Black individuals have a visual impairment odds ratio of 1.50 compared to Caucasians. Photo: Getty Images.

An understanding of the social determinants of health associated with severe visual impairment may guide targeted interventions and outreach programs with the ultimate goal of improving ophthalmic health in patients with higher odds of severe visual impairment. Researchers recently determined that various social determinants of health are associated with severe visual impairment, including self-identification as belonging to a racial or ethnic minority group, low socioeconomic status and educational level, long-term unemployment and inability to work, divorced, separated or widowed marital status, poor mental health and lack of healthcare coverage.¹

The Behavioral Risk Factor Surveillance System is an annual survey of US civilians conducted by the Centers for Disease Control and Prevention. Survey data collected includes self-identified demographic information, chronic health conditions, behavioral health risks, access to health care and use of preventive care services. During the study period, 820,226 people (53% female) participated in the survey, of whom 5.2% self-identified as “blind or having serious difficulty seeing, even while wearing glasses.”

Compared with Caucasian, non-Hispanic individuals, risk of severe visual impairment was increased among American Indian/Alaska Native (OR: 1.63), Black/African American (OR: 1.50), Hispanic (OR: 1.65) and multiracial (OR: 1.33) individuals. Lower annual household income and educational level (e.g., not completing high school) were associated with greater risk of severe visual impairment. Individuals who were out of work for one year or longer (OR: 1.78) or who reported being unable to work (OR: 2.90) had higher odds of severe visual impairment. Mental health diagnoses and 14 or more days per month with poor mental health were associated with increased risk of severe visual impairment (OR: 1.87).

The researchers noted that healthcare access factors associated with increased visual impairment risk included lack of healthcare coverage and inability to afford to see a physician. They noted that the data from this study may form the framework for a discussion on the ophthalmologist’s role in addressing healthcare access disparities.

“Increasing public awareness of these disparities is critical to furthering research on the subject and fueling targeted healthy policy initiatives,” they wrote in their paper.¹

A commentary, also published in JAMA Ophthalmology, highlighted that datasets may exclude populations from diverse racial and ethnic backgrounds or with low incomes. The prior study evaluated social determinants of health—largely in the areas of economic stability, education access and quality and healthcare access and quality—associated with increased odds of subjective, self-reported severe visual impairment. Therefore, 76% of the sample were non-Hispanic white. The authors of the commentary point out that people from racial and ethnic minority backgrounds and people with lower socioeconomic status are disproportionately affected by social risk factors.²

“Although individual-level interventions (e.g., a clinician becoming engaged in community outreach or creating a sliding financial scale for ophthalmic services) may help one patient at a time, they will not address the root cause of the population-level association between poverty and severe visual impairment because the interventions are not aligned to the level of analysis,” the commentary stated. “With social determinants of health factors at a systemic level, interventions to improve severe visual impairment likely need to be broad policy changes.”

The commentary stated that the key factors to consider in health equity research are an awareness of the different terminology (social determinants of health, social risk factors and social needs), being mindful of using datasets that may not be generalizable or representative and a focus on the interpretation of the data.

“Eyecare professionals and vision researchers should be aware that community-engaged research requires time and resources and should be thoughtfully conducted so as not to cause additional harm to communities,” the commentary concluded. “Shining a spotlight on the associations of poor vision and social determinants of health provides our community of clinicians and scientists the impetus to improve the lives of all the patients whom we serve.”²

1. Besagar S, Yonekawa Y, Sridhar J, et al. Association of socioeconomic, demographic, and health care access disparities with severe visual impairment in the US. JAMA Ophthalmol. November 3, 2022. [Epub ahead of print]. 2. Hicks PM, Woodward MA, Newman-Casey PA. Considerations for using large data sets to assess disparities in eye care and vision health. JAMA Ophthalmol. November 3, 2022. [Epub ahead of print].