Socioeconomic Risk Factors for Visual Loss
and Decrease in Quality of Life
Eve J. Higginbotham MD
Professor and Chair
Department of Ophthalmology
University of Maryland School of Medicine
Previous studies have suggested a higher prevalence of glaucoma
among African Americans compared to Caucasian Americans. More
recently, Projecto VER documented high rates of glaucoma among
older, female Mexican Americans.
The Baltimore Eye Survey reported age-adjusted prevalence
rates for POAG measuring four to five times higher among African
Americans compared to Caucasians.
In the clinic survey performed by Grant and Burke, African
Americans were more likely to be either blind or visually impaired
from glaucoma compared to Caucasians.
In Proyecto VER, the prevalence of POAG was intermediate
(1.97%) between reported rates of African Americans (3.44%)
and Caucasians (1.11%). However, the rate increased more steeply
with increasing age compared to other reported ethnic rates.
Untreated or undertreated disease adversely affects quality
of life.
Severe visual loss adversely affects quality of life.
Moderate visual loss (20/60 -20/100) is comparable to a moderate
stroke or home dialysis for 8 years.
Severe visual loss (20/200 -NLP) is comparable to the loss
Age and family history have been considered significant risk
factors for developing glaucoma. But is race?
Based on recent advances in genetics research, it has been
suggested that race is not a valid biological construct but
a social construct.
Multivariate analyses in the Ocular Hypertension Treatment
Study did not uncover race as a significant risk factor. Age,
thin corneae, and large CDR were among the significant risk
factors noted.
Socioeconomic factors must be considered.
After considering socioeconomic factors in the Baltimore
Eye Survey, the rates for visual impairment and blindness due
to ocular disease was reduced from 1.79 and 2.3, respectively
when only age was considered versus 1.22 and 1.42 when other
sociodemographic variables were considered.
Factors considered in the Baltimore Eye Survey
Educational level
Visual impairment - comparative rates between 0 to
6 years of education versus greater than 12 years
of education
0-6 years: 5.09%
>12 years: 1.94%
Blindness -- comparative rates between 0 to 6 years
of education versus greater than 12 years of education
0-6 years: 1.80 %
>12 years: 0.64%
Employment status: Among the disabled, there were
higher rates of visual impairment and blindness, compared
to employed, homemakers. Those individuals who were
retired evidenced the lowest rates.
Median household income (based on census tract data)
For every additional $1000 of median income,
the prevalence of visual impairment declined 0.32%
(p < .005)
For every 10% increase in the percentage of families
below the poverty level, the prevalence of low vision
rose 0.44%.
Health status was positively related to lower rates
of visual impairment and blindness.
Corroborating evidence that socioeconomic factors matter is
noted in other studies.
Ho and Chang assessed the prevalence of ocular disorders
among the homeless and nonhomeless poor in Los Angeles.
Higher rates of glaucoma and cataracts were notes in the
both of these groups compared to the general population.
The National Health Interview Survey evidenced an association
between the inability to read a newspaper and the highest
level of education achieved by the head of the household
and family income.
There was an inverse association of visual acuity and
educational level in the The National Health and Nutrition
Examination Survey.
High rates of visual impairment and blindness were noted
in elderly adults in nursing homes. A lower 1982 income,
age, residence in a nursing home were among the significant
factors associated with functional blindness and visual
impairment.
Socioeconomic factors must be considered.
Evidence from the transplant literature, suggests that other
factors must be considered such as health and functional status,
and attitudes towards treatment. Including other factors reduced
the impact of socioeconomic measures on the odds of 1. being
on a wait list for a kidney transplant and 2. receiving a transplant.
Insurance coverage strongly affects an individual’s
access to care. The uninsured represents 15% of the general
US population and 17% of the population over the age of
65 years of age.
Two-thirds of all uninsured individuals are derived from
lower-income families (less than 200 percent of the federal
poverty level)
One-third of all members of lower income families are
uninsured.
One quarter of all uninsured adults have not earned a
high school diploma. Forty per cent of adults who have not
graduated from high school are uninsured.
African Americans are twice as likely to be uninsured
and Hispanics are three times as likely to be uninsured.
Non-Hispanic whites comprise approximately half of all uninsured
individuals.
Residents of the South and West are more likely to be
uninsured.
Physician’s attitudes towards the uninsured must be
considered.
In a recent survey of practicing physicians, 31% admitted
not offering patients useful services due to perceived lack
of coverage for these services. At least 35% of physicians
admitted making such decisions more frequently now compared
to 5 years ago.
Specifically in glaucoma, African Americans have been
noted to undergo surgical procedures at half the rate of
whites. Undertreatment of disease may contribute to higher
prevalence rates.
An endless cycle ensues that is intertwined with environmental
factors, including those that have been identified and those
that are yet to be identified (See figure).
Failed appointments influences continuity of care.
Level of education influences consistency of appointment
keeping. Patients who have not completed high school
are more likely to fail appointments.
People who fail appointments repeat this behavior.
One investigator noted that 14% of patients contributed
to 42% of the failed appointments. The absence of health
insurance was one factor that contributed to failure
to make appointments.
Patient education is very important. In a prospective
study of glaucoma patients, those patients who received
information about their disease and who spoke with a
nurse for 3 to 5 minutes were more likely to keep their
appointments than those individuals who were scheduled
simply with a secretary.
Does psychic stress influence IOP? It is unclear if there
is any casual relationship between IOP and stress.
Other factors that may influence disparities in care
1. Fewer available resources for out-of pocket costs
2. Geographic proximity and inadequate transportation
3. Literacy and knowledge
4. Cultural traditions favoring nontraditional or noninvasive
care
5. Lack of confidence or self-efficacy to comply with
therapy
6. Trust and cultural compatibility with physicians
7. Subtle and overt racism
Economic disparity continues to be a basic problem. Housing
is just one example (Baltimore Sun, July 3, 2003, page 21A)
1. High interest loans are three times more likely
in low-income neighborhoods and five times more likely
in black neighborhoods
2. Black homeowners received 18% less in value for
their homes compared to whites (“segregation
tax”)
Conclusions: “Race” is a socially relevant term
that is currently serving as a surrogate for a number of nonbiological
factors that affect our patients. Physicians must continue to
individualize their approach to patients and treatment plans based
on relevant socioeconomic and biological risk factors.
