Ensuring the Physical Health of Students: How Schools Can Play an Essential Role

           Schools have a lot to do. They are responsible for ensuring that their students develop skills and confidence in all subjects, as well as social-emotional learning, citizenship, patriotism, and much more.

            Yet schools also have a unique capability and a strong need to ensure the physical health of their students, particularly in areas of health that affect success in the schools’ traditional goals. This additional goal is especially crucial in high-poverty urban and rural schools, where traditional health services may be lacking and families often struggle to ensure their children’s health. In high-poverty schools, there are many children who will unnecessarily suffer from asthma, lack of needed eyeglasses, hearing problems, and other common ailments that can have a substantial deleterious effect on student learning.

            In partnership with health providers and parents, schools are ideally situated to solve such chronic problems as uncontrolled asthma, uncorrected vision problems, and uncorrected hearing problems. One reason this is so is that every student attends school, especially in the elementary grades, where the staff is likely to know each child and parents are most likely to have good relationships with school staff.

            Every school should have a qualified nurse every day to deal with routine health problems. It is shocking that there are no nurses, or just part-time nurses, in many high-poverty schools. However, in this blog, I am proposing a strategy that could have a substantial impact on the health problems that need constant attention but could be managed by well-trained health aides, following up on more time-limited assistance from other health professionals. The idea is that each school would have a full- or part-time Preventive Health Aide (PHA) who would work with students in need of preventive care.

            Asthma. In big cities, such as Baltimore, as many as 20% or more of all children suffer from uncontrolled asthma. For some, this is just an occasional problem, but for others it is a serious and sometimes life-threatening disease. In Baltimore and similar cities, asthma is responsible for the largest number of emergency department visits, the largest number of hospitalizations, and the largest number of deaths from all causes for school-aged students. Asthma can also cause serious problems with attendance, leading to negative effects on learning and motivation.

            There is a very simple solution to most asthma problems. Based on a doctor’s diagnosis, a student can use an inhaler: safe, effective, and reliable if used every day. However, in high-poverty schools, the great majority of students known to have asthma do not take their medicine regularly, and they are therefore at serious risk.

            Asthma cannot be cured, but it can be managed with daily inhaler use (plus, as necessary, access to rescue inhalers for acute situations). For the many children in high-poverty schools who are not regularly using their inhalers, there is a simple and effective backup: Directly Observed Therapy (DOT), which involves a health aide or nurse, most often, giving students their full daily dose of inhalant. As one example, Baltimore’s KIPP school has a specially-funded health clinic, and they have a health aide work in a room near the cafeteria to give DOT to all students who need it. Research on DOT for asthma has found substantial reductions in emergency department visits and hospitalizations, possibly saving children’s lives. By the way, at a cost of about $7,500 per hospitalization and $820 per emergency room visit, it would not take much reduction in asthma to pay the salary of a health aide.

            Vision. Along with the Wilmer Eye Clinic at Johns Hopkins Hospital, the Baltimore Department of Health, the Baltimore City Public Schools, Vision to Learn (which has vans that do vision services at school sites) and Warby Parker (an eyeglass company that provides free eyeglasses for disadvantaged children), we have been working for years on a project to provide eyeglasses to all Baltimore City K-8 students who need them. We have provided almost 10,000 pairs of eyeglasses so far. It is crucial to give students eyeglasses if they need them, but we have discovered that giving out free eyeglasses does not fully solve the problem. Kids being kids, they often lose or break their glasses, or just fail to use them. We have developed strategies to observe classes at random to see how many students are wearing eyeglasses, with celebrations or awards for the classes in which the most students are wearing their eyeglasses, but this is difficult to do across the whole city. Preventive Health Aides could easily build into their schedules random opportunities to observe in teachers’ classes to note and celebrate the wearing of eyeglasses once students have them.

            Hearing. Many children cannot hear well enough to benefit from lessons. The Baltimore City Health Department screens students at school entry, first grade, and eighth grade. Few students need hearing aids, but many suffer from smaller problems, such as excessive earwax. Health aides might supplement infrequent hearing screenings with more frequent assessments, especially for children known to have had problems in the past. Preventive Health Aides could see that children with hearing problems are getting the most effective and cost-effective treatments able to ensure that their hearing is sufficient for school.

            Other Ailments. A trained Preventive Health Aide ensuring that treatments are being administered or monitored could make a big difference for many common ailments. For example, many students take medication for ADHD (attention deficit-hyperactivity disorder). Yet safe and effective forms of ADHD medication work best if the medication is taken routinely. A treatment like DOT could easily do this. Other more rare problems that could be managed with regular medication and observation could also help many children. With greater knowledge and collaboration with experts on many diseases, it should be possible to provide cost-effective services on a broad scale.

            Health care for children in school is not a frill. As noted earlier, many common health care problems have serious impacts on attendance, and on vision, hearing, and other school-relevant skills. If school staff take up these responsibilities, there needs to be dedicated funding allocated for this purpose. It would be unfair and counter-productive to simply load another set of unfunded responsibilities on already overburdened schools. However, because they may reduce the need for very expensive hospital services, these school-based services may pay for themselves.

            You hear a lot these days about the “whole child.” I hope this emphasis can be extended to the health of children. It just stands to reason that children should be healthy if they are to be fully successful in school.

This blog was developed with support from the Laura and John Arnold Foundation. The views expressed here do not necessarily reflect those of the Foundation.

Teachers’ Crucial Role in School Health

These days, many schools are becoming “community schools,” or centering on the “whole child.”  A focus of these efforts is often on physical health, especially vision and hearing. As readers of this blog may know, our group at Johns Hopkins School of Education is collaborating on creating, evaluating, and disseminating a strategy, called Vision for Baltimore, to provide every Baltimore child in grades PK to 8 who needs them with eyeglasses. Our partners are the Johns Hopkins Hospital’s Wilmer Eye Institute, the Baltimore City Schools, the Baltimore City Health Department, Vision to Learn, a philanthropy that provides vision vans to do vision testing, and Warby Parker, which provides children with free eyeglasses.  We are two years into the project, and we are learning a lot.

The most important news is this:  you cannot hope to solve the substantial problem of disadvantaged children who need glasses but don’t have them by just providing vision testing and glasses.  There are too many steps to the solution.  If things go wrong and are not corrected at any step, children end up without glasses.   Children need to be screened, then (in most places) they need parent permission, then they need to be tested, then they need to get correct and attractive glasses, then they have to wear them every day as needed, and then they have to replace them if they are lost or broken.

School of Education graduate student Amanda Inns is writing her dissertation on many of these issues. By listening to teachers, learning from our partners, and trial and error, Amanda, ophthalmologist Megan Collins, Lead School Vision Advocate Christine Levy, and others involved in the project came up with practical solutions to a number of problems. I’ll tell you about them in a moment, but here’s the overarching discovery that Amanda reports:

Nothing can stop a motivated and informed teacher.

What Amanda found out is that all aspects of the vision program tended to work when teachers and principals were engaged and empowered to try to ensure that all children who needed glasses got them, and they tended not to work if teachers were not involved.  A moment’s reflection would tell you why.  Unlike anyone else, teachers see kids every day. Unlike anyone else, they are likely to have good relationships with parents.  In a city like Baltimore, parents may not answer calls from most people in their child’s school, and even less anyone in any other city agency.  But they will answer their own child’s teacher. In fact, the teacher may be the only person in the school, or indeed in the entire city, who knows the parents’ real, current phone number.

In places like Baltimore, many parents do not trust most city institutions. But if they trust anyone, it’s their own child’s teacher.

Cost-effective citywide systems are needed to solve widespread health problems, such as vision (about 30% of Baltimore children need glasses, and few had them before Vision for Baltimore began).  Building such systems should start, we’ve learned, with the question of how teachers can be enabled and supported to ensure that services are actually reaching children and parents. Then you have to work backward to fill in the rest of the system.

Obviously, teachers cannot do it alone. In Vision for Baltimore, the Health Department expanded its screening to include all grades, not just state-mandated grades (PK, 1, 8, and new entrants).  Vision to Learn’s vision vans and vision professionals are extremely effective at providing testing. Free eyeglasses, or ones paid for by Medicaid, are essential. The fact that kids (and teachers) love Warby Parker glasses is of no small consequence. School nurses and parent coordinators play a key role across all health issues, not just vision. But even with these services, universal provision of eyeglasses to students who need them, long-term use, and replacement of lost glasses, are still not guaranteed.

Our basic approach is to provide services and incentives to help teachers be as effective as possible in supporting vision health, using their special position to solve key problems. We hired three School Vision Advocates (SVAs) to work with about 43 schools entering the vision system each year. The SVAs work with teachers and principals to jointly plan how to ensure that all students who need them will get, use, and maintain their glasses. They interact with principals and staff members to build excitement about eyeglasses, offering posters to place around each school. They organize data to make it easy for teachers to know which students need glasses, and which students still need parent permission forms. They provide fun prizes, $20 worth of school supplies, to all teachers in schools in which 80% of parents sent in their forms.  They get to know school office staff, also critical to such efforts.  They listen to teachers and get their ideas about how to adapt their approaches to the school’s needs.  They do observations in classes to see what percentage of students are wearing their glasses. They arrange to replace lost or broken glasses.  They advocate for the program in the district office, and find ways to get the superintendent and other district leaders to show support for the teachers’ activities directed toward vision.

Amanda’s research found that introducing SVAs into schools had substantial impacts on rates of parent permission, and adding the school prizes added another substantial amount. Many students are wearing their glasses. There is still more to do to get to 100%, but the schools have made unprecedented gains.

Urban teachers are very busy, and adding vision to their list of responsibilities can only work if the teachers see the value, feel respected and engaged, and have help in doing their part. What Amanda’s research illustrates is how modest investments in friendly and capable people targeting high-leverage activities can make a big difference across an entire city.

Ensuring that all students have good vision is critical, and a hit-or-miss strategy is not sufficient. Schools need systems to bring cost-effective services to thousands of kids who need help with health issues that affect very large numbers, such as vision, hearing, and asthma. Teachers still must focus first on their roles as instructors, but with help, they can also provide essential assistance to build the health of their students.  No system to solve health problems that require daily, long-term monitoring of children’s behavior can work at this scale in urban schools without engaging teachers.

Photo credit: By SSgt Sara Csurilla [Public domain], via Wikimedia Commons

This blog was developed with support from the Laura and John Arnold Foundation. The views expressed here do not necessarily reflect those of the Foundation.

Vision and Blindness

If you wear reading glasses, please remove them for a moment, and continue reading.

Back to normal? For a moment, you had an experience like that of about 30% of Baltimore students. Some have myopia (nearsightedness) and some hyperopia (farsightedness), and some other problems. But few have glasses. A study in grades 2-3 found that only 6% of students had glasses in school, and 30% needed them. Kids being kids, even those who have glasses may soon lose or break them, and glasses are rarely replaced for kids in inner-city schools. As a result, some students can’t see the whiteboard, some can’t see their books, and many quietly think they are not smart because they struggle to focus on the printed word. In Maryland, students’ vision is tested only at school entry (usually pre-k), first grade, and eighth grade. If routine screenings find a problem, a note goes to parents asking them to get a formal assessment. In Baltimore, this results in about 10% of children who need glasses getting them. And then what do you think happens to those glasses between first and eighth grade?

I’ve been involved with studies of vision in inner-city schools along with colleagues Megan Collins, David Friedman, Michael Repka, and others from the Wilmer Eye Clinic at Johns Hopkins Medical Institutions, and Nancy Madden and others from the Johns Hopkins School of Education. The name of the project is Vision for Baltimore, and it operates under the authority of the Baltimore City Health Department, which has been a strong supporter. What we are finding is in one sense a privileged glimpse into the perfectly obvious. Inner city children who need glasses don’t often get them. We tested all students in grades 2-3 in 12 high-poverty Baltimore schools, and we gave those who needed them free glasses. We also followed up to make sure the students were wearing glasses, and we replaced those that were lost or broken. Students who received the glasses gained significantly on reading tests in comparison to those who never needed glasses. Of course. Yet this was the first U.S. study of its kind to show an effect of glasses on reading (two Chinese studies had found the same).

We are now doing a much larger study. A philanthropic group called Vision to Learn (VTL) wanted to provide assessments and free glasses to every elementary and middle school student in Baltimore over a three-year period. VTL has mobile vision vans, staffed with an optometrist and an optician. The vans can test all students who were found in screening to need assessment, and then provide free glasses if needed. With funding from Baltimore’s Abell Foundation and the Laura and John Arnold Foundation, we arranged to randomly assign schools to receive their vision services either in the first, second, or third year, enabling us to find the impact of these services in reading and math performance, mostly on state tests.

It will be a couple of years before we will know the results of our research, but I can tell you this much. As in our smaller study, we found that very few children already had glasses, and about 30% needed them. This fall, the first glasses are arriving, and the students are blown away. One fifth grade girl said, “Is this the way things are supposed to look?”

Now think about that girl. If she needs glasses now, she has probably needed them for years. How much damage was done to her essential early education? How much was her self-esteem damaged by learning problems due to nothing more than poor vision?

I should hasten to add that eyeglasses for students who need them are an inexpensive intervention. In the enormous quantities involved, a pair of glasses that kids are eager to wear may cost less than $20. Further, Medicaid pays for eyeglasses for all children who qualify as low income, which equates to nearly every child in Baltimore. Vision to Learn has worked out ways to make this easy to administer, so that modest funds from an existing federal program can be used for this essential service.

Vision is important. We hope our work and that of others around the U.S. will develop simple, replicable means of improving the achievement of disadvantaged children by giving them needed eyeglasses. But what I really want to talk about today is not vision, but blindness. Moral blindness. Policy blindness. Pragmatic blindness.

It so happens that vision is an excellent case to illustrate our moral, policy, and pragmatic blindness. We spend approximately $11,000 per child per year, on average, to educate a child. From all that expenditure, we want successful, capable, skilled students, who can enter higher education or the workforce with confidence and well-founded hopes of success. We want students who will follow the rules because they know that they can succeed if they do.

Yet we let $20 worth of eyeglasses stand in their way.

We spend vast amounts of money on special education, remedial services, even tutoring. Yet some proportion of the children who receive these services just needed eyeglasses instead. The policy world has tried for years to reduce special education costs and integrate children in regular classes. Many likely never needed special education to begin with.

Yet we let $20 worth of eyeglasses per child stand in our way.

We know that young people who fail in school are far more likely to become delinquent and later criminal. The costs of policing and incarceration are huge, and we need to reduce them.

Yet we let $20 worth of eyeglasses per child stand in our way.

There are lots of very difficult problems in education. This does not happen to be one of them. Can we all agree to put glasses on every disadvantaged child who needs them? This will not solve all of our problems, but if would be a heck of a start. While we’re at it, we also ought to look into hearing and other medical problems that hold kids back.

There are none so blind as those who will not see.

Correction

In an earlier version of this blog, I forgot to mention the name of the project and the authority under which is operates. I apologize for the omission.