Making Eye Health a Population Health Imperative Vision for Tomorrow (2016) / Chapter Skim
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1 Introduction
1 Introduction
Pages 23-54
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From page 23... ...
. Uncorrectable vision impairment can lead to a progressive inability to participate in family, social, and community activities and is associated with a higher prevalence of chronic health conditions, death, falls and injuries, social isolation, depression, and other psychological problems (Court et al., 2014; Crewe et al., 2013; Crews et al., 2016a,b; Kulmala et al., 2008, 2012; Lord, 2006; Rees et al., 2010; van Landingham et al., 2014)
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. Conversely, the promotion of 1 The committee adopted these definitions of vision loss and vision impairment to help facilitate discussion of eye and vision health in the context of population health.
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in most state and local health departments because of resource limitations and competing priorities. Some of the most notable successes in preventing vision loss have been anchored in population health strategies (e.g., CDC, 2015b; Kumaresan, 2005; Rao, 2015)
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From page 26... ...
. Population health approaches targeting uncorrectable vision impairment often focus on improving functionality, productivity, and independence through access to visual assistive devices, vision rehabilitation services, and reasonable accommodations -- although earlier access to effective treatments may prevent the progression of modifiable to uncorrectable vision impairment for certain conditions and diseases.
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, along with the American Academy of Ophthalmology, the American Academy of Optometry, the American Optometric Association, the Association for Research in Vision and Ophthalmology, the National Alliance for Eye and Vision Research, the National Center for Children's Vision and Eye Health, Prevent Blindness, and Research to Prevent Blindness asked the National Academies of Sciences, Engineering, and Medicine to conduct a consensus study on the current and potential roles of public health in addressing the burden of blindness and vision impairment, and the conditions, diseases, and injuries that cause them. Specifically, the Committee on Public Health Approaches to Reduce Vision Impairment and Promote Eye Health was asked to characterize the public health burden of major eye diseases, as well as the state of surveillance systems used to measure this burden; to examine existing models of vision care and eye disease prevention; to identify evidence-based health promotion interventions for vision care and encourage their development and utilization; and to develop strategies to promote collaboration among stakeholders in vision care in order to reduce the burden of low vision through the coordinated deployment of public health resources (see Box 1-1)
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Explore innovative models of care, innovative technolo • gies, their application to eye disease/vision impairment detection and manage ment, as well as barriers to their development and use. Examine and explore current and future areas of research on public health interventions that target prevention; access to, and utilization of, vision and eye care; and improved patient outcomes.
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Eye and vision health is local. The priorities and interventions related to vision impairment and population health must be assessed according to individual communities needs, resources, and values.
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Inconsistent definitions make it difficult to search for and compare relevant literature, and they also create confusion in trying to explain the nature, scope, impact, and treatment of eye and vision health. In fact, when conducting literature searches related to eye and vision health, the committee had to include a wide array of terms such as vision loss, vision impairment, visual impairment, blindness, eye health, vision health, and low vision (in addition to specific diseases or conditions)
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To provide greater clarity and consistency in its analysis and recommendations throughout this report, the committee defined specific key terms, which are provided in Table 1-1 along with functional descriptions. The committee chose to define "vision loss" as a process because it emphasizes the importance of approaching vision impairment as the result of a series of decisions, exposures, or circumstances -- many of which can potentially be altered to affect the trajectory of the severity of vision impairment across the lifespan.
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promote health. The dilated eye examination may lead to referrals for other health care and non clinical services or suggest future eye and vision care to avoid or slow progression of vision impairment.
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do not notice the changes that occur until their inability to see begins to affect every day activities. Vision loss is often chronic, progressive, and/or irreversible.
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It is a continuum that highlights subclinical and observable processes to yield important points of intervention for population health strategies that are aimed at reducing or delaying a wide range of vision impairments and related consequences. The most effective policies and interventions take into account the specific etiology and causation of vision loss as well as the availability of treatments or therapies for resulting vision impairment.
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These interpretations are not standardized across populations and should not be interpreted to mean that two people with the same measured acuity will see the same thing. However, it is important to have a general understanding of how visual acuity loosely translates into measures of function and the population health burden of vision impairment, especially in the context of uncorrected refractive error.
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a at This Levelb 20/10 to Range of NA NA 20/25 normal vision 20/30 to Near-normal • Reduced detail and/or • Street signs not easily read 20/60b,c vision contrast discrimination • People or objects across the • After acuity is worse than room lose detail 20/40, normal newspaper • Regular size print found in print is less legible, and the newspaper, school books, inability to recognize usual utility bills, and magazines and customary visual detail becomes difficult to read becomes apparent • Skips letters or words when reading • Must sit closer to the computer or television to see image details • Holds phone, tablet, reading materials closer to face • Restrictions may be placed on driver's licensure (e.g., driving in daylight only) • Need for intense lighting/ increased illumination • Some difficulty maneuvering stairs, sidewalks, and/or unfamiliar environments, especially in dusk conditions • Labels on food packaging, medication difficult to discern 20/70 to Moderate In addition to the above… In addition to the above… 20/160 visual • Continued loss of • Loss of facial feature impairment detail and/or contrast discrimination discrimination • Highway signage, distance • Increased delay in response details in low lighting, to adapting from bright to scrolling television dark settings and vice versa screen information is not • With acuity worse than discernable 20/70, large print (e.g., • Large print text becomes twice the size of normal difficult to read, size print)
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may be only majority of distance images remaining discernable are not discernable without component of the human magnification form • Largest available "off- • Loss of recognition of the-shelf" television or facial features, fingernails computer monitor does • Inability to apply make-up; not provide large enough extreme difficulty image to discern visual with shaving, personal detail maintenance • Visual field restriction • Shopping for groceries, results in severe loss of cooking becomes extremely peripheral vision (i.e., difficult tunnel vision) • Sensory substitution technology (i.e., talking watch, books on tape, GPS)
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A POPULATION HEALTH APPROACH TO IMPROVE EYE AND VISION HEALTH AND REDUCE VISION IMPAIRMENT It is easy to overlook (and perhaps forget) that some of the most notable successes in preventing vision loss have been anchored in population health strategies.
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From page 39... ...
, and the World Health Organization (WHO) have defined vision impairment and blindness as national or global public health problems.9 The CDC has also identified vision loss as a public health problem, funding a variety of activities to combat the effects of poor eye and vision health on at-risk populations.10 In 2007 the CDC published the report Improving the Nation's Vision Health: A Coordinated Public Health Approach, which identified three key public health activities: assessment (surveillance and epidemiology)
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From page 40... ...
. The report also proposed eight core elements to improve the nation's health: engaging key national partners, collaborating with state and local health departments, implementing vision surveillance and evaluation systems, eliminating eye health disparities by focusing on at-risk populations, integrating vision health interventions into existing public health programs including systems and policy changes that support vision health, addressing the role of behavior in protecting and optimizing vision health, assuring professional workforce development, and establishing an applied public health research agenda for vision.
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Figure 1-2 provides examples of specific risk and protective factors by health determinant category, which may be the targets of a broad population health approach to improving eye and vision health across the lifespan. Many other examples are provided throughout this report.
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42 FIGURE 1-2 Examples of factors that could be part of a population health approach to eye and vision health. SOURCE: Adapted from IOM, 2003, p.
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However, early and appropriate access to eye care and rehabilitation services will be an important component of any comprehensive population health approach to reduce the severity of vision impairment and the impact of vision impairment on quality of life. For example, comprehensive eye examinations may help identify eye and vision diseases and conditions before a patient notices symptoms (CDC, 2009a; Li et al., 2013)
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Even in its statement of work, the committee was asked to focus on mitigating the effects of vision impairment, a critical but downstream effect of vision loss that is not typically the focus of prevention efforts, which characteristically focus on more upstream determinants of health. As a result, it became important for the committee to develop a conceptual framework that illustrated the relationship between more traditional population health focuses and eye care.
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FIGURE 1-3 A conceptual framework to advance eye and vision health. SOURCE: Adapted from CDC, 2014.
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Examples include screenings for children to detect and treat amblyopia and its risk factors and having a comprehensive eye examination to detect subclinical changes in the eye for glaucoma or diabetic retinopathy. Tertiary prevention includes activities designed to preserve and enhance the health, function, and quality of life of individuals with vision impairment.
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The long-term goal of a population health approach in eye and vision health is to transform vision impairment from an exceedingly common to a rare condition, reducing related health inequities. Given the genetic and biological components of many eye diseases and conditions, the occurrence of eye injuries, and the aging process itself, populations will never be without vision impairment.
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Prevention and early access to effective eye care is critical to avoiding, identifying, monitoring, and treating many eye diseases and conditions that can lead to vision impairment across the lifespan. Short- and long-term population health strategies should also account for the broad determinants of health, including policies that influence individual behaviors, safe and healthy environments and conditions, and their potential impact on eye and vision health.
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2016a. Falls among per sons aged > 65 years with and without severe vision impairment -- United States, 2014.
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2015. Geographic disparity of severe vision loss -- United States, 2009–2013.
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2010. Vision specific distress and depressive symptoms in people with vision impairment.
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Paper prepared for the Committee on Public Health Approaches to Reduce Vision Impairment and Promote Eye Health. http://www.nationalacademies.org/hmd/~/media/ Files/Report%20Files/2016/UndiagnosedEyeDisordersCommissionedPaper.pdf (accessed September 15, 2016)
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2013. Socioeconomic disparity in use of eye care services among U.S.
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