How social determinants influence eye health

Patrice Hicks, PhD, MPH, an ophthalmic epidemiologist and assistant professor in the department of Ophthalmology and Visual Sciences at the University of Michigan, first recognized how social factors could shape eye health outcomes thanks to her own family.

Her two grandmothers both were at high risk for glaucoma, a disease that can cause gradual vision loss, often without early warning signs. One grandmother, who was white, knew the condition ran in the family. She was able to access monitoring and treatment to reduce the risk of vision loss. 

Her other grandmother was African American and grew up in the shadow of the U.S. Public Health Service’s project called The Untreated Syphilis Study at Tuskegee. She distrusted the medical establishment and didn’t understand her risk for the disease. She only received a diagnosis once her vision had deteriorated to the point where she felt her only choice was to visit the emergency room.

Glaucoma is more common in people of African ancestry than in white populations, and it tends to appear earlier and progress further before detection in a comprehensive eye examination. Higher baseline risk and reduced access to monitoring can easily compound each other.  

“Seeing these two different perspectives on healthcare in my own family made it clear there were a variety of different social factors that could influence eye health outcomes,” said Dr. Hicks. “My research looks at how we can address these social determinants of health (SDoH) and improve care.”

Understanding SDoH

Beyond Dr. Hicks’ family, most people recognize that individuals who are exposed to the same eye health risks can have very different outcomes — even after diagnosis and treatment. Some of those differences can be chalked up to genetics or other disease-related factors. 

But there is another factor in eye health that is often overlooked: social determinants of health (SDoH), also known as social drivers of health. 

SDoH are defined as “the conditions in the environments where people are born, live, learn, work, play, worship and age.” And they affect almost every aspect of health, from risk of diseases to outcomes after treatment.

According to Healthy People 2030, the U.S. Office of Disease Prevention and Health Promotion’s 10-year public health initiative, SDoH play a pivotal role in supporting health and well-being. 

They are often categorized into five core domains: 

• Economic stability
• Education
• Health care access and quality
• Neighborhood and built environment
• Social context 

Additional factors within each category can influence health outcomes including eye health, both directly and indirectly. More specifically, SDoH could include: 

• Disability status
• Job opportunities
• Housing
• Nutrition and access to healthy food
• Literary skills
• Substance use and more

Together and separately, SDoH can limit access to eye care due to distance or expense. They might exacerbate existing chronic conditions due to environmental hazard exposure. They can also interfere with treatment adherence if patients lack the education to understand what they need to do.

“Once you start treating patients, you see there is so much that happens outside of the exam room that has an effect on patients. Most providers aren’t really trained to ask about those factors or do something to address them,” said Diane Russo, OD, MPH, MBA, FAAO, Dipl AAO PH, an associate professor at the New England College of Optometry.

Dr. Russo said many people need more than just unfettered access to eye care. They also need the education, economic stability and social context to support regular eye screenings as well as necessary follow-up care and treatments.

How do SDoH affect eye health?

Many of the SDoH core domains tend to travel together. For example, a patient with poor economic stability may not be able to afford health insurance or vision coverage. That means reduced access to comprehensive eye care or ongoing management for conditions like glaucoma, diabetic retinopathy and cataracts.

If patients are screened and found to have an issue, they may not be able to afford prescribed treatments. Lower socioeconomic status often means that individuals are living in substandard housing or in neighborhoods with higher levels of air pollution. While the exact causes are not known, both have been associated with conditions like age-related macular degeneration (AMD) and poorer vision outcomes.

“You see a trickle-down effect,” said Dr. Russo. “If a person has difficulty affording housing, groceries, and utilities, they will also have difficulty affording routine eye care. And, ultimately, that will negatively impact eye health.”

The effect can also occur in reverse. Untreated vision problems can make it harder to work and earn income, deepening the same instability that limited access to care.

What can be done to improve eye health equity?

While researchers have done a good job of identifying how social drivers can affect health, mitigating those effects is a challenge. Providers are already short on time — and most healthcare workflows are only designed to address clinical needs. Having sensitive conversations with patients about food security, transportation or one’s ability to pay for medications can be difficult.

The first step to address SDoH, according to Drs. Hicks and Russo, is increasing access to affordable eye care. It’s not always easy to find an eye care center that can treat patients with social risk factors. That’s one reason why Dr. Russo would like to see community health centers integrate vision care into their services. These health centers already serve vulnerable patient populations. As a result, they have important resources on hand to help address many SDoH.

“[Community health centers] often have educational handouts to explain care, different resources to help with housing, food availability, paying for utilities and cash assistance,” said Dr. Russo. “And they're likely to have them in more than one language.”

Yet, every eye care professional can help identify and mitigate SDoH when they screen for social risk factors during appointments. This can help them offer their patients more individualized care plans and, in some cases, be reimbursed for their efforts. It can help connect those patients to community services that could help address barriers to care like insurance problems, transportation needs or housing challenges. 

Dr. Hicks recommends that practices designate one staff member to act as a care coordinator. That person can take the time to become familiar with available resources in the area and then provide them to patients.

“We can do more than just screenings or eye exams. We need to be able to help patients, if they need glasses or are diagnosed with an eye condition, manage the next steps,” said Dr. Hicks. “When you have someone who can act as a care coordinator, you can help ensure those next steps are happening.”

Tackling SDoH is not easy — but it is possible. Dr. Russo said that supporting eye health and preventing vision loss starts by understanding the world in which patients live. Increasing access to eye care, eye health education and better vision starts by taking the time to understand how SDoH may be impacting patients. 

“Addressing SDoH is absolutely something within our wheelhouse as eye care providers,” Dr. Russo said. “We need to stop assuming that someone else is handling these issues. Because if we do, they probably aren’t getting done, and our patients’ outcomes are not going to be what we want them to be.”