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Dotan G, Truong B, Snitzer M, et al. Outcomes of an Inner-City Vision Outreach Program: Give Kids Sight Day. JAMA Ophthalmol. 2015;133(5):527–532. doi:10.1001/jamaophthalmol.2015.8
Low-socioeconomic urban children often do not have access to ophthalmic care.
To characterize the demographic characteristics and ophthalmic conditions in children attending Give Kids Sight Day (GKSD), an outreach ophthalmic care program held annually in Philadelphia, Pennsylvania, providing vision screening and immediate treatment when needed.
Design, Setting, and Participants
Retrospective case-series study of children attending GKSD in 2012 (GKSD 2012) at an ophthalmology center in Philadelphia. Registration forms and records of all children attending GKSD 2012 were reviewed.
Main Outcomes and Measures
Demographic characteristics, insurance status, spoken languages, reasons for attending, prior failure of vision screening, and attendance pattern of previous events were analyzed. The ophthalmological findings of these children were examined, including refractive errors, need for optical correction, and diagnoses for which continuous ophthalmic care was necessary. For children who needed ophthalmic follow-up, the rate of return to clinic and barriers for continuous care were analyzed.
We studied 924 children (mean age, 9 years; age range, 0-18 years; 51% female; 25% speaking a non-English language) coming from 584 families who attended GKSD 2012, of whom 27% were uninsured and 10% were not aware of their insurance status. Forty-two percent of participants had public insurance, which covered vision care and glasses, but 35% did not know their benefits and did not realize vision care was covered. Forty-nine percent of children attended because they failed community vision screening. Provision of free glasses and failure of previous vision screening were the most common reasons families elected to attend GKSD (64% and 49%, respectively). Eighty-five percent of children attended GKSD 2012 for the first time, whereas 15% attended prior events. Glasses were provided to 61% of attendees. Ten percent of the attendees needed continuous ophthalmic care, most commonly for amblyopia. Ten children needed ocular surgery for cataract, strabismus, nystagmus, ptosis, or nasolacrimal duct obstruction. With the assistance of a social worker, 59% of children requiring continuous treatment returned to the clinic, compared with 2% in prior years before social worker intervention.
Conclusions and Relevance
Programs such as GKSD can bridge the gap between successful vision screening and ophthalmic treatment, a gap that often occurs in low-socioeconomic urban populations. Those with public insurance coverage for vision services may not realize these services are covered. Social worker intervention is useful in overcoming common barriers to follow-up care.
Vision loss is a common pediatric problem.1 Unless treatment is provided promptly and effectively, long-term implications on quality of life for both child and family may occur.2 The 2020 US government health objectives include reducing childhood visual impairment and blindness and increasing the proportion of children undergoing vision screening.3 These goals are not necessarily linked: increases in US vision screening have not been matched with declines in visual impairment.3-5 One explanation may be that some children who fail vision screening do not receive proper follow-up ophthalmic care. This problem is more pronounced in urban, low-income minorities.2,6,7
Herein, we analyze our experience with Give Kids Sight Day (GKSD), an annual free outreach program combining vision screening and ophthalmic care in Philadelphia, Pennsylvania. We examine the demographic characteristics, social background, and insurance status of children who attended, and we identify reasons for attending, methods of successful communication, and ophthalmological problems. We also report barriers for continuous care and provide recommendations based on our experience.
Give Kids Sight Day is an annual event that has been held since 2009 at Wills Eye Hospital and Thomas Jefferson University. Children up to age 19 years can obtain free eye care. The event is coordinated by the Philadelphia Vision Coalition, a conglomerate of stakeholder agencies with an interest in childhood vision in Philadelphia including Public Citizens for Children and Youth, Eagles Youth Partnership, Wills Eye Hospital, Thomas Jefferson University, the Philadelphia District School Board, Philadelphia City Health Clinics, St Christopher’s Hospital for Children, and others. Families are informed by multiple means: notes sent home with children from schools; automated calls; direct referrals by school nurses and pediatricians; posters in appropriate languages posted in public housing, clinics, and community centers; radio; other media; and multilanguage flyers distributed specifically to medical and social organizations that work with immigrant, uninsured, and low-income families. Although GKSD is open to any child in the Philadelphia area seeking free eye care, efforts target uninsured or underinsured children. Approximately 1200 children are examined annually.
The day starts at 8 am and ends at approximately 6 pm. Three campus buildings are used. Families are escorted between buildings by volunteers from the lay and medical communities. Attendees complete registration forms including age, sex, child’s grade level in school, medical insurance (to analyze demographic characteristics—insurance is not billed), how the family became aware of GKSD, and reason for attending.
We analyzed data from the GKSD held in 2012 (GKSD 2012). This study was approved by the Wills Eye Hospital Institutional Review Board and was granted a waiver of consent as a retrospective study. All aspects of this study complied with the Health Insurance Portability and Accountability Act of 1996.
Children older than 5 years received vision screening by trained medical personnel, checking Snellen and Allen visual acuity, stereopsis with the Titmus test, and color vision with the Ishihara color blindness test. These tests were selected in keeping with Pennsylvania’s legislated requirements for school screening.8 Failed screening was defined as visual acuity of 20/30 or worse in either eye or 2 or more lines of difference between eyes. Failed stereopsis without obvious strabismus or failed color vision testing in asymptomatic children with normal visual acuity did not elicit further evaluation. Children failing initial vision screening underwent manifest refraction by an optometrist or ophthalmologist. If vision could be corrected optically to 20/20, glasses were prescribed. Such children were then fitted for glasses on-site, frames were selected, and 2 pairs of glasses were made at no cost to the family and delivered 2 to 3 weeks thereafter to the child’s school by an optician who checked the fit. If a child’s best-corrected visual acuity by manifest refraction was subnormal or if obvious abnormalities were detected at screening or refraction, the child was referred that day on-site for full pediatric ophthalmic consultation including recheck of visual acuity, slitlamp examination, cycloplegic refraction, and dilated ophthalmoscopy.
Children aged 5 years or younger and those with obvious developmental delay precluding Snellen and Allen visual acuity testing were screened by pediatric ophthalmologists who assessed fixation preference, qualitative subnormal visual response, red reflex test, eye movements, and alignment. Concerns on any of these tests led to a full evaluation by a pediatric ophthalmologist, including cycloplegic refraction and dilated eye examination. Need for further care including follow-up was determined. If glasses were indicated, children were fitted on-site and glasses were later delivered to the child’s home.
To lessen recognized barriers of follow-up care,9 a social worker was present to ensure that sufficient and accurate contact information was collected. For children needing to return to the clinic, at least 5 telephone numbers were recorded. All children needing follow-up were contacted by the social worker following GKSD to arrange appointments. Assistance was provided at GKSD for insurance enrollment if needed. Where indicated, vouchers for transportation to follow-up were provided. Children needing less than 1 year of follow-up were typically children whose best-corrected visual acuity was less than 20/20 or those with ophthalmic conditions such as strabismus, optic nerve cupping, or other eye abnormalities.
For children older than 5 years, vision-screening results were recorded on a standard state-mandated form. Patients were discharged if they passed or moved to a manifest refraction area if they failed. An autorefraction was obtained before the child saw an ophthalmologist or optometrist. Manifest refraction was recorded on glasses prescription forms if indicated, collected by the opticians and support personnel who did the glasses fitting. For children aged 5 years or younger with failed manifest refraction or with any other reason requiring full pediatric ophthalmology examination, results were recorded on GKSD medical record forms.
Registration forms from GKSD 2012 were collected for data analysis. We reviewed the manifest refraction data, glasses prescriptions, and GKSD medical records. All data were anonymized for analysis. For children needing follow-up, descriptive analysis of their diagnosis, treatment outcome, and return rate to scheduled visits was performed. Parameters were also compared with GKSD 2010 data,9 in which no social worker was present.
Table 1 summarizes the characteristics of the 924 children (mean age, 9 years; age range, 0-18 years; 51% female) from 584 households who attended GKSD 2012. Eleven percent were non-Philadelphia in-state residents and fewer than 1% were out-of-state residents. Eighty-five percent of children attended GKSD 2012 for the first time, whereas 15% had attended prior events. Most children (67%) were in the fifth grade or less and 25% spoke a non-English language.
Twenty-seven percent of participants did not have health insurance, and an additional 10% did not know their health insurance status. Among the 924 participants, 385 (42%) had government-provided health insurance through Medicaid (n = 325) or the Children’s Health Insurance Program (n = 60); however, 136 of those 385 participants (35%) were unaware or unsure of their policy’s vision coverage.
The most common method by which families became aware of GKSD was communication in some form by the school (school nurse, flyers, announcement, telephone call). In families who indicated that they saw a flyer, we were unable to discern whether the flyer was a communication from school or was publicly posted (eg, at a health clinic). Word-of-mouth communication from friends or family was less common.
The majority of participants (64%) attended GKSD because free glasses were offered. This includes participants providing more than 1 response, pairing free glasses with reasons including failed vision screenings or ease of having all children seen in 1 day.
Almost half of participants (455 [49%]) failed vision-screening tests at school or in a physician’s office before GKSD; however, of these 455 participants, only 93 (20%) received ophthalmic care prior to their examination at GKSD. The percentage of children who received vision care after failing vision screening was comparable between children with private insurance (21% received care), with public insurance (17% received care), or without medical insurance (19% received care) (P = .78).
Two pairs of free glasses were given to 567 children (61%). Mean (SD) spherical equivalent refractive error was −1.28 (2.28) diopters (D) OD and −1.12 (4.45) D OS. Of these 567 children receiving glasses, 434 (77%) had myopia of −0.50 D or greater, 220 (38%) had astigmatism of 1 D or greater, and 93 (16%) had anisometropia of 1 D or greater.
Among the 924 attendants, 96 (10%) were identified as needing follow-up care. With social worker assistance, 57 of the 96 participants (59%) returned. Children who returned were of comparable age and visual acuity to children who did not return (both P = .39). Children who attended follow-up appointments were more likely insured than without insurance (54 of 74 [73%] vs 3 of 22 [14%], respectively; P < .001). Of 86 children with complete medical information available, amblyopia and significant refractive errors were the most common diagnoses (Table 2). Ten required eye surgery, for strabismus (n = 5), nystagmus (n = 1), nasolacrimal duct obstruction (n = 2), cataract (n = 1), or ptosis (n = 1).
It has been estimated that 21% of American children have vision disorders,10 and 3% of children have trouble seeing or are blind.11 Vitale et al12 found that nearly 10% of Americans between ages 12 and 19 years have visual acuity of 20/50 or worse. Minority race/ethnicity, low education, income below poverty level, and lack of health insurance are recognized factors associated with increased prevalence of visual impairment and reduced access to ophthalmic care.1,12-14
In the United States, it is estimated that 15% of the population is without health insurance.15 An additional 33% of people are covered by government-provided health insurance. It is calculated that 8% of Americans with self-reported vision problems do not have health insurance.16 Philadelphia, like many other major cities in the United States, has known racial disparities and socioeconomic hardship. In 2013, the Philadelphia population was 1 553 165, of whom 22.2% were children.17 African American and Hispanic individuals constitute 44% of Philadelphia’s population, and the median annual household income in the city is significantly lower than in the state of Pennsylvania ($37 000 vs $52 000, respectively).17 In the last decade, efforts have been made to provide public health insurance for children from families with low to moderate incomes, which resulted in 158 000 children in Philadelphia being insured through Medicaid and an additional 20 000 by the Child’s Health Insurance Program.9 The latter covers 1 annual eye examination and 1 pair of glasses per year, with some policies requiring a co-pay. Medicaid covers 1 examination and 2 pairs of glasses annually. Despite these measures, it is estimated that 16 000 children living in Philadelphia are uninsured.18
Besides lack of insurance, which is an obvious barrier for receiving ophthalmic care, children with publicly provided insurance also have difficulty accessing care.6 Many families with public insurance do not know how to use it and may have challenges with literacy. In the GKSD 2012 event, 35% of participants with publicly provided insurance did not realize that it included vision coverage. Patients with public insurance may feel that financial discrimination had a role in their inability to receive eye care as it may be more difficult for them to schedule an appointment when the optometrist’s or ophthalmologist’s receptionist becomes aware of their type of insurance coverage.6 A survey performed by Public Citizens for Children and Youth in Philadelphia among vision care offices found that many of them were unfamiliar with the vision benefits of children under Medicaid and the Child’s Health Insurance Program, which may lead to misinformation given to parents on the ophthalmic services they can access for their children and therefore refusal to give an appointment to the patient.19 Inconvenience of follow-up, lack of understanding about the benefits of early intervention, family priorities, concerns about costs, transportation issues, and lack of effective communication methods are some of the other barriers for continuous ophthalmic care typical for low-socioeconomic urban populations.6,7,9 These difficulties were reflected in the reasons families gave for attending GKSD 2012, including ease of having all children of the family examined at once on a weekend day, lack of health insurance, and lack of knowing where to go for ophthalmic care. The primary reason for attending was the offer of free glasses. Although government-provided insurance plans typically cover glasses, coverage can be limited and optical shops either may not accept the insurance or may be unaware of the correct insurance benefit. In a random survey sampling of 50 Philadelphia optical shops, Public Citizens for Children and Youth found that approximately half had incorrect knowledge of glasses benefits (C.M. [Public Citizens for Children and Youth] and A.V.L., oral communication, 2014). Immigrant children face unique difficulties in accessing ophthalmic care, including language and cultural issues.20 They may also be undocumented residents and therefore not entitled to insurance. Children of immigrant families are the fastest-growing group of American children, constituting 25% of all US children.21 At GKSD 2012, 25% of attendants spoke at least 1 of 23 foreign languages at home.
Give Kids Sight Day is designed to overcome many of the recognized barriers to care typical for urban populations. Eye examination is provided at no charge, without need for health insurance. All of a family’s children can be examined together on a Saturday, so most parents or accompanying persons do not need to miss a workday. Interpreters are present to assist with translation when needed. Children who fail screening immediately undergo refractive assessment and are prescribed 2 pairs of glasses at no cost. Children whose vision cannot be corrected optically or who are considered to have a more serious problem receive a full ophthalmic examination that day. A social worker becomes immediately involved in assisting all children who need continuous ophthalmic care, trying to resolve any issue that might prevent them from returning to the clinic. This immediate intervention has significantly increased the proportion of children who return to the clinic compared with previous years. In the 3 years of GKSD before the inclusion of a social worker, follow-up return rates were less than 5%. Since the addition of a social worker, the follow-up return rate is nearly 60%. Although we cannot prove cause and effect, we cannot find any other factors to explain this dramatic change.
Several other programs in Philadelphia provide eye care to children with no insurance or those whose insurance does not provide vision coverage. Each serves an important role and we partner with these groups to provide GKSD as an adjunct to their efforts, which addresses some challenges the other programs face. The Eagles Eye Mobile program, run by Eagles Youth Partnership, the charitable arm of the National Football League Philadelphia Eagles, and the Wills on Wheels program, a community outreach effort of Wills Eye Hospital, use a mobile eye center that visits elementary and middle schools to examine children who have failed vision screening by a school nurse or by their own in-school screening programs. Eagles Youth Partnership pays for glasses in their program, but the Wills Eye Hospital effort failed to provide glasses as the school district that planned to provide funding either was unable to provide the funding or required an application process well beyond the abilities of the families. Like GKSD, 2 pairs of glasses from Eagles Youth Partnership are sent to the school nurse to be delivered to the child. Children with more serious eye problems are referred for further treatment by a pediatric ophthalmologist. Not all children who fail a school screening are examined by the Eagles Eye Mobile program owing to issues with capacity, obtaining consent, truancy, and other administrative factors. Only 50% of children referred to a pediatric ophthalmologist actually attend an appointment despite free busing during school, payment for the eye examination by Eagles Youth Partnership if the child does not have insurance, and chaperones to take the child to the pediatric ophthalmologist when a parent cannot attend. Give Kids Sight Day provides immediate pediatric ophthalmology consultation to all of the children who need it. Thirty-four percent of children who attend come because of a failed vision screening. Although several ophthalmic care outreach programs are available nationwide, we are unaware of an ophthalmic program similar to GKSD in which screening, immediate refraction, provision of free glasses, and more extensive ophthalmic care are all done on a single day.
Give Kids Sight Day is a costly event supported by a multitude of donors who contribute everything from hard funding to food. Wittenborn et al22 calculated the annual cost of pediatric vision loss as $9400 and of complete blindness as $40 400, largely related to costs of vision aids and devices, special education, federal assistance programs, and indirect costs such as productivity loss. In addition to its role in treating and preventing vision loss in children, GKSD has many intangible benefits including raising public awareness, team building, attracting interested parties to invest in eye care, and increasing eye care accessibility. It is difficult to analyze the cost-effectiveness of GKSD. The total cost for GKSD is approximately $274 000, with nearly half of that related to the provision of free glasses. These glasses provide enormous savings to the families, and in many cases the glasses would otherwise be unaffordable. Nearly half of the attendants came because they failed vision screening and did not receive any vision treatment afterward. As the calculated cost of US vision screening in school is $92 million each year,22 GKSD may provide an effective bridge between screening and treatment, thus making the investment for the former more worthwhile.
Despite the many advantages of the GKSD program, it has several limitations. Although we can likely see more than 1200 children, as a single day event there is a capacity limitation. Some families use this program as their annual examination of their children, returning to this event yearly. This does not allow for proper longitudinal follow-up and documentation. Efforts of GKSD might be considered “wasted” on children who already have health insurance, but many cannot find an optometrist or ophthalmologist who accepts their insurance, will see them on a weekend, is located conveniently, or can see multiple children in 1 day. At GKSD, we educate families about their insurance benefits, assist with the application process, and help direct them to optometrists or ophthalmologists who are accessible.
Our study also has limitations. This is a retrospective review and incorporates the disadvantages of such a design. Some of the registration records were missing relevant information and often suggested issues with literacy. Medical records were occasionally incomplete and needed to be excluded from analysis. Registration did not identify race/ethnicity, vision coverage, or immigration status. Illiteracy, large crowds, and the business of this day may have interfered with the ability of some parents to carefully consider their responses to our questions.
Our study leads us to suggest interventions for future improvement. As families were most likely to attend as a result of communications from school or posted flyers, the costs of public media might be avoided. To increase the number of attendees without medical insurance, in keeping with one of the objectives of GKSD, such publicity should more carefully target low-income and immigrant communities. Social work intervention is critical to assist families needing follow-up care.
Corresponding Author: Alex V. Levin, MD, MHSc, Wills Eye Hospital, Ste 1210, 840 Walnut St, Philadelphia, PA 19107 (firstname.lastname@example.org).
Submitted for Publication: June 17, 2014; final revision received December 24, 2014; accepted December 26, 2014.
Published Online: February 12, 2015. doi:10.1001/jamaophthalmol.2015.8.
Author Contributions: Drs Dotan and Levin had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Truong, Levin.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Dotan, Truong, Levin.
Critical revision of the manuscript for important intellectual content: Truong, Snitzer, McCauley, Martinez-Helfman, Santa Maria, Levin.
Statistical analysis: Dotan, McCauley, Levin.
Obtained funding: Levin.
Administrative, technical, or material support: Truong, Snitzer, McCauley, Santa Maria, Levin.
Study supervision: Levin.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Ms Santa Maria reported receiving consulting fees from Wills Eye Hospital for administration of Give Kids Sight Day and other projects. Dr Levin reported receiving financial and material support for Give Kids Sight Day from Eagles Youth Partnership, for which he is a board member. The authors represent groups that contributed financial and human resources to Give Kids Sight Day, but they have no financial interest in the data presented. No other disclosures were reported.
Funding/Support: Dr Levin is supported by the Foederer Fund from Wills Eye Hospital and by the Robison D. Harley, MD, Endowed Chair in Pediatric Ophthalmology and Ocular Genetics from Wills Eye Hospital. Give Kids Sight Day is supported by donations and grants from a wide variety of sources, including Wills Eye Hospital, Public Citizens for Children and Youth, and Eagles Youth Partnership.
Role of the Funder/Sponsor: The funding and supporting organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
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