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Research Navigator: Complex Crossings - Navigating the Intersection of Health and Vision Loss

Published June 1, 2016

This edition of the Navigator will summarize currently available data about the health of people with vision loss, providing answers to some essential questions:

People cross a busy city street. Image is blurred

People cross a busy city street. The image is blurred.

About This Series

Welcome to the sixth edition of AFB's Research Navigator. This is a quarterly series - accompanying AFB's DirectConnect newsletter - from the AFB Public Policy Center. The purpose of this series is to keep you informed of user-friendly facts and figures and the latest research pertaining to people with vision loss. The series will also include the necessary background information so you may use the information most accurately. Have an idea for a Research Navigator topic? Want to know more about a particular statistic or line of research? Send your thoughts to AFB's Senior Policy Researcher, Rebecca Sheffield. Readers are also encouraged to check out AFB's Statistical Snapshots. This webpage is regularly updated with a wide variety of information and tools that address commonly asked questions about people with vision loss.

Introduction to the Topic

In previous editions of the Navigator we have sorted through statistics and data sources related to various segments of the population of people with disabilities: the entire U.S. population, infants and toddlers, school-age children, and seniors. With that background information in mind, in this edition we are going to look at an issue which impacts people with vision loss across all ages: health.

Certainly eye health is an issue of utmost concern for people with vision loss, and we have previously discussed sources for data about the prevalence eye diseases like glaucoma and diabetic retinopathy. But what can be said about the general health status of people with all types of vision loss? Are they more/less likely to have additional healthcare complications? Do they participate equally in recommended screenings and preventative health measures? Differences in health experienced by a particular subgroup within the larger population (such as people with vision loss) are known as health disparities, and research into health disparities has received increased attention in recent years, particularly as a result of the Affordable Care Act. (For more about health reform and health disparities, take a look at the publications from the National Health Law Program.)

In the following paragraphs, we will consider (for people with vision loss) statistics for prevalence of additional disabilities, prevalence of chronic health conditions, and participation in necessary/preventative healthcare activities and health risks.

Researcher's Note: As mentioned previously, there are a few major - but very different - large, national, population-level surveys with questions about vision loss. All of these surveys are of the civilian, non-institutionalized U.S. population. The National Health Interview Survey (NHIS), a project of the Centers for Disease Control and Prevention (CDC), asks participants "Do you have trouble seeing, even when wearing glasses or contacts?" and, if the response is "Yes," "Are you blind or unable to see at all?" The American Community Survey (ACS), a project of the Census Bureau, and the Behavioral Risk Factor Surveillance System (BRFSS), also a CDC survey, ask participants, "Are you blind or do you have serious difficulty seeing, even when wearing glasses?" These slightly different questions result in two very different estimates of the number of Americans with vision trouble. The NHIS estimates (for 2014) that over 23 million people in the U.S. have trouble seeing, while the ACS (2014) estimates that the number of persons with vision difficulty is closer to 6.8 million. Neither is "wrong;" the ACS is simply counting people who self-identify with a somewhat more severe definition of vision loss than the definition used in the NHIS.

The ACS, BRFSS, and the NHIS allow researchers to gather data about people with vision loss with and without additional disabilities. The larger sample size of the ACS enables more reliable estimates for sub-populations and specific geographies; however the NHIS contains many more variables related to health. The BRFSS has an even smaller sample size but even more health-related questions.

Acknowledgement

Before we begin, it is essential to acknowledge the amazing contributions of Dr. John Crews and his colleagues at the Center for Disease Control and Prevention's Vision Health Initiative to our field's knowledge of health and healthcare disparities for people with vision loss. (Dr. Crews was honored with AFB's Kirchner Research Award in 2015 ). As you will read in the citations for much of the information in this issue of the Navigator, Dr. Crews' work has provided us with incredible insights into the health of people with vision loss, and he continues to challenge us to better understand and address critical disparities.

Vision Loss & Additional Disability

Looking at the intersection of vision loss with additional disabilities, we will focus first on ACS data. As a requirement of the Affordable Care Act, most federally funded surveys now include the same six disability questions, frequently called "the ACS questions." Even the NHIS now includes these six questions, in addition to the broader questions about vision loss and other conditions. (For this Navigator, when we refer to NHIS data, we are referring to data from the original NHIS questions, not the ACS questions.) Along with the previously described question about vision, the five additional ACS disability questions are:

  • Hearing Disability (asked of all ages): Is this person deaf or does he/she have serious difficulty hearing?
  • Cognitive Disability (asked of persons ages 5 or older): Because of a physical, mental, or emotional condition, does this person have serious difficulty concentrating, remembering, or making decisions?
  • Independent Living Disability (asked of persons ages 15 and older): Because of a physical, mental, or emotional condition, does this person have difficulty doing errands alone such as visiting a doctor's office or shopping?
  • Ambulatory Disability (asked of persons ages 5 and older): Does this person have serious difficulty walking or climbing stairs?
  • Self-Care Disability (asked of persons ages 5 or older): Does this person have difficulty dressing or bathing?
    (U.S. Department of Commerce, 2014, p.9).

The following figures are based on data for these questions in the ACS over 5-years (2010-2014).

% of People with
Vision Difficulty
% of People w/out
Vision Difficulty
Hearing difficulty 32% 4%
Cognitive difficulty* 37% 5%
Ambulatory difficulty* 50% 6%
Self-care difficulty* 27% 3%

* ages 5 and up

(U.S. Department of Commerce, 2015a).

The NHIS includes questions which help to measure the presence of additional disabilities beyond the six ACS questions (and also questions which - like the NHIS vision question - are similar but not quite the same as the ACS questions) (Centers for Disease Control and Prevention, 2016). For children, ages 0-17, the NHIS asks a responsible adult whether a doctor or health professional has ever told him/her that the child has any of a number of specific conditions (autism and related disorders, attention deficit hyperactivity disorder[ADHD]/attention deficit disorder[ADD], etc.) For adults, ages 18 and up, the NHIS asks whether the respondent has any of a number of functional limitations (difficulty walking, difficulty climbing steps, difficulty standing, etc). If the person has any of these difficulties, then they are asked if their difficulties are due to any specific conditions, such as intellectual disability, musculoskeletal problems, etc.

The following are a few selected estimates from the NHIS data for 2014:

% of People with
Vision Difficulty
% of People w/out
Vision Difficulty
difficulty* hearing (all ages) 14.5% 4.2%
functional limitations (ages 18+)
any functional limitation 39.2% 13.1%
need help with daily living 7.1% 1.7%
difficulty** walking/climbing steps 22.7% 6.1%
disability categories
autism/related disorders (ages 0-17) 5.1% 1.8%
ADHD/ADD (ages 0-17) 17% 7.3%
cerebral palsy (ages 0-17) 7.7% 0.3%
intellectual disability (ages 0-17) 7.0% 0.8%
intellectual disability*** (ages 18+) 0.5% 0.2%
musculoskeletal problem*** (ages 18+) 13.5% 5.9%

* moderate trouble hearing, a lot of trouble hearing, or deaf
** some difficulty, a lot of difficulty, or cannot do at all
*** to be identified in this category, adults must report experiencing a functional limitation due to the problem/disability

(Centers for Disease Control and Prevention, 2015a).

Keep in mind that the NHIS uses a different definition of vision loss than the ACS, so the estimates from the two surveys are not directly comparable. However, it does appear that people who self-identify with the narrower ACS definition of vision loss are more likely to also experience additional disabilities, while the larger population of people who self-identify with the NHIS definition of vision loss are less likely to have additional disabilities.

How do these differences vary by other demographic characteristics?

The U.S. Census Bureau's DataFerrett tool is an excellent resource for cross-tabulating ACS data from multiple survey questions. Here are a few highlights from ACS data (2011-2014, 5-year dataset) for persons with vision loss:

  • Geography and Combined Vision and Hearing Difficulty: As can be seen from the national ACS data reported previously (5-year dataset, 2010-2014), the prevalence of hearing difficulty is approximately 30% greater among people with vision loss than those without. However, looking at the prevalence in individual states, the difference in prevalence for those with vision loss and those without ranges from just 19% in the District of Columbia to 41% in Alaska. (It should be noted that DC has a very low reported prevalence of hearing difficulty according to the ACS). The prevalence of combined vision and hearing difficulty is 0.8% for the United States but ranges from 0.5% in DC to 1.6% in West Virginia (U.S. Department of Commerce, 2015b).
  • Gender and Additional Disability (U.S. Department of Commerce, 2015c):
    • Hearing difficulty: Within the general population, hearing difficulty is more common in men (4.2%) than women (3.0%); this difference is more pronounced for people with vision loss, among whom 35% of males have hearing difficulty, compared to 31% of females.
    • Ambulatory difficulty (ages 5 & up): Within the general population, difficulty moving around is more common in women (8.5%) than men (6.1%); the difference is more pronounced for people with vision loss, among whom 54% of females have ambulatory difficulty, compared to 44% of males.
    • Self-care difficulty (ages 5 & up): Within the general population, difficulty with self-care tasks like bathing is more prevalent among women (3.5%) than men (2.6%). This difference is more pronounced for people with vision loss, among whom 30% of females have self-care difficulties, compared to 23% of males.
    • Cognitive difficulty (ages 5 & up): Within the general population, cognitive difficulty is almost evenly distributed among men (5.4%) and women (5.2%). For people with vision loss, approximately 38% of women and 36% of men have cognitive difficulty.
    • Independent living difficulty (ages 15 & up): Within the general population, difficulty living independently is more common in women (7.1%) than men (4.9%); the difference is more pronounced for people with vision loss, among whom 49% of females have independent living difficulty, compared to 38% of males.

Researcher's note : A word of caution! Every introduction to statistics course contains a lecture on the important maxim that "Correlation does not equal causation!" Just because it appears that visually impaired women are more likely than visually impaired men to have ambulatory, self-care, and independent living difficulties, this does not mean that being female or having visual impairment necessarily causes any additional disabilities. Other factors may be in play, especially the fact that women (on average) live longer than men, and increasing age is associated with vision loss and many other disabilities and health conditions. Cultural factors may be involved as well, perhaps with regards to differences in women's and men's self-perceptions of independence and ability.

Vision Loss & Chronic Health Conditions

Analyses conducted by Dr. John Crews (mentioned above) and others at the CDC are among our best sources for information about the intersection of disability and chronic health conditions. Chronic illnesses are "conditions that last a year or more and require medical attention and/or limit activities of daily living" (Warshaw, 2006). Although vision loss is often excluded from public health initiatives focusing on people with multiple chronic conditions (Crews, 2015), it is essential that advocates in the arena of vision loss pay attention to differences and disparities related to chronic health conditions in order to promote health and quality of life for people who are blind or visually impaired.

As with vision loss and additional disabilities, there are an infinite number of possible research questions with respect to vision loss and illness/health conditions. Here are just a few recent research findings:

  • In the Women's Health and Aging Study, Fried and colleagues (1999) ranked the prevalence of "comorbid chronic conditions" (co-occurring disabilities and/or illnesses) among women ages 65 and up from their sample of older women living in Baltimore. Six of the top ten most prevalent pairs of chronic conditions included visual impairment, and the most common pair of co-occurring conditions was the combination of arthritis and visual impairments.
  • In his 2015 talk on Shaping Services and Systems to Improve the Lives of Older People with Visual Impairment at the AFB Leadership Conference, Crews shared an analysis of the NHIS data from 2007-2011 in which he found that 29.4% of people age 65 and up who report kidney disease also report visual impairment. Among those who had experienced a stroke, 25.5% reported vision impairment, and among those with asthma or diabetes, 19.9% reported vision impairment. The 2013 NHIS estimated that the prevalence of vision trouble among all people ages 65 and up was just 14.3% (Centers for Disease Control and Prevention, 2014); therefore these higher rates of vision loss among older people with chronic conditions should be a cause of concern and an impetus for targeted interventions and further research. Notably, as Crews shared in his presentation, people with chronic conditions (hypertension, heart disease, stroke, arthritis, etc.) were much more likely to report fair or poor health if they also experienced vision impairment (as compared to those who had chronic illness but were not visually impaired).
  • For the vision loss community, diabetes is a particularly concerning chronic health condition which can cause vision loss and which can be difficult for people with vision loss to manage. A 2011 report in the CDC's publication Morbidity and Mortality Weekly Report (MMWR) described some positive findings from an analysis of NHIS data: from 1997 to 2010, the age-adjusted prevalence of visual impairments declined significantly among adults with diagnosed diabetes (including among subgroups such as men, women, whites, and Hispanics) (Burrows, Hora, Li, & Saaddine, 2011).
  • For many more summaries and studies of the available data about vision and health conditions, take a look at the webpages for theCDC's Vision Health Initiative, especially their Resource Center.

Vision Loss, Healthcare & Health Risks

Staying healthy, accessing healthcare, and accessing preventative health services are essential for people with and without visual impairment. Good habits, early detection, and timely treatment can prevent some of the chronic health conditions described previously and can enable people who are blind or visually impaired to pursue their goals, care for their families, and maximize their quality of life. Yet, we know that people with all types of disabilities face challenges and barriers to staying healthy and accessing healthcare - transportation, communication, awareness, etc. What can data and statistics tell us about the current status of health risks and healthcare access for persons with vision loss?

  • At the 2014 Annual Disability Statistics Compendium, data were presented highlighting a massive research project into health and healthcare disparities among people with disabilities (Drum, 2014). This research involved an analysis of data from the Medical Expenditures Panel Survey, 2004-2010, which includes a subsample of respondents from the NHIS (Reichard, Stransky, Phillips, Drum, & McClain, 2015). Among the findings surrounding healthcare, it was reported that only 70% of people with visual disabilities have a "usual source of care," lower than any of the other disability categories reported (although similar to the rate of 71% for people without disabilities). Furthermore, 22% of people with visual impairments reported being uninsured (higher than any other disability category and higher than the 18% rate for people without disabilities). Only 62% of women with visual impairments had received a mammogram within the past two years (lower than any other disability group and lower than the 80% rate for people without disabilities). Hopefully some of these statistics are improving since the implementation of the Affordable Care Act; however, continued research needs to be done to monitor and support access to healthcare.
  • Accessing eye care is an especially important component of staying healthy; unfortunately significant disparities exist in this area as well. Again, the CDC's Vision Health Initiative has led the charge on investigating and revealing areas of concern. In their 2012 report, Chou and colleagues found significant variance in the rate of annual eye exams for people with moderate-to-severe visual impairments (based upon 2006-2009 data from the BRFSS). In particular, there were variations for race/ethnicity, income, education, and state of residence. The probability that a person with vision loss whose income was below $35,000 had received an annual eye exam ranged from 39% (Colorado) to 71% (Massachusetts). For those with higher incomes, the probability ranged from 50% (Colorado and Missouri) to 69% (Arizona).
  • In addition to being at increased risk of additional disability and illness, people with vision loss may be more likely to experience certain types of accidents and injuries. Dr. Crews and colleagues from the CDC recently published findings from their analysis of 2014 BRFSS data, concluding that people with severe vision loss ages 65 and up are at increased risk for falls, which can cause major injuries or can even be fatal. They found that the rate for older adults without visual impairments having fallen within the past year was 27.7%, and the corresponding rate for seniors with severe vison impairment was 46.7%. Crews and colleagues (2016) noted that, despite hospitals' emphasis on falls-prevention interventions, thus far only one falls intervention plan had been systematically studied (through a technique called a randomized control trial) for adults with vision loss. Please take a look at this new and important report for more information
  • Finally, it is important to consider trends and patterns in healthy and unhealthy characteristics of people with vision loss, which might contribute to overall health and the prevalence of disease and additional disability. A quick analysis of the NHIS data (2014) provides the following insights (Centers for Disease Control and Prevention, 2015b):
    • Smoking (age 18+): While about 38% of responding adults report having smoked at least 100 cigarettes in their entire lives, the rate for people with vision loss is almost 51%! Of all those who had smoked at least 100 cigarettes in their lifetimes, 33% of adults remained daily smokers. For adults with vision loss, this rate was 38%.
    • Body mass index (age 18+): The CDC has established guidelines for "body mass index" (BMI, a ratio of weight to height). BMI below 18.5 is considered underweight, 18.5-24.9 is considered normal/healthy, 25-29.9 is considered overweight, and 30+ is considered obese. Health consequences of obesity include high blood pressure, diabetes, stroke, cancer, and more (see http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/). According to NHIS data, adults with vision loss are more likely than those without to be underweight (2.7% vs. 1.6%); they are also more likely to be obese (38.4% vs. 31.7%).

Conclusion

"He who has health has hope, and he who has hope has everything." - Thomas Carlyle

The simple fact of having vision loss does not - in itself - diminish health in any particular way. However, in our complex world and even more complex healthcare system, people with vision loss can be at a disadvantage in their efforts to live long and healthy lives.

Although much work has been done, additional, consistent, ongoing research is needed in order to study and understand the differences and disparities in health, healthcare access, and health risks and habits of people with vision loss. These data points and indicators point the way for advocates and allies as we work to provide equal access for all people to lives of health and happiness. For example, AFB's work to promote legislation to fund low vision devices under Medicare has direct implications for the health of persons with vision loss - enabling individuals to use technology to manage their medications and other healthcare needs more independently. Likewise, our renewed Agenda on Aging and Vision Loss will tackle challenges in funding, service provision, and collaboration which are essential to helping seniors with vision loss lead healthy, independent lives (Curious about the Agenda? Read how to get involved!)

We need better data to understand all areas where technology, transportation, and services can be provided to increase independence and health. Furthermore, we need to speak up in national conversations about healthcare to ensure that the needs of people with vision loss are considered in equal priority for all initiatives to improve the health of Americans.

By continuing to work towards understanding the intersections of health and disability - and also being aware of the influence of factors like income, poverty, race, ethnicity, age, and gender - we are better prepared to promote positive changes for individuals, families, communities, states, and our nation.

References

Burrows, N. R., Hora, I. A., Li, Y., & Saaddine, J. B. (2011). Self-reported visual impairment among persons with diagnosed diabetes - United States, 1997-2010. Morbidity and Mortality Weekly, 60(45), 1549-1553.

Centers for Disease Control and Prevention (2014). National Health Interview Survey, 2013. Universe: (visionprob(all), age(65-99)); Weight used: sampweight. Generated via Minnesota Population Center and State Health Access Data Assistance Center, Integrated Health Interview Series: Version 6.12. Minneapolis: University of Minnesota, 2015. https://www.ihis.us/ihis/

Centers for Disease Control and Prevention (2015a). National Health Interview Survey, 2014. Universe: (visionprob(all), hprobamt(all), lany(all), ladl(all), lawalkclimdif(all), autismev(all), addev(all), cerebpalev(all), retev(all), flretc(all), flmuscle(all), age(all)); Weight used: sampweight. Generated via Minnesota Population Center and State Health Access Data Assistance Center, Integrated Health Interview Series: Version 6.12. Minneapolis: University of Minnesota, 2015. https://www.ihis.us/ihis/

Centers for Disease Control and Prevention (2015b). National Health Interview Survey, 2014. Universe: (visionprob(all), age(18-99), smokev(all), smokfreqnow(all), bmi(all)); Weight used: sampweight. Generated via Minnesota Population Center and State Health Access Data Assistance Center,Integrated Health Interview Series: Version 6.12. Minneapolis: University of Minnesota, 2015. https://www.ihis.us/ihis/

Centers for Disease Control and Prevention (2016). NHIS data, questionnaires, and related documentation. Retrieved from http://www.cdc.gov/nchs/nhis/data-questionnaires-documentation.htm

Chou, C., Barker, L. E., Crews, J. E., Primo, S. A., Zhang, X., Elliott, A. F., Bullard, K. M., Geiss, L. S., & Saaddine, J. B. (2012). American Journal of Ophthalmology, 154, S45-S52.

Crews, J. (2015, April). Shaping services and systems to improve the lives of older people with vision impairment [PowerPoint slides]. Presented during A national conversation on aging and vision loss: Giving feedback for the 2015 White House Conference on Aging session at the AFB Leadership Conference, Phoenix, Arizona.

Crews J. E., Chou, C., Stevens, J. A., & Saaddine, J. B. (2016). Falls among persons aged ≥65 Years with and without severe vision impairment - United States, 2014. MMWR Morbidity and Mortality Weekly Report, 65, 433-437. Retrieved from http://www.cdc.gov/mmwr/volumes/65/wr/mm6517a2.htm?s_cid=mm6517a2_w

Drum, C. E. (2014, December). Disability and rehabilitation research project: Health and healthcare disparities among individuals with disabilities (Health disparities) project highlights [PowerPoint slides]. Presented during 2014 Annual Disability Statistics Compendium, Washington, DC. Retrieved from http://www.disabilitycompendium.org/docs/default-source/2014-compendium/drrp-hd.pdf

Fried, L.P., Bandeen-Roche, K., Kasper, D., & Guralnik, J. M. (1999). Association of comorbidity with disability in older women: the Women's Health and Aging Study. Journal of Clinical Epidemiology, 2(1), 27-37.

Reichard, A., Stransky, M., Phillips, K., Drum, C., & McClain, M. (2015). Does type of disability matter to public health policy and practice? Californian Journal of Health Promotion, 13(2), 25-36.

U.S. Department of Commerce, Bureau of the Census (2014). The American Community Survey. Retrieved from http://www2.census.gov/programs-surveys/acs/methodology/questionnaires/2014/quest14.pdf

U.S. Department of Commerce, Bureau of the Census (2015a). American Community Survey 5-Year Estimates - Public Use Microdata Sample, 2010-2014. Universe: (AGEP(all) DEYE(all), DEAR(all), DDRS(all), DPHY(all), DREM(all), DOUT(all)); Weight used: PWGTP. Generated via DataFerrett http://dataferrett.census.gov/

U.S. Department of Commerce, Bureau of the Census (2015b). American Community Survey 5-Year Estimates - Public Use Microdata Sample, 2010-2014. Universe: (GEOG-101 (all states), DEYE(all), DEAR(all)); Weight used: PWGTP. Generated via DataFerrett http://dataferrett.census.gov/

U.S. Department of Commerce, Bureau of the Census (2015c). American Community Survey 5-Year Estimates - Public Use Microdata Sample, 2010-2014. Universe: (SEX(all),AGEP(all) DEYE(all), DEAR(all), DDRS(all), DPHY(all), DREM(all), DOUT(all)); Weight used: PWGTP. Generated via DataFerrett http://dataferrett.census.gov/

Warshaw, G. (2006) Introduction: Advances and challenges in care of older people with chronic illness. Generations, 30(3), 5-10. (See also: Hwang, W., Weller, W., Ireys, H., Anderson, G. (2001) Out‐of‐pocket medical spending for care of chronic conditions. Health Affairs, 20, 267-278)

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