 The talk of the afternoon will be given by Megan Collins, whom I introduced this morning as she moderated one of our earlier programs. Megan is an associate professor of pediatric ophthalmology at the Wilmer Eye Institute at Johns Hopkins. Her talk today is entitled, School-Based Vision Care, Working at the Intersection of Ophthalmology, Public Health, and Ethics. Megan, please. Thank you. Hello, everyone. My gosh, I've got to follow psychedelic drugs and influenza. I sort of want to go home and wash my hands. I did get my flu vaccine, and I've never tried a class 1 drug. Those are my disclosures for today. But it's a little bit different than was in the program, so thanks to all of you who are still here today. I was originally going to talk about ophthalmology and ethics curriculum that I helped run at Wilmer Eye Institute with Maggie Moon, who's in the audience here. But a couple of weeks ago, I had chatted with Mark and Anna when I was in town for the American Academy of Ophthalmology meeting, and we started talking about another program that I've been involved in at Hopkins. And Mark said, why don't you talk about that? So here I am today talking about this. Before I get started, I want to acknowledge this incredibly long list of individuals who are working with me on this project. I've had a lot of great opportunities to go speak about it nationally at this point in time, but there's a number of people who are doing all the day-to-day efforts to make these programs work, and this is just an acknowledgment of some of our very generous funding support as well. So it looks like there's a whole bunch of you in the audience who are actually wearing glasses, which is always good because it helps to prove my point that vision problems have a significant magnitude in kids, and it turns out in the US about one in four school-aged children actually have a vision problem, most commonly refractive error, meaning nearsightedness, farsightedness, or astigmatism. And we know that that can interfere not only with how well kids do in school, but also their well-being and health and adulthood. And a fun party trick that only ophthalmologists or optometrists can do is I can look at you wearing your glasses and predict what your prescription is. So if anybody wants, later, I can diagnose you. Now, if you don't wear glasses and want to understand what it's like to look at the board in a classroom or a conference auditorium like this, you can see this is blurry. So you can imagine if you were a child in a classroom, and this is how the board looked to you. You might get kind of fidgety. You might get kind of bored. You might not pay any attention at all. You might get out of your class. Your seat, go walk up to the board, and we know kids do all of these different things. Turns out the good news is that for most kids with eye problems, there's a very simple and very inexpensive solution. It turns out to be eyeglasses. And lots of kids who have vision problems just simply need to wear a pair of glasses. The challenge comes in all of the elements between knowing that a vision problem exists and getting glasses on a kid's face. So vision screening is the standard way that we actually recognize vision problems in kids in the United States. And 40 out of our 50 states actually mandate vision screenings, which is a good thing. The challenge is there's a big variation in between what different states mandate, meaning some will mandate screening every grade in a school, some will mandate only early grades, and then eighth grade or high school, and they'll mandate different components of the screening assessments. For Maryland, which is where I practice, we screen kids at the grade of first entry into a school system, first grade and eighth grade. So you can imagine there's a big gap there between second and seventh grade where kids are not even getting screened. So what happens when a child fails a vision screening? In the best case scenario, what happens is the vision screening happens at the school. A form goes home notifying parents that they have a vision problem. Parents make an appointment to see an eye doctor. They attend the appointment, and then if a child has prescribed glasses, they go to the optical shop, they get the glasses, they go back multiple times, because any of you who've worn glasses or have had children wear glasses know that they sometimes get broken, lost, damaged, flushed down the toilet. I've seen kids do lots of interesting things. The challenge though is that there are a lot of disparities in every single aspect of this, from getting vision screenings in the first place, to getting eye exams, to obtaining and wearing glasses, and we know that kids who are living in higher poverty cities and with families with a lower household income and lower education levels and non-English speaking families are not getting any of these services to the level that they need. So there's a concept of school-based care, which has become very popular in the US probably in the last 10 years or so, and I don't know if anybody's aware of the CDC as what's called a whole child initiative, and it's this concept that everything that happens outside of the classroom can impact how you're performing in the classroom. So that might be health, that might be nutrition, that might be safety, and the idea is, should we be doing some things in the school, particularly around health? And there's been interventions that have been done, primarily in asthma, diabetes care, dental, vaccines, and now vision. So I'm gonna talk a little bit about two programs that we've run in Baltimore around vision care in schools. The first, which was a small pilot program called the Baltimore Reading and Eye Disease Study and the second vision for Baltimore, which is our current program. So the Baltimore Reading and Eye Disease Study was a two-year pilot study, and we were actually trying to look at the feasibility of conducting exams in schools, as well as the impact of wearing glasses on academic performance, particularly reading proficiency. So it turns out if you're not reading well by the end of third grade, then you really fall off the academic achievement curve. So we were trying to intervene early with students, and we would go into schools and we would conduct vision and reading assessments, both baseline and then the end of their first year and again at the end of their second year. And when I say we, it was definitely a team of myself and a number of individuals from Hopkins. And as you can see from this picture here, we literally brought all of the equipment from my clinic. We packed into a bunch of boxes and bags and brought it into schools. And there's two things that I love about this picture. One is Nitta is pointing to a sign that says failure is not an option, which I think we felt very much with this project. But the other, if you notice the stairs in the background, I swear every single school in Baltimore does not have a working elevator, at least not when we were there. So I was in the best shape of my life between 2014 and 16 because of the number of stairs I had to carry, heavy boxes up. But there you have it. So we found a couple of significant things out of this study. The first is that we were right. There was certainly a significant on-met need for eye care, particularly in this early childhood population. The second is after kids receive glasses, they actually did better in terms of their scores on their individual reading assessments. And they had sustained improvement in their vision, both at distance and near for a two-year period. The other good thing is that kids were all provided glasses through the program and they provided a pair at home and a pair at school. And we worked close through the parents and teachers to remind them to wear the glasses. We actually individually labeled the inside temple of every pair of glasses so people would know which glasses were theirs. And if you do all of these things, lots of kids will actually wear their glasses. And the question I get asked a lot in my audiences is whether or not kids like to wear glasses. When I was a kid, I was made fun of for wearing glasses and was called Four Eyes. These days, glasses are incredibly popular to the point that we have lots of kids who are just wearing cosmetic frames. So they'll just be wearing glasses, sometimes still, they still have the sticker on there because they bought it from the store and they haven't taken it off yet. So that's a good point for us. But the interesting and somewhat intuitive thing is the factor most predictive of kids actually wearing their glasses was if their parents and teachers reminded them to do so, just underscoring the importance of having that level of engagement. So as we were finishing our first project, which was the Baltimore Read and Eye Disease Study, a new health commissioner came into Baltimore, Dr. Lena Nguyen, who unfortunately has just left us a few weeks ago to go join Planned Parenthood. But one of her health priorities for children in the city was vision. And so the Baltimore City Health Department spearheaded a program called Vision for Baltimore. And this started in 2016 as a collective effort between the Baltimore City School System, Baltimore City Health Department, Johns Hopkins University, Vision to Learn, which was our optometric provider, and then Morby Parker, who provided our eyeglasses. And this was a three-year pilot program to provide school-based eye care to all 62,000 kids in Baltimore City who were between grades of pre-kindergarten through eighth grade. There's roughly 150 schools in the city, so we've been able to serve about 50 schools per year through this program. And the process by which the program operates is the health department comes into the schools and does vision screenings for every student. As I had mentioned earlier, the state mandate is only to screen kids in pre-kindergarten, kindergarten first, and eighth grade. We as a program felt that we're probably missing a lot of kids in those middle grades, so we actually screen all those kids as well. For kids who fail a vision screening, they have the opportunity to have an eye exam at school done by one of our licensed optometrists, and they actually come to the school with their equipment. And then kids who need glasses or prescribed glasses that they're able to pick out on their own, they're provided, they bring them to the school, dispense them, and building on the knowledge we learned from BREDS, we learned that kids will lose and break these glasses about 50% of the time, so we've got to replace them, and we have to have a mechanism that involves parents and teachers, everybody knowing who needs to be wearing their glasses. So we have a big program that's involved in long-term monitoring. And my arms are no longer in good shape anymore because we have this van that comes to schools and it has an entire eye clinic right in there, and the van has the optometrist in there, and it actually has a mini optical shop, and kids are able to select, this is only a part of our selection, but there's a huge variety of colors and sizes, and because I live in Baltimore, because the Bravins are very popular, purple is our most popular color for the girls. But Warby Parker has donated all of these glasses to us free of charge. So part of what Hopkins is doing is building upon that earlier research project we had done, B-REDS, and looking at a larger scale of what's the impact of school-based delivery of eye care on academic performance. And also building on the earlier work we had done in B-REDS, thinking about all of these models, so how do you actually, in addition to coming to school and setting up services, how do you get kids to participate in the program, how do you get them to wear their glasses regularly, how do you make systems so that when their glasses need to be replaced if it actually happens, as well as looking at the cost of something like this, which I'll get into a little bit later, but a program like this is not exactly inexpensive. And finally, thinking that we've certainly fallen upon something that's significant, which is there's this big on-met need for eye care, and if we're developing a model to deliver in the schools, we need to figure out something that's gonna be sustainable. So this is our work to date, and this slide is updated a couple of weeks ago, so there's actually more numbers from there, but so far we've actually been able to screen about 40,000 kids in the city, and about 13,000 have failed division screening, roughly 33 to 34%, and 6,200 have completed their eye exams, and over 5,000 kids who needed glasses were able to get glasses. As I mentioned, not every single kid has a vision problem that actually has refractive air. Some will have more serious things. It's roughly about 4% of our population, so we've been able to connect them into the community for further evaluation in eye care. As I mentioned, one of the things we wanted to do in this program was see whether we were right in our assumption that kids in grade second through seventh who needed eye care were still failing vision screenings at a relatively high rate, and as you can see here from the box, I mean the numbers just pretty much go up as kids get older, so a lot of those kids in those middle grades had never been receiving eye care or all failing vision screenings and are now fortunately able to access eye care. I'm gonna pause just a minute to start talking about some of our team that actually helped make these day-to-day operations and us being able to get to these numbers that we have actually happened. So when this program started, the city had never done anything like this on this scale on this idea of a partnership between the school system and the health department in an outside optometric organization and an optical provider in a large research university and making a great idea into practice is a very challenging thing. And particularly this is something, this is a complete paradigm shift. People had always gone to, they'd failed a vision screening, a form went home, and that was pretty much all the school had to do in this. Now they need to be involved in the fact that lots of these services are coming to school, we're asking them to help get forms home and help get forms back. One of the funny things that we learned is the Baltimore is still not, the student health records are actually not electronic at this point in time, they're still paper-based. So every time somebody from the health department comes into a school system, it needs to document something like the results of a vision screening. They actually have to pull these pink health cards out of a big filing cabinet. So you can imagine the amount of work it actually takes if you're going to see every single kid at that school for somebody to do that. And when we created this entire system we had sort of the infrastructure for the people who were gonna do the screenings, the people who were gonna do the eye exams, but there has to be this glue in the middle who's gonna actually get all the kids ready to do the screenings in the first place and communicate with the teachers when kids fail an eye exam. So this group of women has been worked insanely hard to make this program work. The other thing is we started a lot of things as far as education for teachers. Again, we've asked teachers to do something very different than what we've traditionally asked them to do. The good thing is that teachers get it. Teachers get that when kids can't see they're struggling in the classroom and they appreciated the fact that we were coming into schools and helping and providing resources with that. I even had one teacher that she had previously, the year before we came in, she had actually taken all of her kids in her classroom to Lens Crafters and had them get eye exams and paid for it out of pocket herself just because she knew how many of them had eye problems and they weren't accessing care in the community. We've also felt that it's very important to target our consumers, our patients, the students and get them to have a sense of education about the importance of eye health and some of the fun things that kids want to know which is, can you pull your eye out? The answer is no. Can a contact ever get stuck behind your eye and stay there? The answer is still no. But they love dissecting eyeballs. That's one of their most popular activities when we do these school-based fairs. One of the challenges, if you looked at the numbers as far as the number of kids who'd failed in vision screening versus the numbers who had an eye exam, there's a disconnect there. And the disconnect has to do with the permission form. So in order for people to get this eye exam at school, they need to fill out a permission form. We want to make sure that they're aware of the program and they know what they're agreeing to. The challenge, however, again, since this was very new to the city, people weren't familiar with having to return something to the school. Teachers weren't necessarily familiar with this at first. So, and what we realized is when we went to schools and asked teachers, do you mind getting this form filled out? The teachers of Baltimore City, I can say, are unsung heroes. They do so much for their students, but they have very limited resources. And when you're asking them to do one more thing at some point in time, you sort of feel like you can't do one more thing. So what we realized is that parents were the most important link and showing some type of appreciation and acknowledgement of parents and bringing them into the partnership would be critical. And what we did is we asked teachers, if you can help get forms home and back to us, we'd like to offer you some school supplies for your classroom. And they asked for very simple things, literally things like Kleenex hand sanitizer, dry erase markers. And as soon as we did that, our consent form return rate went from kind of the mid-20s to over 65%. So it was a huge difference by getting them involved. And these are just some of the things that we offered them. What we also did though is even though our consent return rate got up to 65%, we realized there's still a bunch of reasons that people are not participating, and we need to understand that. So we started doing focus groups. We've done focus groups with, we've done 40 focus groups across the city between parents and teachers and looking at all these different things around their perceptions about eye care, their perceptions about wearing glasses, their attitudes about school-based programs, trust and cost and strategies for, if programs like this to succeed, what do we need to do? When we just finished our data collection or starting some analysis, but here are some of the interesting things about reasons for non-participation. And one of them is actually having an eye doctor or already having glasses. The interesting thing to me there is we have so much data that shows that people are not seeing their eye doctor. But there was the other two major themes identified, focused around both cost and trust. And trust seems to be a big issue in terms of somebody coming in external into a school system and offering some type of health intervention. So we're trying to understand this more in terms of thinking, how to improve the program and the future. The other, more minor themes but identified were stigma around receiving free services, stigma around wearing eyeglasses, which is again somewhat generational because kids love eyeglasses, but sometimes they're taken care of by parents or grandparents or even great-grandparents and they had different attitudes about eyeglasses when they were kids. And then the final, which is very interesting as well, is just the idea of the concern about schools invading into people's private lives and the idea of the school-based health system not being viewed necessarily as a positive thing but as an invasion of people's privacy and their decisions to do what they want with regards to their child's health. As I mentioned there were, we're trying to understand the costs of this program and then go on to do some analysis as far as cost benefit. But the cost of operating this program for one year is about $800,000, which again is not a small ticket item. But when you look at it, calculated out for the cost of student screened is actually $46. And in the context of the fact that the Maryland spends $14,917 per year educating a student, it's actually much less than 1% of that annual overall cost for something that may have a significant benefit on how children are doing in schools. I'm out of time so I'm gonna just quickly go to the fact that as we were building this program and having all kinds of challenges and successes, we realized that lots of people across the country were dealing with the same issues that we were in terms of engagement and building relationships and communication and advocacy. And it was not only in vision, it was dental, it was asthma, it was diabetes, it was all the other areas as well. And so out of that we have just created the Hopkins Consortium for School-Based Health Solution. This is something that we just received support from our president of the university a couple weeks ago. And the idea behind this is to create a single entity that brings together all the people, both within the various Hopkins schools who are working on these areas to develop models that are gonna be successful, scalable, replicable, as well as continue to do research, advocacy, outreach, education, and consultation to help partner with our other colleagues across the country. So I apologize for going over time. I'm happy to answer questions or diagnose eye problems. But thank you so much and thank you again to Mark and the McLean Center for the invitation. One question, please. Yeah, Norman Hogekin, I'm a current McLean fellow. This is a nice body of work. I think Warby Parker has the model, buy one, give one away. I'm curious if you could comment a little bit more about what it's like working with them. So I only have positive things to say about Warby Parker. They have a very interesting business model in general as far as the way the group was founded. There were four people that co-founded, and I think when they were students at Warden, they were all getting their MBAs together. And the story that they tell, at least, is that one of them had been, before he had started his MBA, he'd been backpacking through Thailand, lost his glasses. And by the time he got back to the US and he was still a student at this point in time, he tried to get a new pair of glasses, and it was like $700. And so he was complaining about it to his classmates and saying, why do glasses cost so much money? So Warby created this model that, it's sort of a vertically integrated model of not having the middleman of somebody that they license, somebody, the designers who make the frames and the kind of optical houses that own the license. So they make their own frames and then they sell them directly to consumer. So one of the co-founders had actually done a lot of work internationally with an organization called Vision Spring, I think. And that was, they had this sort of idea of social entrepreneurship and social consciousness in terms of buy a pair, give a pair. So initially what they did was they would, anytime you would buy a pair from them, they would give a pair overseas. They've expanded a lot of their work domestically as well. They're doing things both in the New York City public school system as well as the Baltimore school system. Thank you.