Increasing Access and Reducing Barriers to Children's Vision Care Services

  • Date: Oct 24 2020
  • Policy Number: 20202

Key Words: Access, Childrens Health, Childrens Vision Care, Vision Care

Abstract

Clear, healthy, functional vision is a foundational component of children’s educational, social, communication, and extracurricular success. Problems with children’s vision have been shown to preclude or limit their lifelong academic, extracurricular, and social success. Vision problems are correctable with timely diagnosis and treatment; however, current approaches to prevention often fall short of ensuring that all children have timely access to comprehensive and high-quality care. APHA recommends a series of action steps that will increase access to timely, high-quality vision and eye care for children through the coordinated collection and analysis of needed data to inform policy and program development, increase public education, improve precision in language and description of eye care services, increase coordination and collaboration between stakeholders in children’s vision, and encourage access to care through provision of eye care services in delivery sites working with underserved populations.

Relationship to Existing APHA Policy Statements

  • APHA Policy Statement 8203: Children’s Vision Screening
  • APHA Policy Statement 20011: Improving Early Childhood Eyecare
  • APHA Policy Statement 20067: Promoting the Use of Protective Eyewear For Children In Sports
  • APHA Policy Statement 20116: Reducing Barriers and Increasing Access to Children’s Vision Care Services
  • APHA Policy Statement 20191: Coordinated Nationwide Approaches to Promote Eye Health and Reduce Vision Impairment

Policy Statement 20116 is the only related existing policy statement that is not set to be archived imminently. The action steps have been slightly modified to reflect changes in the past 8 years and are included in this policy statement. Policy Statement 20191 is not primarily directed at children but proposes action steps aimed at improving vision and eye health at a population level. This statement should be considered complementary to 20191, and several of the action steps proposed will also have a direct impact on children’s vision and eye health.

Problem Statement

Vision disorders, including amblyopia, strabismus, and significant refractive errors, are the most prevalent disabling childhood conditions in the United States,[1,2] and one in four children have some form of vision problem.[3] Comprehensive data on vision in children are limited, but an estimated 857,000 children in the United States are blind or have uncorrectable mild, moderate, or severe vision impairment.[4]

Vision and eye health problems among children: Refractive error occurs when the irregular shape of the cornea, lens, or eyeball improperly focuses light on the retina, producing blurred vision that can be corrected through use of spectacles or contact lenses or through refractive surgery. Refractive errors, including hyperopia, myopia, astigmatism, and anisometropia, are the most common causes of vision impairment in children.[5,6]

Amblyopia, sometimes called “lazy eye,” is a neurological disorder in which vision fails to develop in one or both eyes when the corresponding part of the brain “shuts off” in response to a lack of clear images from the eye. Amblyopia is the leading cause of vision loss in one eye in children, although good outcomes can be achieved with early diagnosis and treatment.[7]

Strabismus is a condition in which the eyes are incorrectly aligned, with one eye turning out or in or up or down and the other looking straight ahead.[4] Strabismus affects between 2.5% and 4.6% of children, but early diagnosis and treatment can prevent the development of amblyopia, particularly among preschool-aged children whose visual system is still developing.[7]

The prevalence of myopia (nearsightedness) among children has increased significantly in the past few decades, affecting nearly half of young adults in the United States and Europe.[8] News of this epidemic has transcended the academic and research realms to reach the lay reader.[9] Uncorrected myopia causes significant vision impairment, and a high degree of myopia is associated with a significantly increased risk of serious ocular pathologies, including long-term risk of permanent vision loss.[8]

Other than refractive errors, the most common vision problems among children are accommodative and binocular vision anomalies, although epidemiological data at the population level are limited.[10] These conditions include eye movement disorders, convergence insufficiency, and accommodative dysfunctions in which each individual eye may produce a clear image but, because the eyes are not working together properly, the image transmitted to the brain is not clear or cognitively interpreted.[11] These conditions affect learning, particularly reading, by inducing symptoms such as eye strain, headaches, blurred vision, sleepiness, difficulty concentrating, movement of print while reading, loss of place, and loss of comprehension after short periods of reading, as well as difficulty maintaining focus or shifting focus from near to far and back again.[12]

Changes in technology and lifestyle have also created emerging challenges for children’s vision. The increase in the prevalence of myopia has been shown to be related to near work (e.g., reading, writing, and computer and device use), lack of time spent outdoors, and greater levels of parental income and education.[8] Digital eye strain, also called computer vision syndrome, has been documented in adults since the 1990s, but device use among children, including very young children, has been increasing in the past 20 years with the revolution among mobile devices.[13] This may overlap with emerging research on “video game syndrome” and is an area that merits further investigation.[14] Symptoms include accommodative problems such as blurred vision and dry eye. Among other issues, individuals blink less frequently when viewing digital devices than their analog counterparts, reducing the frequency with which tear film is spread across the surface of the eye for lubrication. Increased device use in early childhood could be the beginning of a lifetime of discomfort, meibomian gland dysfunction, and dry eye sequelae.[13]

Aside from vision conditions and eye diseases, injuries also play a part in children’s vision. Eye injury is the leading cause of blindness in children.[15] High-risk activities such as paintball, racquet sports, lacrosse, and hockey and moderate-risk activities such as tennis, volleyball, and football collectively accounted for 82% of the 208,517 sports-related eye injuries treated in emergency departments between 2001 and 2009.[16,17] In addition, traumatic brain injury has been shown to lead to very high rates of vision disorders among adolescents.[18] Concussions and other traumatic brain injuries can result in vestibular-ocular and vision-specific dysfunction that can contribute to difficulty in reading and learning.[19]

Rarely, serious diseases of the eye can result in irreversible vision impairment and blindness in children. These conditions include retinal detachments, defects, and disorders; glaucoma; cataracts; cancers; and other diseases.[4]

Impact of vision and eye health problems among children: Left unidentified and uncorrected, vision problems can challenge a child’s general development,[20] school performance,[21] social interactions,[22] and self-esteem.[23] Impaired vision can affect a child’s cognitive, emotional, neurological, and physical development by potentially limiting the range of experiences and kinds of information to which the child is exposed.[24] Childhood visual impairment is associated with developmental delays, lower educational attainment, and the need for special education and for vocational and social services.[24]

Childhood vision disorders, especially those that remain untreated, often manifest as problems well into adulthood, affecting an individual’s level of education, employment opportunities, and social interactions.[24] In some cases, students with undiagnosed vision impairment may be misdiagnosed as having learning disabilities or attention deficit disorders because of undetected vision problems.[25,26] As children have only a few years to learn to read before they read to learn, early diagnosis and treatment of vision impairments is crucial. Early intervention is crucial to preserve vision and can bolster a child’s self-esteem, elevate reading comprehension, boost test scores, and reduce or eliminate behavior problems.

According to the Centers for Disease Control and Prevention (CDC), fewer than 15% of preschoolers receive an eye examination from an eye care professional, and fewer than 22% receive some type of vision screening.[27]

Rates of insurance coverage for vision and eye care are high among children relative to adults. In 2017, 98.7% of children were insured.[28] For almost all children, medical insurance includes vision coverage. In Medicaid, Early and Periodic Screening, Diagnosis, and Treatment Services include screening for, diagnosis of, and treatment of vision conditions, and eye examinations and eyeglasses are offered. Children receiving insurance through the Children’s Health Insurance Program (CHIP) have access to comparable eye care services. The essential health benefits provision of the Affordable Care Act requires that qualified health plans, plans in the small group market, and individual market plans include pediatric vision services. For most children with private insurance, that means coverage of one comprehensive eye examination and one pair of glasses per year through the age of 17 years, although it does not dictate associated cost sharing.[4] Vision screening is covered under those plans without associated cost sharing as a United States Preventive Services Task Force (USPSTF) B-rated service.[4] Coverage of vision services for children has not guaranteed receipt of needed services, but health insurance coverage does correlate with increased receipt of services and improved health outcomes.[29]

Disparities: Vision problems among children are not evenly distributed across the population; children in low-income homes have an increased risk of vision loss and untreated vision impairment. A child living below the federal poverty line has almost double the risk of being visually impaired relative to a child living at 200% of the federal poverty line or higher.[30] There is variation in the prevalence of childhood vision disorders among racial and ethnic groups. For example, Hispanic children have been shown to have significantly higher rates of strabismus than African American children.[31]

Analysis of data from the Maternal and Child Health Bureau’s National Survey of Children with Special Health Care Needs indicates that children without health insurance are approximately five times more likely to have an unmet vision care need.[32] Furthermore, racial and ethnic disparities among insured and uninsured children are well documented, and vision-related services under Medicaid and CHIP vary significantly among states.[33,34] A review of health records from nine states by the U.S. Office of the Inspector General showed that 60% of those states’ children with Medicaid did not receive vision screenings under the EPSDT program, nearly 50% more than the percentage of children who did not receive medical screenings.[35] Research also suggests that children are being screened at low rates and often do not receive the necessary follow-up diagnosis and treatment services,[3,36] which suggests a lack of coordination, consistency, and accountability for national and state vision programs.[37,38]

It has been established that children are relatively likely to have insurance coverage for comprehensive eye care, but insurance is only one factor in assessing the likelihood that a child will receive needed care. As do adults, children suffer from the effects of social determinants of health on eye health. “Socioeconomic status itself is an important determinant of visual impairment,”[39] and there is an increased risk of eye disease and vision impairment among Americans of all ages who are poor, are unemployed, or have less education.[40] The likelihood that an individual will report having an eye care visit in the preceding 12 months decreases with lower incomes and lower levels of educational achievement.[41]

Because of inequities in health care access and ability to afford care, minority communities and individuals of lower economic status are at risk for poorer overall health[42]; many of the factors related to overall health quality, such as poor diet, inadequate physical fitness, and increased tobacco use—all of which are more common among low-income populations—also impact eye and vision health.[43] Eye health disparities generally mirror the overall state of health disparities, with members of racial and ethnic minority groups having higher rates of chronic disease than Whites.[44] The relationship is a complex one, encompassing access to and receipt of health care, health behaviors, nutrition, employment, discrimination, income, physical and social environments, transportation, and housing.[44]

In addition to the personal and educational impacts of children’s vision, vision and eye problems among children contribute a significant economic burden to the nation. In 2013, the economic burden of vision and eye problems among children from birth to the age of 17 years was $5.7 billion.[4] This includes direct costs such as medical treatment, assistance programs, and aids/devices as well as indirect costs such as informal care (e.g., that provided by parents).

Providing care to prevent, diagnose, and treat vision problem has a cost of its own. A private analytic firm calculated that the annual cost, per covered child, of a pediatric vision benefit covering comprehensive eye examinations and corrective lenses without cost sharing would be $42 per year in 2011, shortly after the signing of the Affordable Care Act (privately commissioned study from the Hays Group). Comprehensive eye care is not within the set of preventive services that are protected from cost sharing in qualified health plans, and the direct cost for families varies by source of insurance. Financial cost is only one aspect of the burden of delivering care to children. If care is provided outside of a school or child-care setting, presumably parents have to take time off work and arrange transportation for children to receive care.

Evidence-Based Interventions and Strategies

Appropriately timed receipt of quality comprehensive eye care, including diagnosis, treatment, and management, can significantly reduce the impact of childhood vision and eye problems on individual children.[4,7] According to the Institute of Medicine, “quality care must be safe, timely, effective, efficient, equitable, and patient-centered.”[45] A comprehensive eye examination by an optometrist or ophthalmologist is the gold standard of eye care.[4] The Affordable Care Act identified pediatric vision care as an essential health benefit, increasing coverage of vision among children from birth to the age of 18 years in all qualified health plans to an annual comprehensive eye examination and materials benefit in almost all states.[46] Insurance coverage has been shown to correlate with improved vision and eye health outcomes and lower rates of vision impairment.[4] Not all children have medical insurance, and for some cost sharing may make the cost of care prohibitive. In these cases, a number of charitable programs sponsored by professional societies, insurers, eyewear manufacturers, nonprofits, and others may help to close the gap.[4] In addition, 90% of sports-related eye injuries can be prevented with the use of protective eyewear.[47] The challenge, then, is ensuring that all children have access to quality eye care.

Data collection: The first step is to better define the problem. The limitations of existing epidemiological data on children’s vision and eye health, as well as their receipt of eye care, hamper the development of evidence-based clinical care and population health strategies.[4] Surveillance is one of the foundations of public health and the basis for policy-making and decision making.[48] There are a variety of national health status and access surveys, including the National Survey of Children’s Health, the Medical Expenditure Panel Survey, the National Health and Nutrition Examination Survey, and the Behavioral Risk Factor Surveillance System. Robust use of these surveys to gather objective clinical data (including disability data) on children’s vision and eye health is crucial to the improvement of population health. If these surveys ask about children’s vision, it is usually a question about existing vision impairment or about “vision screening.” None of the national surveys collect information on receipt of or access to comprehensive eye care that can be correlated with outcome data, but access to such information could substantially inform policy decisions at the federal, state, and local levels and help measure the success of interventions. Surveys could include such questions as “Has your child received a comprehensive eye examination from an eye doctor (optometrist or ophthalmologist) in the past 12 months?” Survey questions could also be adapted for use in surveys administered in schools or school systems, early childhood programs, or juvenile justice settings. Data on children’s vision care and eye health outcomes could potentially be paired with information on educational outcomes to provide greater support for the role of vision and eye health in learning.

Aside from national surveys, data from eyewear manufacturers, low vision device manufacturers, clinical data registries, insurance claims, and other sources could contribute to a full picture of children’s vision in the United States.

All additional data on children’s vision should, as recommended in APHA Policy Statement 20191 (Coordinated Nationwide Approaches to Promote Eye Health and Reduce Vision Impairment), be included in a coordinated data collection model built on the CDC’s Vision and Eye Health Surveillance System.[49]

Proper terminology: Evidenced-based screenings involving testing instruments with high sensitivity and specificity can complement early and periodic comprehensive eye examinations as a means of identifying children 3 to 5 years of age at high risk for amblyopia. However, such screening does not replace a comprehensive vision examination performed by an eye doctor.[24] These screenings have commonly been referred to as “vision screenings” by such entities as the United States Preventive Services Task Force. Upon further examination, the USPSTF recommends “vision screening” to detect amblyopia in children 3 to 5 years old.[50] Using the proper terminology is key in making health recommendations—in this case, “vision screening” as recommended by the USPSTF should be labeled “amblyopia screening” or, possibly, “visual acuity screening.” If other tools are proven effective to screen for other conditions, they should be named according to the condition for which they seek to determine risk. For example, the USPSTF has recommendation statements on at least 12 different kinds of cancer screenings, each of which is referred to specifically by name (e.g., breast, cervical, skin).[51] “Cancer screening” is not used to describe screening solely for skin cancer. In the same way, “vision screening in children” misleads parents and primary care providers that screening for amblyopia somehow covers all potential childhood vision conditions at any age, when in fact amblyopia is but one of several vision-affecting conditions, each of which merits independent consideration.

The USPSTF’s choice of language is common. The phrase “vision screening” can be found in descriptions and recommendations from such entities as Medline.gov, HealthyChildren.org, and multiple federal agencies. Evidence-based screenings do have a role to play in ensuring that children receive early and comprehensive treatment for their eye and vision health. Furthermore, “screening” itself is a fundamental concept in public health, and the term is ubiquitous for describing population-based programs that link individuals to clinical care.[12] “Vision screening” does not have the degree of reliability required to merit the presumption of value that the public health community affords other targeted screening programs, as shown in the opposing arguments portion of this statement. Precision in language allows for better public education and more accurate health care recommendations.

Public education: Public awareness campaigns are a long-standing way to increase public visibility and priority for specific health issues. When structured properly, with the right resources to reach the right audiences (considering, for example, literacy skills and unequal access to resources), public awareness campaigns have been shown to improve awareness of specific issues.[52] The CDC and other federal agencies have significant experience in conducting public education campaigns, including those designed to educate parents about health risks and health care needs for their children.[53] Since the designation of pediatric vision care as an essential health benefit, the U.S. Department of Health and Human Services (DHHS) and the Centers for Medicare and Medicaid Services (CMS) have not undertaken substantial public education campaigns to raise awareness about the availability of insurance coverage for children’s vision care. Public education campaigns could raise awareness about the importance of children’s vision for learning and about the availability of insurance coverage for comprehensive care, among other messages. Such campaigns, if successful, would increase receipt of comprehensive vision care, would improve outcomes for children with vision and eye problems, and could even lead to improved school performance, although this downstream impact may be more difficult to measure.

In a more targeted way, the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program provides health education to a specific at-risk population. MIECHV initiatives must meet specific benchmarks to improve child health and promote school readiness, among other requirements.[28] By educating parents about the importance of vision health for school readiness and achievement and helping to connect parents with programs and resources for care (e.g., charitable programs and information about insurance coverage), MIECHV could serve as a small and targeted public education campaign. Other related programs at the federal, state, and local levels that address child welfare, including Head Start, Early Head Start, and Home Instruction for Parents of Preschool Youngsters, provide similar opportunities.

Collaboration and coordination: Activities to improve children’s vision are spread across the federal and state governments and private sector. Unfortunately, there is little or no coordination of existing vision care services in state health department programs, and many states do not require any vision screenings or eye examinations and follow-up services.[54] The Maternal and Child Health Bureau of the Health Resources and Services Administration (HRSA) is well positioned to coordinate collaboration between governmental and private organizations, in part because of its role with regard to Title V maternal and child health funding. As a first step, the agency could undertake a project to identify vision-related requirements and resources in health programs, school systems, and insurance plans across the United States.

Access to care: Minority and underserved populations with reduced access to health care services have consistently been shown to have poorer health outcomes.[55] Access to care is determined by a variety of factors, including income, geography, employment status, and insurance coverage.[4] Federally qualified health centers and school-based health clinics are delivery sites intended to increase access to care among underserved populations, including children, but they rarely have the capacity to deliver in-person, comprehensive vision and eye care. In 2009, fewer than 20% of health centers reported having an optometrist or ophthalmologist on site. The number of vision care full-time equivalents in health centers increased by 52% between 2014 and 2016, but they were not evenly distributed, and access remains limited and uneven.[4] School-based health clinics have been shown to improve health-related quality of life, particularly for children without health insurance or otherwise at higher risk for poor health outcomes.[55]

Mobile eye clinics that provide a variety of different services, from “vision screening” to comprehensive eye exams and eyeglasses, are a strategy that has been pursued by health systems and community groups. While some of the services they offer may be more valuable than others, they can potentially help to fill a gap in care or help to identify a previously unrecognized demand for services but are unlikely to be able to provide the continuity of care and doctor-patient relationship that could be offered by an on-site eye doctor in a health center setting. Among adults, mobile clinics have been shown to be of much greater value when they offer direct, immediate access to comprehensive care and an established relationship with a local specialist for those who meet referral guidelines.[56–60] Similar to adults, children suffer from loss of follow-up, even when a social worker pursues the follow-up appointment.[61] Bringing the comprehensive exam unit to the school setting could improve follow-up completion.[62] Providing access to comprehensive eye care in delivery settings that increase access to care among underserved pediatric populations could improve vision and eye health outcomes, much as it can for overall health. A set of case studies performed by the Oral Health Workforce Research Center determined that co-location of dental services with the primary care services of a community health center “is a facilitator of integrated delivery” that has benefits in terms of completion of referrals, and it may offer similar results for eye care services.[63] A survey of federally qualified health centers in Missouri indicated that, of the respondents who did not have vision services available to their patients, all but one indicated a desire to incorporate them, given sufficient funding and space.[64] An on-site optometrist or ophthalmologist in a community health center or school-based health clinic could provide comprehensive vision care to children in that setting. The potential for community health centers to address disparities in eye care has long been recognized.[65] Many underserved and low-income populations rely on federally funded community and rural health centers, which may often be the only locally available source of eye and vision care services.[4]

Opposing Arguments

Some stakeholders in the vision community have resisted universal access to comprehensive eye care for children in favor of more limited “vision screenings,” either in a community setting or in a pediatrician’s office. Screening for amblyopia has a role in comprehensive vision and eye care systems for children. However, relying on “vision screening” to identify children in need of eye care and connect them to that care has not been proven to be effective—in too many cases, it fails to catch children with vision problems, and those it does catch often fail to transition to needed care. As discussed above, the term “vision screening” is imprecise. There are a number of forms of eye-related screenings that children receive via different modalities and different means of identifying those at risk for various conditions. When the USPSTF developed its misnamed “Vision Screening in Children Ages 6 Months to 5 Years” recommendation statement, it identified 11 different types of screening tests used in primary care settings that each purported to identify children at risk for at least one of six different conditions.[51] Also, a variety of different pieces of equipment, created by different companies, are used in some of these tests. A screener in a lay or primary care setting uses only one piece of equipment. Knowing that children received a “vision screening” tells us very little about precisely what they received and for what conditions they might be at risk.

Among the variety of vision screening tools and methods available, effectiveness in identifying anything but amblyopia varies widely but is generally quite low. Factors such as training of the individual conducting the screening, room lighting, testing distances, and maintenance of testing equipment can affect test results. Variances in screening approaches and the potential for differences in instrument-based screening products create tremendous inconsistences. Research has shown that when Snellen visual acuity (the most commonly recognized “eye chart”) alone is used as a screening tool, it is 100% specific for identifying reduced acuity due to myopia (nearsightedness), but it misses 75.5% of children found to have hyperopia and/or binocular and oculomotor vision problems when given a complete visual examination.[51] In addition, a study of 1,992 school-aged children showed that 41% of children who failed the State University of New York screening battery would not have been identified if screening was based on visual acuity alone.[66]

A screening can create a false sense of security for individuals who “pass” the screening but have a vision problem that could impact learning. Overall, vision screening procedures lack the evidence needed for identifying the targeted vision problems present in the population of children being screened with proven high sensitivity and specificity.[2,67] The sensitivity of a wide variety of screening techniques was evaluated in the Vision in Preschoolers study, which, unlike standard screenings, involved licensed eye doctors who had completed the study’s specific training and certification.[2] In the study, the sensitivity of 11 vision screening techniques used for detecting clinically significant vision problems among children 3 to 5 years of age varied from 16% to 64%, with specificities ranging from 62% to 98%. These tests were compared again with a specificity of 94%, and the sensitivity dropped even further.[67] Even considering the most generous interpretation of the results, the proportion of children who would not be identified in such a program is still too high, especially in light of the availability of comprehensive care that can include diagnosis and treatment. When screening does identify a child who potentially has a vision problem, that child often fails to receive diagnosis and treatment. A study of public school children revealed that only 38.7% of those who failed a screening received follow-up care.[67]

Supporters of this opposing position argue that “vision screening” is better than no care, which is what many children receive now. This may be true, but substandard care should not be the goal of any policy, and this position could create unethical inequities between children who must rely on a screening system and children whose families have the means and education to independently obtain the standard of care. Supporters of “vision screening” programs also point to transportation and parental work challenges with respect to obtaining comprehensive care. Again, this points to a need to create policies that enable all children to receive comprehensive care rather than relying on a fallback system of “vision screening” for the most vulnerable children. In many cases, financial barriers are the greatest challenge for children in need of comprehensive vision care. Inclusion of pediatric vision care in the essential health benefits package limited (but did not completely eliminate, thanks to variable cost sharing) the impact of these barriers. Rather than providing a more easily accessible but substandard option, policies could be developed to meet these challenges head on to ensure that children receive appropriate care for all of their health needs.

Action Steps

APHA recommends the following action steps:

  1. The DHHS and other agencies conducting surveys related to children’s health and education should include in those surveys the collection of objective clinical data and questions to determine access to comprehensive eye care and receipt of comprehensive eye examinations from an eye care professional.
  2. The DHHS, other government agencies, and national vision-related organizations should use precise and accurate terminology to describe vision and eye care recommendations and services.
  3. HRSA, through the Maternal and Child Health Bureau, should allocate new resources to improve access and reduce barriers to comprehensive vision care services for all children. In addition, HRSA should increase resources to state health departments by expanding state performance measures to better coordinate, track, evaluate, and report on children’s vision and eye care through state Title V programs. HRSA should prioritize the expansion of on-site, in-person comprehensive vision services in the Health Center Program to better serve children where they already receive affordable care. In addition, HRSA should use the MIECHV Program to educate parents about the importance of vision health for school readiness, as well as programs and resources that may help them receive care.
  4. CMS should ensure the availability and accessibility of all vision services as required health care under the EPSDT program by reassessing current regulations to improve screening, diagnostic, and treatment service quality and outcomes and by requiring states to report vision screenings and eye examinations performed by an eye doctor and follow-up diagnosis and treatment services.
  5. Both public and private insurance programs should maintain comprehensive vision care for children from birth to the age of 18 years as an essential standard benefit. Coverage should include comprehensive vision and eye health examinations by an ophthalmologist or optometrist at regular intervals, as well as eyeglasses, contact lenses, and any other vision care services determined by the provider to be necessary.
  6. Federal, state, and local governments, as well as community organizations, should take steps to encourage the provision of comprehensive eye care in all health settings designed to increase access to affordable care among underserved pediatric populations, including federally qualified health centers and school-based health clinics.
  7. Stzate governments and local school boards should enact policies and provide resources to encourage provision of comprehensive vision care to improve education, including comprehensive eye examinations for all children with individualized education plans, diagnoses of attention deficit hyperactivity disorder or other behavioral disorders, and other learning or developmental difficulties. Also, state governments and local school boards should guarantee that children with vision problems that impede learning or reading receive needed accommodations for school success.
  8. The DHHS should engage public and private stakeholders in undertaking a public awareness campaign to educate the public about the importance of children’s vision and the availability of insurance coverage providing comprehensive eye care.
  9. All national vision-related associations should educate parents and health professionals about the importance of children’s vision care and related medical or behavioral health services through culturally competent and literacy-appropriate eye and vision health education and health promotion programs.
  10. State legislatures should mandate that all children wear sports protective eyewear that meets the standards of ASTM International for high-risk sports. Community partners should assist in the funding of protective eyewear for children who cannot afford such equipment. Health educators and facilitators of sports programs (including coaches, officials, athletic directors, athletic trainers, school principals, physical education teachers, and school nurses), upon consultation with eye care professionals, should provide information on the value of quality fitted sports protective eyewear to all athletes engaging in high- to moderate-risk sports, communicate the risks of recreational eye injuries, and offer guidance regarding choice of eye protection to their at-risk populations.

References

1. Pascual M, Huang J, Maguire MG, et al. Risk factors for amblyopia in the Vision in Preschoolers Study. Ophthalmology. 2014;121(3):622–629.e1.
2. Vision in Preschoolers Study Group. Comparison of preschool vision screening test as administered by licensed eye care professionals in the Vision in Preschoolers Study. Ophthalmology. 2004;111(4):637–650.
3. Centers for Disease Control and Prevention. Improving the nation’s vision health: a coordinated public health approach. Available at: www.visionandhealth.org/documents/ReportImprovingtheNationsVisionHealth.pdf. Accessed December 18, 2018.
5. Tarczy-Hornoch K, Cotter SA, Borchert M, et al. Prevalence and causes of visual impairment in Asian and non-Hispanic white preschool children: Multi-Ethnic Pediatric Eye Disease Study. Ophthalmology. 2013;120(6):1220–1226.
6. Multi-Ethnic Pediatric Eye Disease Study Group. Prevalence and causes of visual impairment in African-American and Hispanic preschool children: the Multi-Ethnic Pediatric Eye Disease Study. Ophthalmology. 2009;116(10):1990–2000.
7. Wallace DK, Lazar EL, Crouch ER, et al. Time course and predictors of amblyopia improvement with 2 hours of daily patching. JAMA Ophthalmol. 2015;133(5):606–609.
9. Cha A. The world’s myopia crisis and why children should spend more time outdoors. Available at: https://www.washingtonpost.com/news/to-your-health/wp/2015/09/16/the-world-myopia-crisis-and-why-children-should-spend-more-time-outdoors/?noredirect=on&utm_term=.ea691e0866b2. Accessed January 16, 2019..
10. Cacho-Martínez P, García-Muñoz A, Ruiz-Cantero M. Do we really know the prevalence of accommodative and nonstrabismic binocular dysfunctions? J Optom. 2010;3(4):185–197
11. Borsting E, Mitchell GL, Arnold LE, et al. Behavioral and emotional problems associated with convergence insufficiency in children: an open trial. J Atten Disord. 2016;20:836–844.
12. Scheiman M, Cotter S, Kulp MT, et al. Treatment of accommodative dysfunction in children: results from a randomized clinical trial. Optom Vis Sci. 2011;88(11):1343–1352.
13. Sheppard AL, Wolffsohn JS. Digital eye strain: prevalence, measurement and amelioration.
14. Rechichi C, De Mojà G, Aragona P. Video game vision syndrome: a new clinical picture in children? J Pediatr Ophthalmol Strabismus. 2017;54:346–355.
15. National Eye Institute. About sports eye injury and protective eyewear. Available at: https://nei.nih.gov/sports. Accessed January 16, 2019.
16. Kim T, Nunes A, Mello M, Greenberg P. Incidence of sport-related eye injuries in the United States: 2001–2009. Graefes Arch Clin Exp Ophthalmol. 2011;249:1743–1744.
17. Mishra A, Verma A. Sports related ocular injuries. Med J Armed Forces India. 2012;68(3):260–266.
18. Master CL, Scheiman M, Gallaway M, et al. Vision diagnoses are common after concussion in adolescents. Clin Pediatr (Phila). 2016;55(3):260–267.
19. Swanson MW, Weise KK, Dreer LE, et al. Academic difficulty and vision symptoms in children with concussion. Optom Vis Sci. 2017;94(1):60–67.
20. Ibironke JO, Friedman DS, Repka MX, et al. Child development and refractive errors in preschool children. Optom Vis Sci. 2011;88(2):181–187.
21. Dudovitz RN, Izadpanah N, Chung PJ, Slusser W. Parent, teacher, and student perspectives on how corrective lenses improve child wellbeing and school function. Matern Child Health J. 2016;20(5):974–983.
22. Mojon-Azzi SM, Kunz A, Mojon DS. Strabismus and discrimination in children: are children with strabismus invited to fewer birthday parties? Br J Ophthalmol. 2011;95:473–476.
23. Birch EE, Kelly KR. Pediatric ophthalmology and childhood reading difficulties: amblyopia and slow reading. J AAPOS. 2017;21(6):442–444.
24. Davidson S, Quinn GE. The impact of pediatric vision disorders in adulthood. Pediatrics. 2011;127:334–339.
25. DeCarlo DK. ADHD and vision problems in the National Survey of Children’s Health. Optom Vis Sci. 2016;93(5):459–465.
26. Solé Puig M. Attention-related eye vergence measured in children with attention deficit hyperactivity disorder. PLoS One. 2015;10(12):e0145281.
27. Centers for Disease Control and Prevention. Keep an Eye on Your Vision Health. Available at: https://www.cdc.gov/features/healthyvision/index.html#:~:text=Start%20Early&text=
But%20less%20than%2015%25%20of,needed%20to%20diagnose%20eye%20diseases. Accessed August 14, 2020.
28. Maternal and Child Health Bureau. Home visiting. Available at: https://mchb.hrsa.gov/maternal-child-health-initiatives/home-visiting-overview. Accessed August 1, 2019.
29. Sommers BD, Gawande AA, Baicker K. Health insurance coverage and health—what the recent evidence tells us. N Engl J Med. 2017;377(6):586–593.
30. Cotch MF, Klein R, Brett K, Ryskulova A. Visual impairment and use of eye-care services and protective eyewear among children—United States, 2002. MMWR Morb Mortal Wkly Rep. 2005;54(17):425–429
31. Multi-Ethnic Pediatric Eye Disease Study Group. Prevalence of amblyopia and strabismus in African American and Hispanic children ages 6 to 72 months: the Multi-Ethnic Pediatric Eye Disease Study. Ophthalmology. 2008;115(7):1229–1236
32. What Is Vision Impairment? Atlanta, GA: Centers for Disease Control and Prevention; 2004.
33. Basch CE. Vision and the achievement gap among urban minority youth. J Sch Health. 2011;81:599–605.
34. Data Resource Center for Child and Adolescent Health, Maternal and Child Health Bureau. National Survey of Children With Special Health Care Needs, 2005–2006. Available at: https://www.cdc.gov/nchs/slaits/cshcn.htm. Accessed August 14, 2020.
35. Office of Inspector General. Most Medicaid Children in Nine States Are Not Receiving All Required Preventive Screening Services. Washington, DC: U.S. Department of Health and Human Services; 2010. 36. Ethan D, Basch CE, Platt R, Bogen E, Zybert P. Implementing and evaluating a school‐based program to improve childhood vision. J Sch Health. 2010;80:368–370.
37. Newacheck P, Stoddard J, Hughes D, et al. Health insurance and access to primary care for children. N Engl J Med. 1998;338:513–519.
38. Silow-Carroll S, Hagelow G. Systems of care coordination for children: lessons learned across state models. Available at: https://www.commonwealthfund.org/publications/issue-briefs/2010/sep/systems-care-coordination-children-lessons-learned-across-state. Accessed August 14, 2020.
39. Sommer A, Tielsch J, Katz J, et al. Racial differences in the cause-specific prevalence of blindness in East Baltimore. N Engl J Med. 1991;325(20):1412–1417.
40. Ko F, Vitale S, Chou C, Cotch MF, Saaddine J, Friedman DS. Prevalence of nonrefractive visual impairment in US adults and associated risk factors, 1999–2002 and 2005–2008. JAMA. 2012;308(22):2361–2368.
41. Zhang X, Saaddine J, Chou C, et al. Vision health disparities in the United States by race/ethnicity, education, and economic status: findings from two nationally representative surveys. Am J Ophthalmol. 2012;154(suppl 6):S53–S62.
42 .Health, United States, 2015: With Special Feature on Racial and Ethnic Health Disparities. Hyattsville, MD: National Center for Health Statistics; 2016.
43. Institute of Medicine. Unequal treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press; 2003.
44. National Academies of Sciences, Engineering, and Medicine. Communities in Action: Pathways to Health Equity. Washington, DC: National Academies Press; 2017.
45. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
46. Lieberman S, Cohen AH, Stolzberg M, Ritty JM. Validation study of the New York State Optometric Association (NYSOA) Vision Screening Battery. Am J Optom Physiol Opt. 1985;62:165–168.
47. Goldstein MH, Wee D. Sports injuries: an ounce of prevention and a pound of cure. Eye Contact Lens. 2011;37:160–163.
48. Lee LM, Teutsch SM, Thacker SB, Louis M, eds. Principles and Practice of Public Health Surveillance. 3rd ed. New York, NY: Oxford University Press; 2010.
49. American Public Health Association. Policy statement 20191: coordinated nationwide approaches to promote eye health and reduce vision impairment. Available at: https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2020/01/10/coordinated-nationwide-approaches-to-promote-eye-health-and-reduce-vision-impairment. Accessed August 1, 2019.
50.U.S. Preventive Services Task Force. Vision in children ages 6 months to 5 years: screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/vision-in-children-ages-6-months-to-5-years-screening. Accessed January 16, 2019.
51. U.S. Preventive Services Task Force. Published recommendations. Available at: https://www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations. Accessed January 16, 2019.
52. Seymour J. The impact of public health awareness campaigns on the awareness and quality of palliative care. J Palliat Med. 2017;21(suppl 1):S30–S36.
53. Centers for Disease Control and Prevention. Gateway to health communication and social marketing practice. Available at: https://www.cdc.gov/healthcommunication/campaigns/index.html. Accessed January 16, 2019.
54. National Association of Chronic Disease Directors. A Plan for the Development of State Based Vision Preservation Programs: Summary of a Retreat on Public Health Vision Preservation. Washington, DC: Prevent Blindness America and National Association of Chronic Disease Directors; 2005.
55. Wade TJ, Mansour ME, Line K, Huentelman T, Keller KN. Improvements in health-related quality of life among school-based health center users in elementary and middle school. Ambul Pediatr. 2008;8(4):241–249.
56. Tsui E, Siedlecki AN, Deng J, et al. Implementation of a vision-screening program in rural northeastern United States. Clin Ophthalmol. 2015;9:1883–1887.
57. Cheung NC, Greenberg PB, Anderson KL, Feller ER. Effectiveness of a medical student-organized community vision screening initiative. Med Health R I. 2010;93(8):239, 242–243.
58.Quigley HA, Park CK, Tracey PA, Pollack IP. Community screening for eye disease by laypersons: the Hoffberger program. Am J Ophthalmol. 2002;133(3):386–392.
59. Friedman DS, Cassard SD, Williams SK, Baldonado K, O’Brien RW, Gower EW. Outcomes of a vision screening program for underserved populations in the United States. Ophthalmic Epidemiol. 2013;20(4):201–211.
60. Williams AM, Botsford B, Mortensen P, Park D, Waxman EL. Delivering mobile eye care to underserved communities while providing training in ophthalmology to medical students: experience of the Guerrilla Eye Service. Clin Ophthalmol. 2019;13:337–346.
61. Hark LA, Mayro EL, Tran J, et al. Improving access to vision screening in urban Philadelphia elementary schools. J AAPOS. 2016;20(5):439–443.e1.
62. Diao W, Patel J, Snitzer M, et al. The effectiveness of a mobile clinic in improving follow-up eye care for at-risk children. J Pediatr Ophthalmol Strabismus. 2016;53:344–348..
63. Langelier M, Moore J, Baker BK, Mertz E. Case Studies of 8 Federally Qualified Health Centers: Strategies to Integrate Oral Health with Primary Care. Rensselaer, NY: Center for Health Workforce Studies, School of Public Health, SUNY Albany; 2015.
64. Pike E, McAlister W, Hoang K. Optometric services in federally qualified health centers in Missouri. Available at: https://www.researchgate.net/publication/274065644_Optometric_Services_in_Federally_Qualified_Health_Centers_in_Missouri. Accessed August 1, 2019.
65. Proser M, Shin P. The role of community health centers in responding to disparities in visual health. Optometry. 2008;79(10):564–575.
66. Bodack MI, Chung I, Krumholtz I. An analysis of vision screening data from New York City public schools. Optometry. 2010;81:476–484.
67. Ying GS, Kulp MT, Maguire M, et al. Sensitivity of screening tests for detecting vision in preschoolers—targeted vision disorders when specificity is 94%. Optom Vis Sci. 2005;82:432–438.