Making Eye Health a Population Health Imperative Vision for Tomorrow (2016) / Chapter Skim
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5 The Role of Public Health and Partnerships to Promote Eye and Vision Health in Communities
5 The Role of Public Health and Partnerships to Promote Eye and Vision Health in Communities
Pages 191-270
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From page 191... ...
. A population health approach involves multiple actors who work separately and cooperatively "on the interrelated conditions and factors that influence the health of populations over the life course, .
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From page 192... ...
Successful health promotion in eye and vision health will require innovative partnerships engaged in a variety of activities that advance different objectives within population health. A key role for the governmental PHDs is to act as a convener of the different stakeholders who then develop and implement action plans that may complement national initiatives and that reflect a community's needs and goals.
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The central issue we address in this chapter is the governmental PHD's capacity to improve and promote eye and vision health and how partnerships between actors in the population health system can enhance this capacity. Programs to address the risk factors for vision loss, such as diabetes, tobacco use, and injury are common.
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Federal Agencies and Organizations Public health officials can use an array of legal and public health interventions to promote the population's health, such as issuing and then enforcing regulations. At the federal level, there are numerous agencies, institutes, and centers whose work affects eye health and the impact of vision impairment on populations (see Appendix D)
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and National Eye Health Education Program (NEHEP) , both of which focus on vision loss and the funding of various activities targeting at-risk populations (CDC, 2015a; NEI/NIH, 2015b)
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As described later in this chapter, chronic vision impairment is notably absent from government lists of priority chronic diseases, which means that eye and vision health are passively excluded from many federal programs and initiatives aimed at reducing the burden of chronic disease. Moreover, as described in Chapter 4, vision and eye health surveillance efforts have received only modest attention and support from federal agencies.
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. The Organization of Local Health Departments Except in states that use a centralized model, LHDs have broad authority to take actions necessary to protect and promote the public's health.
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whose educational background and training could make them valuable allies in promoting eye and vision health. Similarly, policy development and policy analysis capabilities are crucial elements lacking in many smaller health departments.
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Nor is eye and vision health well integrated into related programs, such as chronic disease and health education programs, although the risk of vision impairment is associated with a number of current public health issues, such as smoking rates. This opportunity is discussed later in this chapter.
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For example, health departments can serve as navigators between medical care and the community (e.g., arranging transportation, working with providers to use community health workers in coordinating eye health in the community)
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Second, consolidation increases the number of people in the service area who might have vision impairment, making it more likely to detect changes in eye and vision health in response to specific interventions and initiatives. Third, consolidation improves the likelihood that LHDs will be active participants in the community health needs assessment process (discussed later in
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The related concept of health education includes strategies to promote optimal eye health, prevent vision impairment, and provide people with the skills and ability they need to manage vision impairment and rehabilitation, if necessary. This includes
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to collect and analyze data regarding eye health status; • Monitoring access to vision care services; • Assuring access to clinical services, especially for undiagnosed and low-income populations at risk of eye disease; • Incorporating vision care as a strategic planning priority and in conducting health impact assessments; • Incorporating vision care as an integral component of "health in all policies" programs; and • Facilitating community engagement in order to promote eye health and obtain community collaboration in implementing policies and programs. The remainder of this chapter explores some of these strategies in more detail, including efforts to improve public awareness and education, expand access to vision care services and appropriate follow-up care, develop policies to encourage eye healthy environments, promote eye and vision health as part of formal population health programs, and enhance accountability for activities (or lack thereof)
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. This same poll found that blindness ranked either first or second among African Americans, Asians, Hispanics, and whites as the worse disease or ailment.3 Yet a lack of awareness around vision and eye health issues is "a major public health concern," especially for linking patients into care and attempting to make population-level changes in behavior and health practice (Bailey et al., 2006; Zhang et al., 2012)
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. The committee supports this endeavor and encourages federal support for updating data on the public's perception of and familiarity with eye health behaviors, risk factors, the relationship between eye and vision health and other measures of health, and available interventions, including the use of protective lenses, the utilization of health care, and the detection of uncorrected and correctable refractive error.
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. Hispanic Americans are less likely to have knowledge of eye health and disease than Caucasians, African Americans, and Asian Americans (NEI/LCIF, 2008; Zhang et al., 2012)
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Public awareness campaigns -- generally in combination with other public health strategies -- have been used extensively and successfully in population health for decades. These campaigns often focus on behavior change that reduces the risk of poor health (e.g., smoking cessation, improved nutrition and exercise, increased cancer screenings)
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. The Lions Eye Health Program is a community-based education program that promotes healthy vision and raises awareness of the causes of preventable vision loss (Lions Club, 2016)
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6 Personal communication, N Ammary-Risch, National Eye Health Education Program, 2016.
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. Examples of local public awareness campaigns include the Marshall B
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The ubiquity of social media continues to expand opportunities to engage and educate the public about the importance of maintaining eye and vision health, and social media can serve as a valuable resource to connect visually impaired people to needed services and advocacy platforms. The effective use of social media platforms in health promotion intervention programs, in general, remains a fluid topic of discussion (Chou et al., 2009, 2013; Korda and Itani, 2013; Lefebvre and Bornkessel, 2013; Moorhead et al., 2013; Neiger et al., 2012)
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From page 212... ...
Moreover, because a lack of knowledge about vision loss and the possible prevention or treatment of subsequent vision impairment requires increased knowledge among vulnerable populations and practitioners, public awareness campaigns hold promise as a tactic to mitigate these deficits, when included as one component of a larger population health strategy. Assessing the impact of specific campaigns will require carefully designed evaluations, to not only provide some evidence of return
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In this report, unless otherwise stated, the term "vision screening" is used to refer to any of a set of general eye health assessments that can be used to identify potential problems with visual functioning or symptoms suggestive of an eye disease or condition. Screenings cannot diagnose the cause of vision problems, but they can be used to expand entry to the health care system and access to appropriate follow-up care for more vulnerable populations.
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. Mobile clinics and school-based vision screenings that are provided at no cost offer a means of addressing demonstrated financial, social, and political barriers to accessing eye care for children and other at-risk populations (Castanes, 2003)
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. Promoting Follow-Up Care After Screenings Screening programs cannot lead to reduced vision impairment if the process does not include a mechanism to assure appropriate follow-up care.
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. The program's website notes that this program "routinely identifies 10-15 percent of those screened as needing eye care" (MDHHS, 2016a)
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. VSP partners with Boys & Girls Clubs of America, Communities in Schools, Lions Club International Foundation, the National Association of Community Health Centers, the National Association of School Nurses, the National Council of LaRaza, the National Head Start Association, and Prevent Blindness to deliver a free comprehensive exam continued
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. Recently, Vision To Learn partnered with Johns Hopkins University, the Baltimore City Health Department, and the Baltimore City Public School System to launch a citywide initiative, Vision for Baltimore, which will provide vision screenings and free eyeglasses for pre-kindergarteners to eighth-graders in all 50 Baltimore City public schools (Naron and Mendes,
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ENCOURAGING ENVIRONMENTS THAT SUPPORT EYE HEALTH AND VISUAL FUNCTION: POLICY DEVELOPMENT AND ENFORCEMENT Health departments can play an important role in influencing the built environment, i.e., the physical environment constructed by human activity,
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. These are important elements to consider when developing a comprehensive population health approach to address eye and vision health.
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The U.S. Department of Justice has offered guidance on the types of services and practices that can be considered to better accommodate people with vision impairment under the ADA (see Box 5-3)
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Ensuring and enforcing equal access under the ADA will require collaboration among federal, state, and local governments, architects and engineers, city planners, disability rights advocates, and others. BOX 5-3 Examples of Services and Practices That May Assist People with Vision Impairment Under the Americans with Disabilities Act Architectural Barriers "Remove architectural barriers in existing facilities .
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From page 223... ...
. As the population ages and more people experience the vision loss typically associated with the aging process, it will become increasingly important to ensure that retirement communities, assisted living and nursing facilities, and general rehabilitation facilities are designed or furnished to enhance visual function in order to reduce the potential negative downstream consequences of vision impairment.
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From page 224... ...
. The causes of eyestrain may include reading without resting one's eyes if underlying factors are present; driving long distances and performing other activities involving extended focus; being exposed to bright light or glare; working with insufficient light; having an underlying eye problem such as dry eyes, uncorrected refractive error, eye teaming disorder, or accommodative or binocular vision disorders; being stressed or fatigued; and exposure to conditions that may contribute to dry eyes (Barnhardt et al., 2012; Gowrisankaran and Sheedy, 2015)
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From page 225... ...
. The National Institute for Occupational Safety and Health and eye health safety and advocacy organizations have produced similar materials, available online, and OSHA has made an e-tool available to assist employers and employees with understanding the requirements for eye protection in their specific industries or occupations (CDC, 2013b; CPWR, 2014; OSHA, 2016; Prevent Blindness, 2016c)
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. Estimates suggest that more than 90 percent of sports-related eye injuries could be prevented by using appropriate eye protection (Prevent Blindness, 2016c)
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Promote Infection Control and Immunization Poor hygiene, infrequent replacement of contact lens storage cases, and overnight contact lens wear are avoidable risk factors for microbial keratitis, contact lens–related inflammation, and other ophthalmic complications affecting eye health (Collier et al., 2014; Keay et al., 2007; Radford et al., 2009; Stapleton et al., 2008, 2012; Szczotka-Flynn et al., 2010)
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From page 228... ...
is a multilevel collaboration between the CDC's Division of Diabetes Translation and state and national partners, designed to promote vision health and quality of life for all populations, throughout all life stages, by preventing and controlling eye disease, eye injury, and vision loss resulting in disability. VHI has the unique role of collaborating with state and national partners to strengthen science and develop interventions to improve eye health, reduce vision loss and blindness, and promote the
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For example, in 2003, the CDC entered into a partnership with Prevent Blindness America to build capacity in states to address vision and eye health, which led to the active engagement of the National Association of Chronic Disease Directors, an organization that represents the leaders of state health department chronic disease programs (NACDD, n.d.)
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• VHI funded the Innovative Network for Sight Research, a collaborative vision research network of investigators at Johns Hopkins University, University of Alabama at Birmingham, University of Miami, and Wills Eye Institute that assesses and evaluates system-level and individual-level factors that affect access to and the quality of eye care. Site-specific and network studies will investigate barriers to and enablers of the delivery of efficacious and cost effective eye care that prevents vision loss and promotes eye health.
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From page 231... ...
At the state and local levels, vision care remains subordinate to other public health mandates and competing priorities. In short, to elevate eye and vision health as a population health issue, more coordination is needed within the federal government to expand the number and scope of opportunities to enhance state and local capacities.
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From page 232... ...
The Vision Integration and Preservation Program, a collaboration between the New York State Department of Health and Prevent Blindness Tri-State, integrated vision health "preservation strategies into existing programs and functions within [the] state health department to promote public health strategies among community-based organizations and vision partners" (VHIPP, 2012, p.
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. Asfar and colleagues suggested that eye care professionals can "integrate smoking cessation treatment in the standard care of patients' management" and can "serve as powerful public advocates against tobacco use, thereby significantly enhancing public awareness about the link between smoking and eye disease" and reducing vision loss in the long term (Asfar et al., 2015, p.
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in relation to UV exposure and the use of protective equipment could include eye health as another related health outcome. Obesity and Physical Activity A number of eye diseases and conditions may have risk factors that are associated, directly or indirectly, with obesity and exercise levels.
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. The committee concluded that governmental PHDs and other stakeholders should consider including eye and vision health measures and metrics into existing programs to better understand the risk and protective factors for vision impairment and the relationship that exists between eye and vision health and other chronic diseases.
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. Chronic vision impairment qualifies as a general chronic condition under the Assistant Secretary of Health's definition.
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. Although the visibility of other chronic conditions certainly does and should affect the prioritization of eye disease and vision impairment, chronic vision impairment also affects the prevalence and health outcomes associated with other chronic conditions (see Chapter 2)
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. Thus, part of the equation to maximize health equity will be to prevent vision loss and to adequately respond to the burden of vision impairment, including providing eyeglasses, treatments, and rehabilitation services.
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More is needed to ensure that greater improvements in population eye health outcomes can be achieved by addressing both the social determinants of health and individual-level risk factors for vision impairment. Because
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. However, the proposed toolkit can be used by eye care professionals and public health practitioners together to design interventions that improve eye and vision health literacy, including raising awareness, communicating clearly, accounting for culture and other considerations, using health education materials effectively, and working with other health and literacy resources in the community.
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In any population health initiative, accountability is important because it forces partners and collaborators to measure and communicate a program's expectations and the magnitude of its impact to inform and influence the public and elected officials. In 2011, the IOM released the report For the Public's Health: The Role of Measurement in Action and Accountability, which chronicled different types of measures and assessments for characterizing the public health system's impact and how decision makers can use these tools to inform policies and practices (IOM, 2011c)
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A number of tools are available to help governmental PHDs and other population health stakeholders determine what will constitute health priorities within their communities. Box 5-5 describes the broad suggestions of the National Association of County and City Health Officials for prioritizing community health issues.
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In 2006 the National Association of Chronic Disease Directors with the support of the CDC's National Center for Chronic Disease Prevention and Health Promotion, convened a workshop on chronic disease program integration because of its growing interest in state public health agencies. Participants developed a list of eight principles for state health agencies to use as a guide for supporting chronic disease program integration initiatives.
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When evaluating whether eye and vision health rises to the level of a "top priority" within a given community, the committee encourages governmental PHDs, policy makers, private industry, nonprofit organizations, the media, the public, and other stakeholders to carefully consider the scope of the problems associated with vision impairment, the availability of treatments to effectively and relatively easily correct or reverse vision impairment for millions of people, the lack of knowledge about relatively simple behaviors that can reduce the risk of vision loss, and the wide range of strategies available to ensure that eye and vision health are present within formal programmatic designs. Strategies to Improve Accountability for Eye and Vision Health Holding organizations accountable for specific eye and vision health outcomes will be difficult for several reasons.
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Vision impairment should be added to chronic disease surveillance systems. Government public health agencies "can also serve as managers or facilitators of incentives that both reward and serve as a tool for holding stakeholders accountable (i.e., driving other sectors to demonstrate accountability on contributions to health improvement)
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, offer specific opportunities for health departments to be significant actors and partners in vision and eye health. First, under the ACA, nonprofit hospitals and health systems must conduct a community health needs assessment (CHNA)
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Partnerships vary in the scope, objectives, stakeholders involved, and the inclusion of multifaceted interventions to resolve complex health problems. As a result, improvements in public health outcomes cannot BOX 5-6 Key Research Gaps • Surveys on current public awareness about eye and vision health, including knowledge about the etiology and risk factors for specific eye diseases, con ditions, and injuries; behavior to reduce the risk of vision loss; and the links between eye and vision health and overall health and wellness.
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Short- and long-term population health strategies should address the broad determinants of health, including policies that influence individual behaviors, healthy environments, and social conditions, because of their potential impact on eye and vision health. Enhancing public awareness of the etiology, causes, and risk factors related to eye and vision health, as well as the behaviors that effectively reduce the risk of vision loss,
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From page 249... ...
Establishing eye and vision health as public health priorities will not be easy due to limitations in public health capacities, surveillance challenges, limited evidence-based research, among other challenges. However, the chronic nature of many vision impairments and their impact on other chronic diseases and health determinants require federal, state, and local governments and other diverse yet critical stakeholders to carefully and collaboratively consider the potential benefits
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2005. Awareness of age related macular degeneration and associated risk factors.
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2006. Visual impairment and eye care among older adults -- Five states, 2005.
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2011. Age-related macular degeneration and smoking cessa tion advice by eye care providers: A pilot study.
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2012. Eye health tips.
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2012. Disparities in eye care utilization among the United States adults with visual impairment: Findings from the Behavioral Risk Factor Surveillance System 2006–2009.
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2002. A health education program for elderly persons with visual impairments and perceived security in the performance of daily occupations: A randomized study.
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2014. Evaluation of a community-based participatory farmworker eye health intervention in the "black dirt" region of New York State.
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2014. The impact of providing vision screening and free eyeglasses on academic outcomes: Evidence from a randomized trial in Title 1 elementary schools.
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2011. Effects of indoor lighting on occupants' visual comfort and eye health in a green building.
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2014. Poverty and eye health.
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2013. Harnessing social media for health promotion and behavior change.
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2016. Lions eye health program.
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2007. Changes in eye care utilization following an eye health promotion campaign.
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2015c. National Eye Health Education Program (NEHEP)
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https://www.healthypeople. gov/2020/topics-objectives/topic/social-determinants-of-health/objectives (accessed April 13, 2016)
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2016b. Prevent Blindness eye health and safety observance calendar.
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2009. Assessing the need for on-site eye care professionals in community health centers.
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2012. Risk factors for moderate and severe microbial keratitis in daily wear contact lens users.
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2011. Eye health and safety among Latino farmworkers.
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Paper prepared for the Committee on Public Health Approaches to Reduce Vision Impairment and Promote Eye Health. http://www.nationalacademies.
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