Social Determinants of Health: Ophthalmic Implications

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Article initiated by:
Amen Nigussie, Jessica Randolph, M.D.
All authors and contributors:
Amen Nigussie, Jessica Randolph, M.D., Cat Nguyen Burkat, MD FACS
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 by Cat Nguyen Burkat, MD FACS on August 28, 2023.


Introduction

Social determinants of health (SDOH) are conditions that affect people’s health risks and outcomes [1] [2]. These elements are an interaction between structural, patient-level, provider, and healthcare system factors[1]. These include living conditions, socioeconomic status, education levels, and even personal identities[2]. The past few decades have provided increasing evidence that SDOH play an important role in propagating health disparities and shaping health outcomes. Systematic differences between population groups not only affect health status but can also determine life expectancy [2]. Therefore, it is not surprising that these key drivers also have ophthalmic implications. Research shows that SDOH are tightly linked with vision loss[1] [2] [3]. For example, a study by Su et al. demonstrated that lower education level, Medicaid insurance, food insecurity, difficulty paying medical bills, and identifying as a gay male, were significantly associated with self-reported visual difficulty [4].

Categories of Social Determinants of Health

5 domains of SODH[5]

Social determinants of health can be broken down into five main domains:

  1. Education access and quality: Increasing education levels are directly correlated with higher income, safer living conditions, and improved health literacy [6]. As such, these individuals are likely to live longer and have better health outcomes.
    1. Ophthalmic implications: Having a high school education or less is correlated with less likelihood of engaging in preventative eye care [6][7]. If patients do not have a good understanding of health risks, they are less likely to make informed decisions, like seeking out eye screenings.
  2. Health care access and quality: Disadvantaged population groups make up a substantial portion of the uninsured, creating a large barrier to accessing quality health care [8]. Other obstacles include lack of transportation, language as well as cultural differences, provider bias, and low health literacy [1].
    1. Ophthalmic implications: Lack of healthcare puts patients at a higher risk of avoiding doctor’s visits or not seeking out an eye exam [7].
  3. Neighborhood and built environment: Neighborhood crime rates, housing quality, transportation access, air, and water pollution as well as the availability of healthy foods, are important considerations for wellness [1][2][9].
    1. Ophthalmic implications: Safety concerns in neighborhoods are associated with higher BMI and obesity [10]. This increases the prevalence of metabolic disorders and subsequent complications. Underserved communities are also less likely to follow through with initial diabetic retinopathy screening referrals [11].
  4. Economic stability: Socioeconomic status is all-encompassing and influences other domains as well. To name a few, this category includes employment status, food security, and housing stability [1].
    1. Ophthalmic implications: Lower economic status also places individuals at a higher risk for inadequate health coverage and not prioritizing preventive care [7] [8].
  5. Social and community context: This category encompasses family, civic participation, and community networks [2]. These avenues create the necessary support system to promote positive health effects.
    1. Ophthalmic implications: Ethnic and racial minorities are at a higher risk for diabetes [12] and up to three times more likely to experience vision-compromising complications [7].

Common Eye Diseases and Visual Outcome Disparities

Disparities in visual outcomes based on race/ethnicity[1]

According to the CDC, visual impairment is one of the most common disabilities in the United States [1][13]. By 2050, blindness is expected to double to 2 million due to the aging population and continual increase in chronic diseases like diabetes [14]. Ethnic minorities are expected to experience an increased prevalence of visual impairment and blindness. This is due to the fact that minorities are disproportionately affected by poverty, lower levels of education, live in more dangerous neighborhoods and have poor access to quality healthcare [2]. Concurrently, these communities have an increased probability of being diagnosed with diabetic retinopathy, primary open-angle glaucoma and visual impairments due to cataracts [2] [12] [15] [16]. Despite these risk factors, they are also less likely seen by an ophthalmologist [2] [7].

  1. Diabetic Retinopathy (DR): Unlike other retinal pathologies, diabetic retinopathy is largely preventable with screenings and early detection [17]. Currently in the United States, DR has a prevalence rate of 30% in people over 40 [12]. Racial minorities are disproportionately affected and have worse visual outcomes. For example, the Salisbury Eye Evaluation found a 4-fold increase in visual impairments in blacks compared to whites [18]. The Los Angeles Latino Study (LALES) has also demonstrated a high incidence of DR and related visual impairments in the Latinx community [19]. Due to the multidimensional barriers discussed above, African American and Hispanic patients are more likely to present in severe stages and subsequently have worse prognoses.
  2. Primary Open-Angle Glaucoma (POAG): POAG is one of the leading causes of irreversible blindness and also affects racial minorities at an unbalanced rate [20][21]. Despite the high prevalence, there is a considerable gap in disease surveillance and appropriate treatment in these communities. A study by Elam et al. demonstrated that Medicaid recipients with new POAG are less likely to receive glaucoma testing in the 15 months after initial diagnosis when compared to commercial insurances [15]. These disparities were especially magnified in black patients, who had 291% higher odds of not undergoing appropriate testing when compared to their black counterparts with non-Medicaid insurance.
  3. Cataracts: About 20 million Americans are diagnosed with cataracts in one or both eyes [1]. Cataracts, while easily treatable, still remain the leading cause of blindness in the world [22]. Despite increased access in the industrialized world, ethnic minorities, individuals living in rural areas, and patients with lower socioeconomic status appear to have higher rates of visual impairments and blindness from cataracts [16]. These communities live in more impoverished areas, are less likely to visit an ophthalmologist, and have a higher incidence of diabetes, which is a known risk factor.
  4. Uncorrected Refractive Errors (URE): URE is currently the second leading cause of blindness in the world [23]. This has significant economic implications, with substantial social costs and reduced productivity associated with visual impairments [24]. It also affects participation in activities of daily living and facilitates poor social integration. Social determinants of health are responsible for the high prevalence rates of URE in certain communities. For example, economic barriers, limited healthcare access, poor health literacy, and non-white ethnicity are key drivers in these visual outcome disparities [24].

How to Address Social Determinants of Health

Eye care providers can hold an important role in mitigating ocular health disparities. Understanding the interplay between social factors and general as well as ocular health is the first step. Acknowledging and addressing preexisting biases is also key to providing equitable healthcare in the context of varying socioeconomic status, education levels, or ethnic backgrounds [2].

Furthermore, ophthalmologists should consider enhancing routine patient encounters by accessing social needs in a comprehensive or targeted manner[25]. There are several screening tools available through the American Academy of Family Physicians [26], American Academy of Pediatrics [27] and Kaiser Permanente [28] for providers to utilize. Another essential strategy includes collaborating with social workers and legal services [25] to identify and advertise available resources in the community (i.e., transportation vouchers, prescription coupons, insurance registration, etc.)

To provide holistic ophthalmic care, it is also important to consider a patient’s culture, communication style, family dynamics, trust or mistrust in healthcare, gender identity, and sexual orientation [2]. Additionally, reducing language barriers and focusing on patient education in day-to-day practice can address potential obstacles to treatment. Eye care providers can also expand access by providing services in community health centers and vision outreaches in underserved areas.

The promotion of diversity, equity, and inclusion in ophthalmology is another integral part of this process. Combating eye care inequities will involve utilizing population data analytics, including racial minorities in research and participating in advocacy [29]. Perhaps it is also time to develop screening toolkits specific to ophthalmology to better understand patients’ risk factors and identify ways to improve vision outcomes in disadvantaged communities. Finally, it is imperative to build systems in place that will ensure the ophthalmology workforce will mirror the population it serves.

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Social Determinants of Health, Health Equity, and Vision Loss | subsection title | section title | site title. Published June 15, 2021. Accessed August 14, 2022. https://www.cdc.gov/visionhealth/determinants/index.html
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 Diversity - American Academy of Ophthalmology. Accessed August 17, 2022. Chapter 17; Section 1, Update on General Medicine.
  3. ↑ Ulldemolins AR, Lansingh VC, Valencia LG, Carter MJ, Eckert KA. Social inequalities in blindness and visual impairment: A review of social determinants. Indian J Ophthalmol. 2012;60(5):368-375. doi:10.4103/0301-4738.100529
  4. ↑ Su NH, Moxon NR, Wang A, French DD. Associations of Social Determinants of Health and Self-Reported Visual Difficulty: Analysis of the 2016 National Health Interview Survey. Ophthalmic Epidemiol. 2020;27(2):93-97. doi:10.1080/09286586.2019.1680703
  5. ↑ CDC - Social Determinants of Health - STLT Gateway. Published August 9, 2022. Accessed August 14, 2022. https://www.cdc.gov/publichealthgateway/sdoh/index.html
  6. ↑ 6.0 6.1 Zhang X, Cotch MF, Ryskulova A, 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(6 Suppl):S53-62.e1. doi:10.1016/j.ajo.2011.08.045
  7. ↑ 7.0 7.1 7.2 7.3 7.4 Barsegian A, Kotlyar B, Lee J, Salifu MO, McFarlane SI. Diabetic Retinopathy: Focus on Minority Populations. Int J Clin Endocrinol Metab. 2017;3(1):034-045. doi:10.17352/ijcem.000027
  8. ↑ 8.0 8.1 The Uninsured| A Primer. Published Nov, 2015. Accessed August 15, 2022. https://files.kff.org/attachment/primer-the-uninsured-a-primer-key-facts-about-health-insurance-and-the-uninsured-in-the-era-of-health-reform
  9. ↑ Neighborhood and Built Environment - Healthy People 2030 | health.gov. Accessed August 16, 2022. https://health.gov/healthypeople/objectives-and-data/browse-objectives/neighborhood-and-built-environment
  10. ↑ Fish JS, Ettner S, Ang A, Brown AF. Association of Perceived Neighborhood Safety on Body Mass Index. Am J Public Health. 2010;100(11):2296-2303. doi:10.2105/AJPH.2009.183293
  11. ↑ Yusuf R, Chen EM, Nwanyanwu K, Richards B. Neighborhood Deprivation and Adherence to Initial Diabetic Retinopathy Screening. Ophthalmology Retina. 2020;4(5):550-552. doi:10.1016/j.oret.2020.01.016
  12. ↑ 12.0 12.1 12.2 Coney JM, Scott AW. Racial disparities in the screening and treatment of diabetic retinopathy. Journal of the National Medical Association. 2022;114(2):171-181. doi:10.1016/j.jnma.2021.12.011
  13. ↑ Fast Facts of Common Eye Disorders | CDC. Published June 9, 2020. Accessed August 17, 2022. https://www.cdc.gov/visionhealth/basics/ced/fastfacts.htm
  14. ↑ Varma R, Vajaranant TS, Burkemper B, et al. Visual Impairment and Blindness in Adults in the United States: Demographic and Geographic Variations From 2015 to 2050. JAMA Ophthalmol. 2016;134(7):802-809. doi:10.1001/jamaophthalmol.2016.1284
  15. ↑ 15.0 15.1 Elam AR, Andrews C, Musch DC, Lee PP, Stein JD. Large Disparities in Receipt of Glaucoma Care between Enrollees in Medicaid and Those with Commercial Health Insurance. Ophthalmology. 2017;124(10):1442-1448. doi:10.1016/j.ophtha.2017.05.003
  16. ↑ 16.0 16.1 Desai N, Copeland RA. Socioeconomic disparities in cataract surgery. Current Opinion in Ophthalmology. 2013;24(1):74-78. doi:10.1097/ICU.0b013e32835a93da
  17. ↑ Fairless E, Nwanyanwu K. Barriers to and Facilitators of Diabetic Retinopathy Screening Utilization in a High-risk Population. J Racial Ethn Health Disparities. 2019;6(6):1244-1249. doi:10.1007/s40615-019-00627-3
  18. ↑ Muñoz B, West SK, Rubin GS, et al. Causes of Blindness and Visual Impairment in a Population of Older Americans: The Salisbury Eye Evaluation Study. Archives of Ophthalmology. 2000;118(6):819-825. doi:10.1001/archopht.118.6.819
  19. ↑ Varma R, Paz SH, Azen SP, et al. The Los Angeles Latino Eye Study: design, methods, and baseline data. Ophthalmology. 2004;111(6):1121-1131. doi:10.1016/j.ophtha.2004.02.001
  20. ↑ Tielsch JM, Sommer A, Katz J, Royall RM, Quigley HA, Javitt J. Racial Variations in the Prevalence of Primary Open-angle Glaucoma: The Baltimore Eye Survey. JAMA. 1991;266(3):369-374. doi:10.1001/jama.1991.03470030069026
  21. ↑ Varma R, Ying-Lai M, Francis BA, et al. Prevalence of open-angle glaucoma and ocular hypertension in Latinos: The Los Angeles Latino Eye Study. Ophthalmology. 2004;111(8):1439-1448. doi:10.1016/j.ophtha.2004.01.025
  22. ↑ Steinmetz JD, Bourne RRA, Briant PS, et al. Causes of blindness and vision impairment in 2020 and trends over 30 years, and prevalence of avoidable blindness in relation to VISION 2020: the Right to Sight: an analysis for the Global Burden of Disease Study. The Lancet Global Health. 2021;9(2):e144-e160. doi:10.1016/S2214-109X(20)30489-7
  23. ↑ Naidoo KS, Leasher J, Bourne RR, et al. Global Vision Impairment and Blindness Due to Uncorrected Refractive Error, 1990–2010. Optometry and Vision Science. 2016;93(3):227-234. doi:10.1097/OPX.0000000000000796
  24. ↑ 24.0 24.1 Jeganathan VSE, Robin AL, Woodward MA. Refractive Error in Underserved Adults: Causes and Potential Solutions. Curr Opin Ophthalmol. 2017;28(4):299-304. doi:10.1097/ICU.0000000000000376
  25. ↑ 25.0 25.1 Braveman P, Gottlieb L. The Social Determinants of Health: It’s Time to Consider the Causes of the Causes. Public Health Rep. 2014;129(Suppl 2):19-31.
  26. ↑ Social Needs Screening Tool - American Academy of Physicians. Accessed August 17, 2022. https://www.aafp.org/dam/AAFP/documents/patient_care/everyone_project/hops19-physician-form-sdoh.pdf
  27. ↑ Screening Tool Finder. Accessed August 17, 2022. https://www.aap.org/en/patient-care/screening-technical-assistance-and-resource-center/screening-tool-finder/?page=1
  28. ↑ Find Tools:: Risk Screening Tools Review. Accessed August 17, 2022. https://sdh-tools-review.kpwashingtonresearch.org/find-tools
  29. ↑ Diversity - American Academy of Ophthalmology. Accessed August 17, 2022. https://www.aao.org/diversity-equity-and-inclusion
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