Social Determinants of Health Associated With Severe Visual Impairment

A quality improvement study found that severe visual impairment was affected by various social determinants of health, including low socioeconomic status, race, and educational level.

Social determinants of health (SDOH) are associated with severe visual impairment (SVI), according to a study published in JAMA Ophthalmology. Employment status, socioeconomic status, race and ethnicity, and health care coverage all correlated with higher odds of SVI.

There are 32 million Americans who have reported blindness or difficulty seeing despite glasses or contact lens use, making visual impairment one of the most common disabilities in the United States. SDOH have been found to be associated with the risk of visual disability and its consequences. The aim of this study was to use the data from the Behavioral Risk Factor Surveillance System (BRFSS) to evaluate SDOH and their association with increased odds of self-reported SVI.

Data from January 2019 to December 2020 were obtained from the BRFSS Web Enabled Analysis Tool. Independent variables were selected in demographic information, health care access, healthy days, and chronic health conditions categories. The responses to the survey questions represented self-identified data.

There were 820,226 participants in the BRFSS survey; 53.07% were female, and 5.17% self-identified as blind or having serious difficulty seeing. The demographic factors analysis included 633,866 participants.

The study found higher odds of SVI in American Indian/Alaska Native participants (odds ratio [OR], 1.63; 95% CI, 1.38-1.91), Black/African American participants (OR, 1.50; 95% CI, 1.39-1.62), Hispanic participants (OR, 1.65; 95% CI, 1.53-1.79), and multiracial participants (OR, 1.33; 95% CI, 1.15-1.53) compared with the White, non-Hispanic reference group. No associations between SVI and gender or Asian and Pacific Islander participants were found.

Household income below $35,000 was associated with a greater risk of SVI and income of $50,000 and above, with decreased odds of SVI. The lowest annual household income group, less than $10,000, was associated with greater odds of SVI (OR, 1.70; 95% CI, 1.52-1.90) whereas participants with an income of $75,000 or more had lower odds of SVI (OR, 0.59; 95% CI, 0.53-0.66).

Participants who did not complete high school had higher odds of SVI (OR, 1.50; 95% CI, 1.38-1.64) whereas participants who completed secondary education had lower odds (OR, 0.73; 95% CI, 0.68-0.78) compared with the college-educated reference group.

Greater odds of SVI were found in participants who were out of work for 1 year or more (OR, 1.78; 95% CI, 1.54-2.07), were retired (OR, 2.03; 95% CI, 1.89-2.19), or were unable to work (OR, 2.90; 95% CI, 2.66-3.16). Being divorced, widowed, or separated was also associated with higher odds of SVI (OR, 1.26; 95% CI, 1.18-1.34) compared with participants who were married.

A mental health diagnosis was associated with an overall greater chance of SVI (OR, 1.58; 95% CI, 1.48-1.69). Participants who reported having bad mental health for 14 or more days per month had increased odds of SVI (OR, 1.87; 95% CI, 1.73-2.02) compared with participants with not reported days of bad mental health.

Lack of health care coverage was also associated with increased odds of SVI (OR, 1.22; 95% CI, 1.12-1.33), as was an inability to afford to see a physician (OR, 1.62; 95% CI, 1.51-1.73). Having no physician or more than 1 physician was not associated with SVI compared with participants who had 1 physician or health care practitioner.

There were some limitations to this study. The survey responses used were available in a compiled form rather than individually, which prevented more sophisticated analysis. Also, the survey was conducted by telephone, which excludes potential participants without a landline or cellular phone, individuals in correctional facilities, or individuals in long-term care residences. The participants in this study also could have lacked access to ophthalmic care and odds of low vision are increased due to this factor.

The researchers concluded that “ophthalmic health and vision were associated with SDOH and visual impairment was associated with various disparities in care and barriers to health care access.”


Besagar S, Yonekawa Y, Sridhar J, et al. Association of socioeconomic, demographic, and health care access disparities with severe visual impairment. JAMA Opthalmol. Published online November 3, 2022. doi:10.1001/jamaophthalmol.2022.4566

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