Publication: MMWR. Morbidity and Mortality Weekly Report
Date published:
Language: English
PMID: 15976
ISSN: 01492195
Journal code: IMMW

In 2000, an estimated 3.4 million U.S. residents aged >40 years were blind or visually impaired (1). Vision problems place a substantial burden on individuals, caregivers, health-care payers, and the U.S. economy, with the total cost estimated at $5 1 .4 billion annually (2). Although regular comprehensive eye examinations are essential for timely treatment of eye disease to maintain vision health, a previous study has shown that substantial percentages of persons do not seek eye care, despite having visual impairment (3). To ascertain why adults aged >40 years with moderate-to-severe visual impairment did not seek eye care in the preceding year, CDC analyzed data for 2 1 states from 2006-2009 Behavioral Risk Factor Surveillance System (BRFSS) surveys. This report summarizes the results of that analysis, which found that eye-care cost or lack of insurance (39.8%) and perception of no need (34.6%) were the most common reasons given for not seeking eye care. Among those aged 40-64 years, cost or lack of health insurance was the most common reason (42.8%); among those aged >65 years, the most common reason was no need (43.8%). Identifying the reasons for unmet eye-care needs might enable development of targeted interventions to improve vision health among those with moderate-to-severe visual impairment.

BRFSS is an annual, state-based, random-digit- dialed telephone survey of the noninstitutionalized U.S. civilian population aged > 1 8 years that provides socio demographic and other information on health behaviors, chronic illness, and access to health care. For this report, CDC analyzed data from the BRFSS Vision Impairment and Access to Eye Care Module, which was implemented for at least 1 year during 2006-2009 by 21 states.* Median response rates among states for BRFSS during that period ranged from 48.2% to 52.5%; median cooperation rates ranged from 73.3% to 75.0%.'

The study sample consisted of 1 1 ,503 adults aged >40 years with self- reported moderate-to-severe visual impairment who had not visited an eye-care professional in the previous year; the sample constituted 6.96% of those interviewed (6.93% weighted). Prevalences for the 21 states overall and for each individual state were calculated from aggregate data collected during the 4-year study period, regardless of whether a state had 1, 2, 3, or 4 years of data. Data were analyzed using statistical software to account for the complex sampling design. Estimates were weighted to account for individual selection probabilities, nonresponse, and poststratification. Chi-square testing was used to determine statistically significant differences (p<0.05).

Self-reported visual impairment was defined using two questions: "How much difficulty, if any, do you have in recognizing a friend across the street?" and "How much difficulty, if any, do you have reading print in a newspaper, magazine, recipe, menu, or numbers on the telephone?" Those who answered "moderate difficulty," "extreme difficulty," or "unable to do because of eyesight" to either of these questions were classified as having moderate-to-severe visual impairment. Respondents also were asked if they had been told by an eye doctor or other health-care professional that they had cataract, glaucoma, age-related macular degeneration, or diabetic retinopathy. Those responding affirmatively were classified as having "any age-related eye disease."

Respondents were asked when was the last time they had their eyes examined by any doctor or eye-care provider. Those reporting >1 year also were asked the main reason for not visiting an eye-care professional in the past 12 months. The seven possible responses were classified into the following four categories: 1) "cost or lack of insurance"; 2) "have not thought of it" or "no reason to go (no problem)"; 3) "do not have/know an eye doctor," "too far/no transportation," or "could not get an appointment"; and 4) "other."

Overall, the most common reason given for not seeking eye care among those with moderate-to-severe visual impairment was cost or lack of insurance (39.8%), followed by no need (34.6%), other (21.1%), and no eye doctor, no transportation, or could not get an appointment (4.5%) (Table 1). The percentage of those reporting cost or lack of insurance as the main reason was greater among adults aged 40-64 years than adults aged >65 years (42.8% versus 23.3%, p<0.001). However, the percentage of those reporting no need to go as the main reason was greater among adults aged >65 years than those aged 40-64 years (43.8% versus 32.9%, p<0.001). A greater percentage of men than women reported no need to go (4 1.7% versus 28.7%, p=0.005), and a greater percentage of those with no age-related eye disease reported no need to go than those with any age-related eye disease (36.9% versus 28.2%, p=0.001) (Table 1).

Among states, the percentage giving cost or lack of insurance as the main reason for not seeking eye care ranged from 2 1.6% (Massachusetts) to 60.4% (Tennessee) among those aged 40- 64 years and from 8.9% (Massachusetts) to 48.0% (Tennessee) among those aged >65 years. The percentage reporting no need ranged from 25.4% (Florida) to 41 .9% (Arizona) among those aged 40-64 years and from 29.7% (West Virginia) to 61.0% (Massachusetts) among those aged >65 years (Table 2).

Editorial Note

The data in this report support previous findings suggesting that lack of health insurance coverage is a major reason why persons with at least some self-reported visual impairment do not seek eye care (4). The data further indicate that the main reasons for not seeking eye care differ by age, sex, the presence of eye disease, and state of residence among persons with moderate-to-severe visual impairment. The large proportion of persons aged >65 years reporting no need as their main reason for not seeking care is of concern because this population has the highest prevalence of visual impairment (4). A possible reason for this is that older adults might regard impairment as a normal part of aging (5).

A previous study also has shown that persons often are not aware of eye health and the need for routine eye examinations because of lack of attention to eye care from primary-care providers (6). Recommendations from primary-care providers can influence patients to receive eye-care services; persons who had visual screening during routine physical examinations had better eye health because of reminders to visit eye specialists (6,7) Public health interventions aimed at heightening awareness among both adults aged >65 years and health-care providers might increase utilization rates among persons with age-related eye diseases or chronic diseases that affect vision such as diabetes.

In this study, men and women reported different main reasons for not seeking care. Men were more likely than women to report no need to seek eye care, and women were more likely than men to report cost or lack of insurance as their main reason. This finding corresponds with results from a previous study showing that women had less financial access to care than men (9). Reasons for not seeking eye care also differed by eye disease status. Not surprisingly, persons with eye disease were less likely to report no need as the main reason for not seeking care. Instead, cost or lack of insurance was the most common reason for those with eye diseases. Previous research has found that populations without insurance that are at high risk for eye diseases are least likely to seek preventive eye care at the recommended frequency (9)

Differences also were observed among states. Among the 21 states, the percentage of respondents reporting cost or lack of insurance as the main reason for not seeking eye care was lowest for both adults aged 40-64 years and >65 years in Massachusetts, the state with the smallest proportion of residents with no health insurance (10). Surveys such as BRFSS that provide state-level data can help policy makers identify potential areas of unmet health-care needs.

The findings in this report are subject to at least three limitations. First, BRFSS data are self-reported, and their accuracy might have been affected by recall, social desirability, and other biases. Second, perceived visual impairment might not be highly correlated with clinically diagnosed impairment using visual acuity measurements. Finally, only 21 states administered the vision module during the study period, so the results might not be representative of the entire U.S. population.

Reducing visual impairment and improving quality of life among persons with impairment should be public health priorities. By determining reasons why persons with moderateto-severe visual impairment do not seek eye care, this report can help shape policy, develop targeted interventions, and disseminate effective public health messages.

* Alabama, Arizona, Colorado, Connecticut, Florida, Georgia, Indiana, Iowa, Kansas, Maryland, Massachusetts, Missouri, Nebraska, New Mexico, New York, North Carolina, Ohio, Tennessee, Texas, West Virginia, and Wyoming.

[dagger] The response rate is the percentage of persons who completed interviews among all eligible persons, including those who were not successfully contacted. The cooperation rate is the percentage of persons who completed interviews among all eligible persons who were contacted.


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2. Prevent Blindness America. The economic impact of vision problems. Available at Vision_Problems.pdf. Accessed May 16, 201 1.

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7. Strahlman E, Ford D, Whelton P, Sommer A. Vision screening in a primary care setting. A missed opportunity? Arch Intern Med 1990; 150:2159-64.

8. Nelson DE, Thompson BL, Bland SD, Rubinson R. Trends in perceived cost as a barrier to medical care, 1991-1996. AmJ Public Health 1999; 89:1410-3.

9. Zhang X, Saaddine JB, Lee PP, et al. Eye care in the United States: do we deliver to high-risk people who can benefit the most from it? Arch Ophthalmol 2007;125:411-8.

10. Long SK, Masi PB. Access and affordability: an update on health reform in Massachusetts, fall 2008. Health AfF (Millwood) 2009;28w578-87.

Author affiliation:

Reported by

Chiu-Fang Chou, DrPH, Cheryl E. S h err od, Xinzhi Zhang, MD, PhD, Kai McKeever Bullard, PhD, John E. Crews, DPA, Lawrence Barker, PhD, Jinan B. Saaddine, MD, Div of Diabetes Transhtion, National Center for Chronic Disease Prevention and Health Promotion, CDC Corresponding contributor: Chiu-Fang Chou, CDC,, 770-488-1267.

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