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.

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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.

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The Mill and The School

 

On a recent trip to Scotland, I visited some very interesting oat mills. I always love to visit medieval mills, because I find it endlessly fascinating how people long ago used natural forces and materials – wind, water, and fire, stone, wood, and metal – to create advanced mechanisms that had a profound impact on society.

In Scotland, it’s all about oat mills (almost everywhere else, it’s wheat). These grain mills date back to the 10th century. In their time, they were a giant leap in technology. A mill is very complicated, but at its heart are two big innovations. In the center of the mill, a heavy millstone turns on top of another. The grain is poured through a hole in the top stone for grinding. The miller’s most difficult task is to maintain an exact distance between the stones. A few millimeters too far apart and no milling happens. A few millimeters too close and the heat of friction can ruin the machinery, possibly causing a fire.

The other key technology is the water wheel (except in windmills, of course). The water mill is part of a system that involves a carefully controlled flow of water from a millpond, which the miller uses to provide exactly the right amount of water to turn a giant wooden wheel, which powers the top millstone.

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The medieval grain mill is not a single innovation, but a closely integrated system of innovations. Millers learned to manage this complex technology in a system of apprenticeship over many years.

Mills enabled medieval millers to obtain far more nutrition from an acre of grain than was possible before. This made it possible for land to support many more people, and the population surged. The whole feudal system was built around the economics of mills, and mills thrived through the 19th century.

What does the mill have to with the school? Mills only grind well-behaved grain into well-behaved flour, while schools work with far more complex children, families, and all the systems that surround them. The products of schools must include joy and discovery, knowledge and skills.

Yet as different as they are, mills have something to teach us. They show the importance of integrating diverse systems that can then efficiently deliver desired outcomes. Neither a mill nor an effective school comes into existence because someone in power tells it to. Instead, complex systems, mills or schools, must be created, tested, adapted to local needs, and constantly improved. Once we know how to create, manage, and disseminate effective mills or schools, policies can be readily devised to support their expansion and improvement.

Important progress in societies and economies almost always comes about from development of complex, multi-component innovations that, once developed, can be disseminated and continuously improved. The same is true of schools. Changes in governance or large-scale policies can enhance (or inhibit) the possibility of change, but the reality of reform depends on creation of complex, integrated systems, from mills to ships to combines to hospitals to schools.

For education, what this means is that system transformation will come only when we have whole-school improvement approaches that are known to greatly increase student outcomes. Whole-school change is necessary because many individual improvements are needed to make big changes, and these must be carefully aligned with each other. Just as the huge water wheel and the tiny millstone adjustment mechanism and other components must work together in the mill, the key parts of a school must work together in synchrony to produce maximum impact, or the whole system fails to work as well as it should.

For example, if you look at research on proven programs, you’ll find effective strategies for school management, for teaching, and for tutoring struggling readers. These are all well and good, but they work so much better if they are linked to each other.

To understand this, first consider tutoring. Especially in the elementary grades, there is no more effective strategy. Our recent review of research on programs for struggling readers finds that well-qualified teaching assistants can be as effective as teachers in tutoring struggling readers, and that while one-to-four tutoring is less effective than one-to-one, it is still a lot more effective than no tutoring. So an evidence-oriented educator might logically choose to implement proven one-to-one and/or one-to-small group tutoring programs to improve school outcomes.

However, tutoring only helps the students who receive it, and it is expensive. A wise school administrator might reason that tutoring alone is not sufficient, but improving the quality of classroom instruction is also essential, both to improve outcomes for students who do not need tutoring and to reduce the number of students who do need tutoring. There is an array of proven classroom methods the principal or district might choose to improve student outcomes in all subjects and grade levels (see www.evidenceforessa.org).

But now consider students who are at risk because they are not attending regularly, or have behavior problems, or need eyeglasses but do not have them. Flexible school-level systems are necessary to ensure that students are in school, eager to learn, well-behaved, and physically prepared to succeed.

In addition, there is a need to have school principals and other leaders learn strategies for making effective use of proven programs. These would include managing professional development, coaching, monitoring implementation and outcomes of proven programs, distributed leadership, and much more. Leadership also requires jointly setting school goals with all school staff and monitoring progress toward these goals.

These are all components of the education “mill” that have to be designed, tested, and (if effective) disseminated to ever-increasing numbers of schools. Like the mill, an effective school design integrates individual parts, makes them work in synchrony, constantly assesses their functioning and output, and adjusts procedures when necessary.

Many educational theorists argue that education will only change when systems change. Ferocious battles rage about charters vs. ordinary public schools, about adopting policies of countries that do well on international tests, and so on. These policies can be important, but they are unlikely to create substantial and lasting improvement unless they lead to development and dissemination of proven whole-school approaches.

Effective school improvement is not likely to come about from let-a-thousand-flowers-bloom local innovation, nor from top-level changes in policy or governance. Sufficient change will not come about by throwing individual small innovations into schools and hoping they will collectively make a difference. Instead, effective improvement will take root when we learn how to reliably create effective programs for schools, implement them in a coordinated and planful way, find them effective, and then disseminate them. Once such schools are widespread, we can build larger policies and systems around their needs.

Coordinated, schoolwide improvement approaches offer schools proven strategies for increasing the achievement and success of their children. There should be many programs of this kind, among which schools and districts can choose. A school is not the same as mill, but the mill provides at least one image of how creating complex, integrated replicable systems can change whole societies and economies. We should learn from this and many other examples of how to focus our efforts to improve outcomes for all children.

Photo credit: By Johnson, Helen Kendrik [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.

Reading and Vision

A few years ago, I was touring a ruined abbey in Scotland. In a small museum containing objects found in excavations of the site were a pair of eyeglasses worn by monks in the 13th century.

The relationship between vision and reading is not exactly news. Since most adults eventually need reading glasses, most people reading this blog probably have personal experience with the transformational impact they can have.

Along with colleagues at the Johns Hopkins Hospital’s Wilmer Eye Clinic and the Johns Hopkins School of Education, we are doing a study of the relationship between vision and reading in inner-city schools in Baltimore. Our project is not finished, so I can’t report on all aspects of our findings. But what we have found so far is profoundly disturbing.

We are giving comprehensive vision tests to second- and third-graders in some of the most impoverished schools in the city. We are finding high rates of visual impairment, which can be corrected by eyeglasses. Yet only 1 to 3 percent of the children have glasses in school.

The state of Maryland requires vision screening in first grade, and many of these children were found to need glasses previously. Yet a hundred things go wrong in getting glasses on kids’ faces in inner-city schools. Some kids are missed in the screening. Those who are identified get a letter sent to the parents, who may or may not follow up. Some cannot afford glasses, while others qualify for assistance to purchase glasses but do not know how to go through the procedures to get them. Glasses frequently get broken or lost or stolen, and there are no procedures to replace them. As a result, few kids who need them have glasses in school, even just one year after the screening year.

A key factor in all of this is that vision is seen as a health problem, not the school’s problem. Schools do not have resources for eyeglasses, so even though they are accountable for children’s reading, and even though school leaders and teachers know full well that a lot of their kids just need glasses, they feel helpless in solving this simple problem. Title I funds, for example, cannot be used for glasses. The result is that many children are receiving very expensive remedial services, tutoring, or special education, when a $20 pair of glasses would actually solve the problem.

In our project, we are testing kids, and, for those who need them, we are providing two pairs of glasses, one for home and one for school. Teachers are given craft boxes to hold the glasses and facilitate distributing them each day. If glasses are broken, they are replaced. Eyeglasses are in these days, and the kids are very proud of their glasses. Compared with other interventions for struggling readers, the cost of a few pairs of glasses is trivial. Not every struggling reader is struggling due to poor eyesight, but imagine if 20 or 10 or even 5 percent of children in high-poverty schools are struggling in reading or other subjects due to vision problems that are easily remediated with ordinary eyeglasses.

I’m always reluctant to get ahead of the data, but imagine for a moment what it would mean if we do find that significant numbers of inner-city kids are failing year after year just because they lack glasses. Hopefully, this finding would lead to government and private programs throughout the U.S. providing eyeglasses in schools and giving teachers and administrators responsibility to see that children receive and use their glasses. This could make a huge difference in one easily recognizable subgroup of struggling readers.

At a larger level, think what such a finding might say about poverty and education. Educators naturally seek educational solutions to educational problems in high-poverty schools, reasoning that they cannot solve problems of housing, crime, unemployment, and so on. Yet there may be some non-educational interventions that they could use to improve student outcomes. What matters is the outcomes, and it is crucial that proven solutions be allowed to cross traditional boundaries if they require it.

At a larger level still, consider how families get into poverty in the first place. How many kids with poor eyesight fail in school, lose motivation, and ultimately lose access to positive futures? How many impoverished parents were once children with poor eyesight, or other easily solved health difficulties? How many inner-city communities suffer from having many young people who perceive no hope due to reading difficulties that could have been prevented?

Eyeglasses are not new, and they are not magic. Yet they may well be part of a solution to fundamental and persistent problems of education.