2011 to 2012) of students received free or reduced price meals. School B had an enrollment of 707 students from Kindergarten through fifth grade (data from 2012 to 2013; Ed-Data Website, 2013). The student body consisted of 98.7% Hispanic or Latino children (data from 2012 to 2013) and 87.9% of students (data from 2011 to 2012) received free/reduced price meals. In California, a child’s family income must fall
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Table 2. Number of Children Screened.
School A School B
Total
Pass
% Pass
Failure
% Failure
675 631
435 489
64.4 77.5
240 142
35.6 22.5
below 130% of the federal poverty guidelines to qualify for free meals or below 185% to qualify for reduced-cost meals.
Human Subjects Approval Statement An application including study synopsis was submitted to the Institutional Review Board and the Health Information Privacy Board at Marshall B. Ketchum University. The study was exempted from approval, as the protocol was not subject to ‘‘Common Rule,’’ Food and Drug Administration (FDA) regulations, or to California human subject regulations. As there were no personal identifying information about students nor the school, Health Insurance Portability and Accountability Act approval was not necessary as well.
Results A total of 675 students were screened at School A, with 435 students (64.4%) passing all portions of the screening and 240 students (35.6%) failing one or more portions of the screening (Table 2). At School B, 631 students were screened, with 489 students (77.5%) passing all portions of the screening and 142 students (22.5%) failing one or more portions of the screening (Table 2). Among the students who failed the vision screening, the most common reason for failure was reduced visual acuity and/or refractive error (Tables 3 and 4). Parental consent was returned by 48.3% of the screening failures at School A and 57.7% at School B (Table 5). A w2 analysis was performed to evaluate any association between the likelihood of returning the parental consent form and the cause for screening failure. No statistically significant relationship was found between students who returned their consent forms and those who did not and the cause for vision screening failure at either school (p ¼ .153 for School A, p ¼ .811 for School B). Among the students examined, 63 of the 116 students (54.3%) at School A and 64 of the 82 students (78%) at School B required a spectacle prescription (Table 6). Referral for additional services because of conditions such as amblyopia, strabismus, convergence insufficiency, or other eye disease was needed for 13 students (11.2%) at School A and 2 students (3%) at School B (Table 6).
Discussion Although vision screening programs are often advocated, the effectiveness of these programs in reducing visual impairment has yet to be validated largely due to the lack of
adherence to vision screening recommendations (Mathers, Keyes, & Wright, 2010; Powell & Hatt, 2009; Powell, Wedner, & Richardson, 2005). Programs, such as ours, can improve access by providing eye examinations and glasses at no cost to the family and with the convenience of the examinations being performed on-site; however, there remains a higher than expected rate of nonadherence, as about 50% of those requiring an examination did not return the parental consent form. The Vision First Program offered free eye examinations to students in the Cleveland Metropolitan School District and also found about 50% of parents signed the consent form for examination (Traboulsi et al., 2008). The Baltimore Vision Screening Project found that, despite offering free on-site examination and glasses, only 30% of subjects who failed the vision screening returned the following year with glasses (Preslan & Novak, 1998). Manny et al. (2012) found a similar result with no difference in adherence to glasses wear among subjects who received a vision screening and examination (28%) and subjects who received a vision screening and referral recommendation (27%). Health literacy plays an important role in the adherence to vision screening and vision examination recommendations (Nielsen-Bohlman, Panzer, & Kindig, 2004). In the Los Angeles Latino Eye Study, knowledge of a disease was found to be associated with an increased likelihood of seeking care (Unzueta et al., 2004). Interviews with parents/guardians found that a significant percentage of nonadherence to vision screening recommendations was due to not believing the screening results and being unaware of the impact that visual impairment can have (Kimel, 2006; Mark & Mark, 1999; Sharma, Congdon, Patel, & Gilbert, 2012). Tjiam et al. (2011) reported that poor literacy may have been the reason for the bulk of their unsuccessful referrals following a vision screening. Additionally, most printed patient-centered educational materials on vision are not written to an appropriate literacy level for most individuals (Muir & Lee, 2010). Traboulsi and colleagues (2008) recommended utilizing a social worker to increase the number of parental consents in the Vision First Program. Incorporating social workers or community health workers (CHWs) as part of the health care delivery team has been associated with improved health outcomes and gained increased utilization in the management of chronic conditions, such as diabetes (Ayala, Vaz, Earp, Elder, & Cherrington, 2010; Elder, Ayala, Parra-Medina, & Talavera, 2009; Viswanathan et al., 2009). CHWs are trusted members of the community who often serve in low socioeconomic communities that have limited access to health care and limited fluency in English. The role of the CHW can include helping people understand their health condition, linking community members to health care services, translating, and informal counseling (U.S. Department of Labor, 2010). School nurses are already charged with establishing procedures to ensure students receive appropriate follow-up with an eye care professional (Ong & Davis-Alldritt, 2005). Contacting parents to ensure appropriate follow-up has been made
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Table 3. Reason for Screening Failure at School A. Total
Number of Returned Consent Forms
% Returned
Number of Not Returned Consent Forms
% Not Returned
p Value
Refractive error (based on VA and/or retinoscopy, see Table 1) Binocular vision disorders (based on cover testing) Multiple fails
208
98
47.1
110
52.9
19
13
68.4
6
31.6
13
5
38.5
8
61.5
Total
240
116
48.3
124
51.7
.153
Total
Number of Returned Consent Forms
% Returned
Number of Not Returned Consent Forms
% Not Returned
p Value
Refractive error (based on VA and/or retinoscopy, see Table 1) Binocular vision disorders (based on cover testing) Multiple fails
119
70
58.8
49
41.2
9
5
55.6
4
44.4
14
7
50
7
50
Total
142
82
Note. VA ¼ visual acuity.
Table 4. Reason for Screening Failure at School B.
57.7
60
42.3
.811
Note. VA ¼ visual acuity.
Table 5. Number of Signed Consent Forms Returned.
School A School B
Total
Number Returned
% Returned
Number Not Returned
% Not Returned
240 142
116 82
48.3 57.7
124 60
51.7 42.3
Table 6. Examination Outcomes.
School A School B
Total
Number of Glasses Dispensed
% Glasses Dispensed
Number of Referred
116 82
63 64
54.3 78.1
13 2
can be implemented by a CHW in order to expand the school nurses’ role in delivering community-based programs focused on educating parents/guardians on the limitations of vision screening, the impact visual impairment has on learning, and addressing common barriers to wearing glasses in order to address the perceptual barriers that result in parental nonadherence to vision screening recommendations. Furthermore, collaboration between school nurses and teachers can improve the sensitivity of school vision screening programs and adherence to prescribed glasses. Krumholtz (2004) reported improved knowledge, attitudes, and behaviors in the teacher’s ability to identify children at risk for visual impairment after delivering an in-service lecture on vision and its role in learning. Involving teachers in monitoring and
% Number of No Treatment/ Referred Referral 11.2 2.4
40 16
% No Treatment/ Referral 34.5 19.5
encouraging their students to use their glasses resulted in dramatic increases in student adherence to their prescribed glasses (Ethan, Basch, Platt, Bogen, & Zybert, 2010; Kodjebacheva, Maliski, Yu, Oelrich, & Coleman, 2014). These program considerations in conjunction with vision screening and examination programs may improve vision outcomes that impact a student’s quality of life and academic potential.
Implications for School Nursing The aim of this program was to improve adherence to vision screening recommendations by removing the barriers of lack of financial resources and the need to travel to an eye care professional. We propose that future program considerations
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should expand the school nurses’ role in providing eye and vision education; coordination of care between teachers, parents/guardians, and eye care professionals; and if a comprehensive vision program is utilized, coordinating the delivery of the parental consent form for vision examination to coincide with the school’s highest rate of return of signed forms.
Limitations The main limitation was the small sample size at the two schools, which may limit generalizability. We presume that parental lack of awareness of the impact of visual impairment is a major barrier; however, we did not formally assess this in the group that failed to return their parental consent form. In addition, it is possible that adherence to screening recommendation was higher, as families may have elected to entrust their vision care with providers in the community. Postanalysis of the parental consent form determined that the Flesch–Kincaid grade level was 12.0, which may have impacted the number of returned consent forms due to a high reading level demand. However, the consent form was available in both English and Spanish (Figure 1). Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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Author Biographies Raymond Chu, OD, MS, is an associate professor at the Marshall B. Ketchum University. Kristine Huang, OD, MPH, is an assistant professor at the Marshall B. Ketchum University. Carmen Barnhardt, OD, MS, is an associate professor at the Marshall B. Ketchum University. Angela Chen, OD, MS, is an assistant professor at the Marshall B. Ketchum University.
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