 I'd now like to welcome Dr. Megan Collins. She's an assistant professor of ophthalmology at my alma mater, Johns Hopkins. She's at the Wilmer Institute, where she's also a faculty member at the Berman Institute of Bioethics. She was a part of the Johns Hopkins University School based eye care team, which recently won preventive blindness Ginny Pomeroy Award for Excellence in Vision and Public Health for their work researching and addressing vision problems in high-poverty schools. She will give a talk titled, Understanding Parental Trust and Its Impact on School-Based Vision Programs. Please join me in giving a warm welcome to Professor Megan Collins. Thank you so much, Dr. Peek. Let me turn on my mark. Thank you for the invitation. And it's always wonderful to see so many friendly faces every year and to just be inspired by all of the fantastic work that has come out of this center and the collaborations that continue to go on. So I'm really excited to spend a few minutes today talking about my work in school-based vision care programs. As Dr. Peek mentioned, I met Johns Hopkins. These are my disclosures in terms of grant funding and consultancies. And before I start, I really want to acknowledge I have a fabulous team of collaborators at Hopkins, both in the School of Education and School of Medicine, and their sort of determination, perseverance, and work ethic make all the work we've done possible. So I want to acknowledge them from the beginning. Let me give you a little bit background about school-based vision care and eye problems in children. It's always nice when I see people in the audience wearing glasses. And I encourage you to think back to when you first realized you needed glasses. And it turns out about 25% of school-aged children need glasses. Most of them will not know they need glasses. They will just assume that they can't see clearly. And I know Mark has had this experience himself when he was a kid. So the way they typically get detected is through school-based vision screening programs. The challenge, however, is even if they are detected, many children are not connected with care after that, meaning they have to see a doctor in the community and it doesn't happen. And particularly in high-poverty communities, this really doesn't happen. So if you think about the traditional paradigm for school-based care or for vision screening, kids get screened at state-mandated levels. It's typically first grade and eighth grade in most states. And then kids get sent into the community to have an eye exam in glasses. Unfortunately, what happens in high-poverty areas is there are challenges at every point here. Kids don't get screened as frequently. They don't get eye exams as frequently. They don't get glasses as frequently. And even when they do get glasses, they rarely get replaced if they're lost or broken. So in reality, when you think that a quarter of your children should be wearing glasses, our work has shown that in high-poverty areas, less than 6% of kids who are supposed to be wearing glasses are actually wearing them. So why are kids not wearing glasses? Why are they not connecting with care? We know there's a lot of structural barriers. There are things like insurance and transportation and caretaker time-off work that are impacting care utilization. And that has really sort of been the impetus for school-based care programs, which is recognizing there's a lot of health problems that could be addressed by programs in school. That's including asthma, vaccinations, oral health, and now vision health. And for me, it seems especially relevant for vision given we know that vision impacts academic performance. And we've had work come out of our group that's actually specifically studied that. And there's a point that Lainey made yesterday that is really relevant to here in terms of we know that education is a strong predictor of health and adulthood. And now we know that health problems are impacting education and childhood. So the idea is to bring the health delivery into the school to attempt to address that at the same time so it doesn't impact their education so they have good health and adulthood. So it's a challenging cycle. Now the interesting thing for me is while there's been an exponential increase in these programs, the ethical issues related to this new paradigm of delivering care has been largely unexamined. And let me talk a little bit about a program I'm involved in. It's called Vision for Baltimore. This is a program that Hopkins runs with the city of Baltimore. And the mission of this program is to provide school-based eye care to all 60,000 kids within the city schools, within elementary and middle schools. So it's roughly 152 schools. And the way the program works is we do screenings for the kids in all the schools and for the kids who fail the screenings they're offered an eye exam that's done at school. If they need glasses, they're able to pick their glasses. I wish John LaPouma had not left. I was gonna offer to give glasses to people in the audience like he gave plants to people in the audience. The kids get their glasses through the school and if kids lose or break their glasses, which inevitably they do, they would get replaced through the school and we work very closely with mechanisms in the school to make sure they know which kids are supposed to be wearing glasses and they remind them. So it's sort of a wrap-around system. The way that we obtain permission is through paper consent. It goes home to parents. They get notified their child has failed vision screening. They need an eye exam. They need to return this permission form. And then when kids do return the form, the glasses are prescribed at school. This is one of our students, happy that he's wearing his glasses. And we feel like there's a great benefit to providing the glasses directly in school because this is where they're doing their learning. They can take the glasses home. Some of them like to leave them in school at times. And parents are provided written information about this. So parents are not present for the exams. All of the information of parents goes back and forth by paper or passive communication. This is an example of what our Mobile Vision Clinic looks like. It literally is parked outside the school. It has all of the equipment that would make any optometrist or ophthalmologist envious. And kids go right in there. They have their eye exam. The first part, the passenger side, actually becomes a mini optical shop and kids get to pick their glasses. So the interesting thing in terms of our program so far is we've screened over 55,000 children. And we've found that one third of those kids are failing their vision screening. And what we did was we analyzed in terms of the state mandate. So these kids are supposed to get screened at grade of first entry, first and eighth grade. And then we were doing these extra grades, now two through seven, what were the failure rates like in all these grades. As you can see, they're high across the grades. They get higher as they get towards eighth grade. But the interesting thing is they're actually statistically significantly higher in the non-mandated grades. Which is of course great justification for the fact that our state mandate of only going to those certain grades is not working, particularly in a high poverty community. So in terms of the successes of the program, we've served, now actually, the numbers are updated about 10,000 kids at this point in time. And about 80% of which needed glasses and were provided glasses through the program. So if I stop the presentation here, it would sound wonderful and we've had great success and I'm very proud of what we've done. But the story is not totally over. And what I'd like to talk a little bit about is the fact that when you bring care into school, I think it's impressive of how much we can address the access issue, but there are a lot of other issues to consider. And I'm gonna touch on three here. One is participation, the second is compliance, and the third is follow up. And it turns out all of those relate to parental engagement, which doesn't happen as much when care happens in the school setting. So in terms of participation, I told you we have about 10,000 kids we've served. I hadn't yet told you we have about 9,000 kids we haven't served. And the reason we haven't served them is because we weren't able to get permission forms back from their parents. And this is despite having a program that is very well-funded, does extensive outreach, literally has full-time staff who go into schools to tell parents about the program and try to get consent forms back. Now if you look at us in comparison to other programs doing school-based health across the US, what are their consent forms participation looking like? It's about 30 to 60%. So ours over three years was 53%. So we're within the range, but we had massive outreach. So obviously we would like to see more kids. And a lot of questions are of the kids who are not participating. Why are they not participating? Are they among the most disadvantaged and their parents are not engaged at all and not returning the forms? So what we did is we wanted to say, well, why aren't people participating? So we conducted focus groups in Baltimore and Chicago. We actually help with a research program in Chicago because Chicago also does school-based vision care. And what we did was we talked to, we led 41 focus groups with parents and teachers in both cities and tried to elicit from them factors in terms of why people didn't participate in these programs. And they came in multiple categories, but the major themes were they just happened to not be aware of the program. Again, paper consent going home for anybody who has kids knows that things don't always make it out of the backpack. The other thing was misunderstanding of cost and eligibility. Did they have to have certain insurance? Did they have to not have insurance? Would they get billed for being in the program? Some people had negative attitudes about vision and eye care. When we've surveyed kids and asked, kids love glasses, but parents often have the perspective of remembering they got made fun of when they were kids. I got made fun of her wearing glasses. So as a parent, you might be concerned their child's gonna get teased as well. The other thing is sometimes they did, fortunately have an existing eye care provider, but the last one's pretty important. Sometimes they didn't trust the program. And when we delved into details of what they didn't trust about the program, it went into multiple categories. One was safety, where the drops, the medicine we were using, was it safe to use in children's eyes? Would it harm them in any way? Was it effective? Was what we were doing in a school-based program with an optometrist the same as what they would get in a clinic? Who was actually examining their child? Was it a student? Was it a resident? Was it a licensed clinician? And then how are we sharing data? This became particularly salient in Chicago because people were worried about sharing of immigration status when we were in schools that had high Hispanic populations. Also actually more relevant and Baltimore were questions of our research. And what type of research was being done on children? Was it being done without parents permission? And then interestingly, just the question of schools and the role of schools in delivering health and whether parents wanted them in that realm of their life. So let's step away from participation and trust for a minute and talk about the next critical challenge, which is compliance, which to me, I'm very happy that we've been able to serve so many children. But providing glasses is only the first step. Kids have to wear it, and they have to wear them regularly in order for them to be able to see the board and succeed in school. And we've done a lot of research in terms of trying to understand what's predictive of students wearing their glasses. It turns out it's not that they make them see better. It's not that they feel cool wearing their glasses. It's actually if their parents remind them to wear their glasses. And that is a big predictor. So of course, that means it's important for parents to know they need to wear their glasses, know why they're wearing their glasses, and buy into the entire process that they should be wearing them on a regular basis. Finally, in terms of the third challenge, follow-up care, most of the children will see through a school-based program have refractive needs. They need glasses. But a small percentage are gonna have non-refractive needs. They're gonna have more complicated eye problems. They're gonna have strabismus or amblyopia or pediatric cataracts and need to be connected into the community. In our program, that was about 5% of students. In other programs we've reviewed, it's roughly anywhere from I think 8% to 28%. And it depends on sort of what they decide to refer people on. But universally, we struggle with getting these kids connected into the community. Again, that's not surprising because these programs were developed because people were not connecting with care. But then you have these children who actually have serious pathology, need to connect with care and we're still struggling with how do we connect them into the system? And how do you make parents aware and how do they get appointments and things like that? We did survey parents. We wanted to, I should say, we did focus groups with parents because we wanted to understand their perspectives given all of these challenges. How do they feel about school-based programs? What did they recommend that could improve school-based programs? And their suggestions can be really categorized into communication, education, additional eyeglass resources and program logistics. For purposes of today, I'm just gonna talk about requested education. And this is very interesting to me. Parents requested detailed information in terms of what's the difference between a screening and an eye exam? What's the timeline of programs like this in terms of when they are coming to schools? In terms of recommendations, what are signs and symptoms of eye problems? And when should somebody see a doctor? When should somebody know if glasses are working or not working? When should they wear the glasses? When should they replace the glasses? And what are resources to help encouraging kids to wear their glasses? And as I thought about this and I thought about trust, I thought how would I, when I'm in clinic, deal with a parent who's asking all these questions, which are honestly totally normal expected questions that I would want a parent to ask? And the way that I would address it is I have face-to-face interaction with them. And they've never worn glasses before. Well, then I explain to them what their child's refractive error is. I give them examples. I even give them like test lenses so they can sort of experience what their child experiences. And that really engages them in the process and makes it much easier for them to comply. The challenge when we're delivering all the care in the school setting, however, is the parent isn't there. And so that dynamic of having them sort of understand why are they getting the glasses? What's the significance of it? Is challenged because you just don't have those face-to-face interactions. So I guess my argument is that the doctor-patient relationship has really fundamentally changed when you're delivering care in the school setting. And interestingly, you're bringing in a new partner. You're bringing in schools and teachers. And this is relevant now. Of course, I think many of you are aware Chicago Public Schools just went through, I think an 11-day strike by the teachers. And teachers are being asked to do more and more. And in terms of vision care, we're asking them to help return consent forms. We're asking them to remind children to wear their glasses. We're asking them to notify us when children need their glasses replaced. But as we're expanding this role for teacher, in some ways we're diminishing the role of the parent who's still responsible for signing the permission form, complying with wearing the glasses and the follow-up. So there's this tension here. How do we increase access yet still engage the parent in what we would traditionally consider this triadic doctor-patient-parent relationship where you would have shared decision-making based on trust and education? There are a lot of important considerations in school-based care. And I, of course, am a huge advocate, and this is much of my work is in. But what I am trying to move forward with is now that we have figured out how to solve the access issue. And now we've figured out how to effectively deliver care in schools. How do we do this in a sustainable way? And how do we effectively connect children with long-term medical homes in the community when they need them? So as I've mentioned, we've been able to make a lot of progress in terms of delivering care to children who were otherwise not receiving it. But future considerations should be made in terms of how do we address these challenges of parental engagement and sustainability? I would like to thank you all for listening. And this is a picture of my team. We are dissecting cow eyeballs with children. They really seem to enjoy that work most. And we do a lot of things like that because I think engaging the students seems to get them excited about wearing glasses. If you have any questions, I'm happy to answer. I'm struck by the problem with parental participation in this. And I just, I don't think you've mentioned it. But as you probably know, the illiteracy rate in Chicago is estimated or measured to be 30% in Baltimore, 35 to 36%. And in New York, the number of people that don't speak English is set to be 18%. I'm wondering if those kinds of factors also enter into the lack of parental cooperation? I think they hugely do. And I think all of the places that I mentioned, we have consent forms in multiple languages. But even though you have them in multiple languages, you can't necessarily ensure that parents are gonna understand everything about the program. But it's, I think the understanding and the complexity of the forms is honestly a huge deterrent. The challenge always is how much do you, you wanna give the information. And as parents mentioned, they want all of this information, but then you give the information and they don't necessarily read all the information to understand it. I think my challenge is how do we bring the doctor-parent dynamic into school-based setting? Because I think there has to be some type of one-on-one communication for it to actually work. Have you ever considered having attached to a parent night or attached to an existing program? I see you nodding like, yes, we've already tried. Something where there's forum for parents to come. Yes, yes, so we are doing, so this year, actually, we went to every single back-to-school night across the city to talk about the program. But the challenge, again, is the parents who come to back-to-school nights are probably the ones who would have filled out the forms anyway. So it's still trying to figure out all of these strategies to get to people who may not necessarily be coming into the school setting. But what we're trying to do is a lot of sort of consolidating of health-related efforts because they're getting forms about the dental program and the asthma program and the vaccination program and there's just this inundation of health information and they sometimes, after a while, get overwhelmed. Thank you so much. Another round of applause. Thank you.