Disparities in Vision Health and Eye Care
2022; Elsevier BV; Volume: 129; Issue: 10 Linguagem: Inglês
10.1016/j.ophtha.2022.07.010
ISSN1549-4713
AutoresAngela R. Elam, Victoria L. Tseng, Tannia M. Rodriguez, Elise V. Mike, Alexis Warren, Anne L. Coleman, Ugochi T. Aguwa, Chrisfouad R. Alabiad, César A. Briceño, Hilda Capó, Melissa Contreras, Jane Edmond, Ann‐Margret Ervin, Tamara R. Fountain, David S. Friedman, James Gao, Lynn K. Gordon, Joy Harewood, Ken Kitayama, O’Rese J. Knight, Aaron Lee, Paul P. Lee, Gary L. Legault, Kristen Nwanyanwu, Mildred M.G. Olivier, César E Pérez-González, Jessica Randolph, Ahmara G. Ross, Ruth Shoge, Sharon D. Solomon, Basil K. Williams, Fasika A. Woreta, Charles B. Wright, Nazlee Zebardast,
Tópico(s)Ophthalmology and Visual Health Research
ResumoHealth disparities exist across all fields of medicine; ophthalmology and vision health are no exception. A health disparity is a difference in health outcomes that arises from health inequities that affect medically underserved populations.1Pérez-Stable EJ, Alvidrez J, Hill CV. Definitions, principles, and concepts for minority health and health disparities research. In: Dankwa-Mullan I, Pérez-Stable EJ, Gardner KL, et al. The Science of Health Disparities Research. Published online February 12, 2021:1-12.Google Scholar A health inequity is the unfair distribution of health determinants, outcomes, and resources between and within different segments of a population based on social, economic, environmental, and structural factors.2National Academies of Sciences, Engineering, and Medicine, Health and Medicine Division, Board on Population Health and Public Health Practice, et alThe Root Causes of Health Inequity. National Academies Press, Washington, DC2017Google Scholar The goal of eliminating health disparities is to achieve health equity, which can be defined as a state in which every individual has a just and fair opportunity to achieve their best health. Attaining this goal requires removing social, political, and structural barriers as well as differences in health and health care–related resources, access, and use.3Braveman P. Arkin E. Orleans T. et al.What Is Health Equity? And What Difference Does a Definition Make?. Robert Wood Johnson Foundation, Princeton, NJ2017Google Scholar The purpose of this paper is to outline the existing disparities in vision health and eye care, explore the possible reasons for these disparities, offer potential solutions, and ultimately stimulate the ophthalmology, eye care, and vision sciences community to move forward toward achieving equity in eye and vision health. Our goal is to engage our broader community in continuously narrowing health inequities to eliminate vision health disparities. To achieve this goal of eliminating health disparities and inequities, we need to expand our traditional focus on access and use of eye care services and understand the foundational role of social determinants of health (SDOH), which are significant drivers of health disparities and inequities. The US Department of Health and Human Services defines SDOH as the conditions in the environment in which people grow, live, learn, work, and age that affect health outcomes.4Social determinants of health.https://health.gov/healthypeople/objectives-and-data/social-determinants-healthDate accessed: April 2, 2022Google Scholar These SDOH are often grouped into 5 domains: health care access and quality, economic stability, education access and quality, neighborhood and built environment, and social and community context.3Braveman P. Arkin E. Orleans T. et al.What Is Health Equity? And What Difference Does a Definition Make?. Robert Wood Johnson Foundation, Princeton, NJ2017Google Scholar As such, access and use of eye care is just one of a number of key factors that drive vision health. In the larger health context, approximately 80% to 90% of a population’s health is determined by SDOH and only 10% to 20% by medical care.5Hood C.M. Gennuso K.P. Swain G.R. Catlin B.B. County health rankings: relationships between determinant factors and health outcomes.Am J Prev Med. 2016; 50: 129-135Abstract Full Text Full Text PDF PubMed Google Scholar In light of these data, it is prudent for eye care providers to consider SDOH as we seek to eliminate disparities in eye care. It is also essential to understand the context in which these determinants were created, often shaped by societal factors related to socioeconomic and related factors, such as structural racism. Structural racism can be defined as differential access and distribution of opportunities, goods, and services, such as health care, by race and is increasingly recognized as a significant contributor to societal ill, including health disparities. Part I of this Position Statement summarizes the growing body of literature examining health disparities as they relate to the field of vision health and eye care, including how these disparities manifest in the presentation of specific eye diseases. Key topics include the following:•Current state of vision health disparities and SDOH•Disparities in access to eye care•Health literacy and how we can improve patient education to enhance care•Effects and origins of disparities in the ophthalmology workforce•Current data sources that can be leveraged to measure progress toward the multifaceted goal of achieving equity in the field of ophthalmology Part II provides a framework for reducing disparities in eye care, addressing issues related to access to care, patient education and health literacy, and physician workforce diversity. Finally, we discuss future areas of inquiry and how we can work together as a global community to improve eye and vision health. Visual impairment (VI) and blindness affect approximately 4.2 million persons aged ≥40 years in the United States.6Vision impairment.http://www.visionproblemsus.org/vision-impairment.htmlDate accessed: April 2, 2022Google Scholar Blindness in the United States is defined as a best-corrected visual acuity of 20/200 or worse or a central visual field of ≤20 degrees in the better eye. Visual impairment is typically defined as best-corrected visual acuity of 20/70 or worse in the better eye (although some studies use 20/40 or worse in the better eye). It has been projected that by 2050 the total number of persons affected by VI and blindness will more than double to 6.95 million.7Varma R. Vajaranant T.S. Burkemper B. et al.Visual impairment and blindness in adults in the United States.JAMA Ophthalmol. 2016; 134: 802-809Crossref PubMed Scopus (0) Google Scholar The prevalence of VI and many eye diseases increases with age and can vary across race and ethnicity, socioeconomic status (SES), geographic location, and sex and gender.8National Academies of Engineering, Sciences, and MedicineMaking Eye Health a Population Health Imperative: Vision for Tomorrow. National Academies Press, Washington, D.C.2016Google Scholar In addition, older adults with VI have been found to have greater prevalence of chronic conditions compared with those without VI.9Crews J.E. Chou C.F. Sekar S. Saaddine J.B. The prevalence of chronic conditions and poor health among people with and without vision impairment, aged ≥65 years, 2010-2014.Am J Ophthalmol. 2017; 182: 18-30Abstract Full Text Full Text PDF PubMed Google Scholar It is vital to understand the factors that contribute to VI and blindness to address ocular health disparities and improve health equity among all populations. It has been well established that racial and ethnic minoritized populations are at high risk for various ocular diseases and subsequent VI and blindness.10Varma R. Ying-Lai M. Klein R. Azen S.P. Prevalence and risk indicators of visual impairment and blindness in Latinos: the Los Angeles Latino Eye Study.Ophthalmology. 2004; 111: 1132-1140Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar, 11Fisher D.E. Shrager S. Shea S.J. et al.Visual impairment in White, Chinese, Black, and Hispanic participants from the Multi-Ethnic Study of Atherosclerosis Cohort.Ophthalmic Epidemiol. 2015; 22: 321-332Crossref PubMed Scopus (12) Google Scholar, 12Congdon N. O’Colmain B. Klaver C.C.W. et al.Causes and prevalence of visual impairment among adults in the United States.Arch Ophthal. 2004; 122: 477-485Crossref PubMed Scopus (0) Google Scholar, 13Deng Z. Fuller-Thomson E. Temporal trends over a decade in serious vision impairment in a large, nationally representative population-based sample of older Americans: gender, cohort and racial/ethnic differences.Ophthalmic Epidemiol. 2022; 29: 39-48Crossref PubMed Scopus (2) Google Scholar It is important to note that race is a sociopolitical construct, not a biologic determinant of disease, and is often assigned on the basis of varying and inconsistent criteria, such as phenotype or self-report. Nationwide estimates of incident blindness from 1968 to 1970 found rates that were up to 2.8 times higher in Black individuals than in White individuals.14Bath P.E. Rationale for a program in community ophthalmology.J Natl Med Assoc. 1979; 71: 145-148PubMed Google Scholar Subsequent epidemiologic studies have similarly demonstrated greater estimates of VI and blindness among Black Americans,11Fisher D.E. Shrager S. Shea S.J. et al.Visual impairment in White, Chinese, Black, and Hispanic participants from the Multi-Ethnic Study of Atherosclerosis Cohort.Ophthalmic Epidemiol. 2015; 22: 321-332Crossref PubMed Scopus (12) Google Scholar,15Tielsch J.M. Sommer A. Witt K. et al.Blindness and visual impairment in an American urban population. The Baltimore Eye Survey.Arch Ophthalmol. 1990; 108: 286-290Crossref PubMed Google Scholar, 16Friedman D.S. West S.K. Munoz B. et al.Racial variations in causes of vision loss in nursing homes: The Salisbury Eye Evaluation in Nursing Home Groups (SEEING) Study.Arch Ophthal. 2004; 122: 1019-1024Crossref PubMed Scopus (0) Google Scholar, 17Chan T. Friedman D.S. Bradley C. Massof R. Estimates of incidence and prevalence of visual impairment, low vision, and blindness in the United States.JAMA Ophthalmol. 2018; 136: 12-19Crossref PubMed Scopus (60) Google Scholar, 18Hamedani A.G. VanderBeek B.L. Willis A.W. Blindness and visual impairment in the Medicare population: disparities and association with hip fracture and neuropsychiatric outcomes.Ophthalmic Epidemiol. 2019; 26: 279-285Crossref PubMed Scopus (0) Google Scholar as well as Hispanic Americans,10Varma R. Ying-Lai M. Klein R. Azen S.P. Prevalence and risk indicators of visual impairment and blindness in Latinos: the Los Angeles Latino Eye Study.Ophthalmology. 2004; 111: 1132-1140Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar,11Fisher D.E. Shrager S. Shea S.J. et al.Visual impairment in White, Chinese, Black, and Hispanic participants from the Multi-Ethnic Study of Atherosclerosis Cohort.Ophthalmic Epidemiol. 2015; 22: 321-332Crossref PubMed Scopus (12) Google Scholar,17Chan T. Friedman D.S. Bradley C. Massof R. Estimates of incidence and prevalence of visual impairment, low vision, and blindness in the United States.JAMA Ophthalmol. 2018; 136: 12-19Crossref PubMed Scopus (60) Google Scholar, 18Hamedani A.G. VanderBeek B.L. Willis A.W. Blindness and visual impairment in the Medicare population: disparities and association with hip fracture and neuropsychiatric outcomes.Ophthalmic Epidemiol. 2019; 26: 279-285Crossref PubMed Scopus (0) Google Scholar, 19Muñoz B. West S.K. Rodriguez J. et al.Blindness, visual impairment and the problem of uncorrected refractive error in a Mexican-American population: Proyecto VER.Invest Ophthalmol Vis Sci. 2002; 43: 608-614PubMed Google Scholar, 20Varma R. Chung J. Foong A.W.P. et al.Four-year incidence and progression of visual impairment in Latinos: the Los Angeles Latino Eye Study.Am J Ophthalmol. 2010; 149: 713-727Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar Asian Americans,11Fisher D.E. Shrager S. Shea S.J. et al.Visual impairment in White, Chinese, Black, and Hispanic participants from the Multi-Ethnic Study of Atherosclerosis Cohort.Ophthalmic Epidemiol. 2015; 22: 321-332Crossref PubMed Scopus (12) Google Scholar,21Varma R. Kim J.S. Burkemper B.S. et al.Prevalence and causes of visual impairment and blindness in Chinese American adults: The Chinese American Eye Study.JAMA Ophthalmol. 2016; 134: 785-793Crossref PubMed Google Scholar,22Fuller-Thomson E. Brennenstuhl S. Hurd M. Comparison of disability rates among older adults in aggregated and separate Asian American/Pacific Islander subpopulations.Am J Public Health. 2011; 101: 94-100Crossref PubMed Scopus (0) Google Scholar and Native Americans.18Hamedani A.G. VanderBeek B.L. Willis A.W. Blindness and visual impairment in the Medicare population: disparities and association with hip fracture and neuropsychiatric outcomes.Ophthalmic Epidemiol. 2019; 26: 279-285Crossref PubMed Scopus (0) Google Scholar,23Goins R.T. Pilkerton C.S. Comorbidity among older American Indians: the Native Elder Care Study.J Cross Cult Gerontol. 2010; 25: 343-354Crossref PubMed Scopus (0) Google Scholar Furthermore, Hispanic older adults and other racial/ethnic minorities with VI have been found to use low-vision devices at lower rates than non-Hispanic White peers.24Choi S. Stagg B.C. Ehrlich J.R. Disparities in low-vision device use among older US Medicare recipients.JAMA Ophthalmol. 2018; 136: 1399-1403Crossref PubMed Scopus (0) Google Scholar This disproportionate burden of VI among racial and ethnic minoritized people is of concern, given that VI has also been associated with a higher likelihood of underutilization of eye care,25Sherrod C.E. Vitale S. Frick K.D. Ramulu P.Y. Association of vision loss and work status in the United States.JAMA Ophthalmol. 2014; 132: 1236-1239Crossref Scopus (28) Google Scholar which is influenced by SES, another important factor impacting VI and overall health states (including life expectancy). Hispanic26Ma F. Lam B.L. Lee D.J. Gómez-Marín O. Uncorrected binocular distance visual impairment in U.S. Hispanic children and adolescents.Ophthalmic Epidemiol. 2001; 8: 57-64Crossref PubMed Scopus (0) Google Scholar, 27Margines J.B. Huang C. Young A. et al.Refractive errors and amblyopia among children screened by the UCLA Preschool Vision Program in Los Angeles County.Am J Ophthalmol. 2020; 210: 78-85Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar, 28Varma R. Tarczy-Hornoch K. Jiang X. Visual impairment in preschool children in the United States demographic and geographic variations from 2015 to 2060.JAMA Ophthalmol. 2017; 135: 610-616Crossref PubMed Scopus (0) Google Scholar, 29Multi-Ethnic Pediatric Eye Disease Study GroupPrevalence and causes of visual impairment in African-American and Hispanic preschool children: the multi-ethnic pediatric eye disease study.Ophthalmology. 2009; 116: 1990-2000 e1Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar and Black29Multi-Ethnic Pediatric Eye Disease Study GroupPrevalence and causes of visual impairment in African-American and Hispanic preschool children: the multi-ethnic pediatric eye disease study.Ophthalmology. 2009; 116: 1990-2000 e1Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar adolescents have also been found to have increased estimates of VI, and they are projected to account for the highest and second-highest prevalence of VI, respectively, through 2060.28Varma R. Tarczy-Hornoch K. Jiang X. Visual impairment in preschool children in the United States demographic and geographic variations from 2015 to 2060.JAMA Ophthalmol. 2017; 135: 610-616Crossref PubMed Scopus (0) Google Scholar Population rates of VI are projected to continue to be higher among non-White groups.30Flaxman A.D. Wittenborn J.S. Robalik T. et al.Prevalence of visual acuity loss or blindness in the US: a Bayesian Meta-analysis.JAMA Ophthalmol. 2021; 139: 717-723Crossref PubMed Scopus (0) Google Scholar Older people are disproportionately affected by VI and blindness.11Fisher D.E. Shrager S. Shea S.J. et al.Visual impairment in White, Chinese, Black, and Hispanic participants from the Multi-Ethnic Study of Atherosclerosis Cohort.Ophthalmic Epidemiol. 2015; 22: 321-332Crossref PubMed Scopus (12) Google Scholar,31Swenor B.K. Guo X. Boland M.V. Goldstein J.E. Leveraging electronic health records to identify and characterize patients with low vision.Ophthalmic Epidemiol. 2019; 26: 132-139Crossref PubMed Scopus (1) Google Scholar The number of people in the United States with VI or blindness has been steadily increasing along with our aging population, and it is estimated that this will result in a 25% increase in VI and a 21% increase in blindness by 2050.7Varma R. Vajaranant T.S. Burkemper B. et al.Visual impairment and blindness in adults in the United States.JAMA Ophthalmol. 2016; 134: 802-809Crossref PubMed Scopus (0) Google Scholar,32Kelly E. Wen Q. Haddad D. O’Banion J. Effects of an aging population and racial demographics on eye disease prevalence: projections for Georgia through 2050.Am J Ophthalmol. 2020; 210: 35-40Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar In persons aged 65 years and older, the estimated prevalence of VI and blindness varies widely between studies: Estimates of VI in this age group range from 2.2% to 26.6%, and estimates of blindness range from 0.6% to 16.6%.33Rein D.B. Lamuda P.A. Wittenborn J.S. et al.Vision impairment and blindness prevalence in the United States: variability of vision health responses across multiple national surveys.Ophthalmology. 2021; 128: 15-27Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar These variations may result from methods of estimation (e.g., patient self-reports vs. examination data), survey question wording, sampling variation, or differences in data collection methodology.33Rein D.B. Lamuda P.A. Wittenborn J.S. et al.Vision impairment and blindness prevalence in the United States: variability of vision health responses across multiple national surveys.Ophthalmology. 2021; 128: 15-27Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Visually impaired elderly patients face a plethora of demographic, social, and health disparities, including physical and functional disabilities, higher healthcare costs, poor psychological health, lower health-related quality of life, and higher medical morbidity and mortality than their non–visually impaired counterparts.9Crews J.E. Chou C.F. Sekar S. Saaddine J.B. The prevalence of chronic conditions and poor health among people with and without vision impairment, aged ≥65 years, 2010-2014.Am J Ophthalmol. 2017; 182: 18-30Abstract Full Text Full Text PDF PubMed Google Scholar,34Crews J.E. Chou C.F. Zhang X. et al.Health-related quality of life among people aged ≥65 years with self-reported visual impairment: findings from the 2006-2010 behavioral risk factor surveillance system.Ophthalmic Epidemiol. 2014; 21: 287-296Crossref PubMed Scopus (40) Google Scholar, 35Monaco W.A. Crews J.E. Nguyen A.T.H. Arif A. Prevalence of vision loss and associations with age-related eye diseases among nursing home residents aged ≥65 Years.J Am Med Dir Assoc. 2021; 22: 1156-1161Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar, 36Umfress A.C. Brantley Jr., M.A. Brantley Jr., M.A. Eye care disparities and health-related consequences in elderly patients with age-related eye disease.Semin Ophthalmol. 2016; 31: 432-438Crossref PubMed Scopus (5) Google Scholar, 37Lord S.R. Visual risk factors for falls in older people.Age Ageing. 2006; 35: ii42-ii45Crossref PubMed Scopus (238) Google Scholar Analysis of Medicare beneficiaries aged 65 years and older demonstrates that VI is associated with hip fracture, depression, anxiety, and dementia and that these patients are less likely to have a usual source of health care.18Hamedani A.G. VanderBeek B.L. Willis A.W. Blindness and visual impairment in the Medicare population: disparities and association with hip fracture and neuropsychiatric outcomes.Ophthalmic Epidemiol. 2019; 26: 279-285Crossref PubMed Scopus (0) Google Scholar,24Choi S. Stagg B.C. Ehrlich J.R. Disparities in low-vision device use among older US Medicare recipients.JAMA Ophthalmol. 2018; 136: 1399-1403Crossref PubMed Scopus (0) Google Scholar,36Umfress A.C. Brantley Jr., M.A. Brantley Jr., M.A. Eye care disparities and health-related consequences in elderly patients with age-related eye disease.Semin Ophthalmol. 2016; 31: 432-438Crossref PubMed Scopus (5) Google Scholar,38Simning A. Caprio T.V. Li Y. Conwell Y. Near vision but not hearing loss is associated with lacking a usual source of health care.J Aging Health. 2021; 33: 786-797Crossref PubMed Scopus (0) Google Scholar Approximately 3.6% of the US elderly population live in nursing homes. Current literature shows that 63.8% to 73.0% of nursing home residents are affected by VI and blindness,37Lord S.R. Visual risk factors for falls in older people.Age Ageing. 2006; 35: ii42-ii45Crossref PubMed Scopus (238) Google Scholar,39Lai K.Y. Pathipati M.P. Blumenkranz M.S. et al.Assessment of eye disease and visual impairment in the nursing home population using mobile health technology.Ophthalmic Surg Lasers Imaging Retina. 2020; 51: 262-270Crossref PubMed Scopus (0) Google Scholar and nursing home residents are 3 times more likely to have VI and 5 times more likely to experience blindness than individuals living in the community.40Keller B.K. Hejkal T. Potter J.F. Barriers to vision care for nursing home residents.J Am Med Dir Assoc. 2001; 2: 15-21Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar According to a 2022 National Academies of Sciences, Engineering, and Medicine report, “sex is a multidimensional construct based on a cluster of anatomical and physiological traits that include external genitalia, secondary sex characteristics, gonads, chromosomes, and hormones,” whereas “gender is a multidimensional construct that links gender identity, which is a core element of a person’s individual identity; gender expression, which is how a person signals their gender to others through their behavior and appearance (such as hair style and clothing); and cultural expectations about social status, characteristics, and behavior that are associated with sex traits.”41National Academies of Sciences, Engineering, and Medicine; Division of Behavioral and Social Sciences and Education; Committee on National Statistics; Committee on Measuring Sex, Gender Identity, and Sexual Orientation. In: Becker T, Chin M, Bates N, eds. Measuring Sex, Gender Identity, and Sexual Orientation. Washington, DC: National Academies Press; 2022.Google Scholar The relationship between VI and sex and gender is not as clear as the other factors considered above. Recent literature suggests that vision loss is more prevalent in women than in men.7Varma R. Vajaranant T.S. Burkemper B. et al.Visual impairment and blindness in adults in the United States.JAMA Ophthalmol. 2016; 134: 802-809Crossref PubMed Scopus (0) Google Scholar,18Hamedani A.G. VanderBeek B.L. Willis A.W. Blindness and visual impairment in the Medicare population: disparities and association with hip fracture and neuropsychiatric outcomes.Ophthalmic Epidemiol. 2019; 26: 279-285Crossref PubMed Scopus (0) Google Scholar,31Swenor B.K. Guo X. Boland M.V. Goldstein J.E. Leveraging electronic health records to identify and characterize patients with low vision.Ophthalmic Epidemiol. 2019; 26: 132-139Crossref PubMed Scopus (1) Google Scholar,35Monaco W.A. Crews J.E. Nguyen A.T.H. Arif A. Prevalence of vision loss and associations with age-related eye diseases among nursing home residents aged ≥65 Years.J Am Med Dir Assoc. 2021; 22: 1156-1161Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar,38Simning A. Caprio T.V. Li Y. Conwell Y. Near vision but not hearing loss is associated with lacking a usual source of health care.J Aging Health. 2021; 33: 786-797Crossref PubMed Scopus (0) Google Scholar,39Lai K.Y. Pathipati M.P. Blumenkranz M.S. et al.Assessment of eye disease and visual impairment in the nursing home population using mobile health technology.Ophthalmic Surg Lasers Imaging Retina. 2020; 51: 262-270Crossref PubMed Scopus (0) Google Scholar No single etiology has been definitively identified for this discrepancy, but it has been proposed that the difference may be attributed, in part, to the longer life expectancy of women.7Varma R. Vajaranant T.S. Burkemper B. et al.Visual impairment and blindness in adults in the United States.JAMA Ophthalmol. 2016; 134: 802-809Crossref PubMed Scopus (0) Google Scholar,13Deng Z. Fuller-Thomson E. Temporal trends over a decade in serious vision impairment in a large, nationally representative population-based sample of older Americans: gender, cohort and racial/ethnic differences.Ophthalmic Epidemiol. 2022; 29: 39-48Crossref PubMed Scopus (2) Google Scholar In addition, known biological differences and predispositions contribute to some ocular conditions such as thyroid eye disease.13Deng Z. Fuller-Thomson E. Temporal trends over a decade in serious vision impairment in a large, nationally representative population-based sample of older Americans: gender, cohort and racial/ethnic differences.Ophthalmic Epidemiol. 2022; 29: 39-48Crossref PubMed Scopus (2) Google Scholar This may help to explain why difference in vision by sex is more often reflected in the total prevalence of VI rather than incidence alone.39Lai K.Y. Pathipati M.P. Blumenkranz M.S. et al.Assessment of eye disease and visual impairment in the nursing home population using mobile health technology.Ophthalmic Surg Lasers Imaging Retina. 2020; 51: 262-270Crossref PubMed Scopus (0) Google Scholar Conversely, sex and gender differences in VI are not as apparent in the younger population, in whom the distribution by sex and gender is more similar.28Varma R. Tarczy-Hornoch K. Jiang X. Visual impairment in preschool children in the United States demographic and geographic variations from 2015 to 2060.JAMA Ophthalmol. 2017; 135: 610-616Crossref PubMed Scopus (0) Google Scholar Future studies measuring differences and disparities both by sex and gender identity are necessary. The World Health Organization defines SDOH as “the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local level.”42Magnan S. Social determinants of health 101 for health care: five plus five.NAM Perspect. 2017; 7Crossref Google Scholar According to the Centers for Disease Control and Prevention (CDC), SDOH consist of the following:43Centers for Disease Control and PreventionAbout social determinants of health (SDOH).https://www.cdc.gov/socialdeterminants/about.htmlDate accessed: April 2, 2022Google Scholar•Healthcare access and quality (includes access to health care, health insurance, and health literacy)•Education access and quality (includes educational attainment, language and literacy, and early childhood education)•Social and community context (includes community cohesion, civic participation, workplace conditions, discrimination, and incarceration)•Economic stability (includes income, poverty, employment, food security, and housing security)•Neighborhood and built environment (includes transportation access, quality of housing, air and water quality, and crime and violence) Furthermore, in an effort to identify the SDOH that particularly influence eye health and access to vision care, the CDC Vision Health Initiative cites factors including lower income, lower educational attainment, food insecurity, and neighborhood safety.43Centers for Disease Control and PreventionAbout social determinants of health (SDOH).https://www.cdc.gov/socialdeterminants/about.htmlDate accessed: April 2, 2022Google Scholar In addition, the Kaiser Family Foundation identifies a specific category for food44Artiga S. Hinton E. Beyond health care: the role of social determinants in promoting health and health equity.https://files.kff.org/attachment/issue-brief-beyond-health-careGoogle Scholar (which is included in the domain of economic stability by the CDC) (Fig 1). This area warrants attention in the prevention of VI, given the importance of appropriate nutrition and micronutrients in the prevention of blinding eye diseases (e.g., vitamin A deficiency, various vitamins and zinc for age-related macular degeneration [AMD]). Table 1 provides an example of how SDOH can impact eye disease and eye health.Table 1Example of SDOH: Air Pollution and Its Impact on Eye Disease and Eye HealthThis exploration of the effects of air pollution can serve as an example of the SDOH domain of neighborhood and built environment, as well as structural racism. Environmental exposure to outdoor and indoor air pollution is a leading global concern that can negatively impact health and cause excess mortality, and has been estimated to affect several times more individuals than previously reported.296Burnett R. Chen H. Szyszkowicz M. et al.Global estimates of mortality associated with long-term exposure to outdoor fine particulate matter.Proc Natl Acad Sci. 2018; 115: 9592-9597Crossref PubMed Scopus (0) Google Scholar Racial and ethnic minoritized people in the United States are disproportionally affected by environmental inequity.297Tessum C.W. Paolella D.A. Chambliss S.E. Apte J.S. Hill J.D. Marshall J.D. PM2.5 polluters disproportionately and systemically affect people of color in the United States.Science Advances. 2021; 7: 4491-4519Crossref Scopus (66) Google Scholar,298Tessum C.W. Apte J.S. Goodkind A.L. et al.Inequity in consumption of goods and services adds to racial–ethnic disparities in air pollution exposure.Proceedings of the National Academy of Sciences. 2019; 116: 6001-6006Crossref PubMed Scopus (0) Google Scholar For example, exposure to ambient fine particulate matter (PM2.5) is higher than average for Black, Hispanic, and Asian American individuals and lower than average for White persons based on the communities in which they live; this, in turn, reflects systematic biases in housing practices and patterns.297Tessum C.W. Paolella D.A. Chambliss S.E. Apte J.S. Hill J.D. Marshall J.D. PM2.5 polluters disproportionately and systemically affect people of color in the United States.Science Advances. 2021; 7: 4491-4519Crossref Scopus (66) Google Scholar Housing practices in the past have been highly influenced by racial segregation and “redlining” in the provision of mortgages by financial institutions, resulting in communities of color being concentrated in histor
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