Coordinated Nationwide Approaches to Promote Eye Health and Reduce Vision Impairment

Abstract

Sight is clearly important to the health and quality of life for children, adults, and seniors, but it has consistently failed to achieve the status of a national health priority. Adults regularly cite vision loss as one of their most feared health conditions; poor vision can hamper a child’s educational, social, and extracurricular opportunities; and vision problems and eye disease can decrease health, increase isolation, and compound the impact of chronic diseases among seniors. The National Academies of Sciences, Engineering, and Medicine (NASEM) released a report in 2016 examining the challenges related to vision and eye health in the American population, the barriers to improving eyesight, and strategies to make this fundamental component of health a national priority. The multidisciplinary committee convened by NASEM produced a set of action steps at the federal, state, and local levels that offer a roadmap to APHA to improve vision and eye health and health equity. Public health advocates must encourage federal, state, and local policymakers to promote population eye and vision health and establish strategies that minimize preventable and correctable vision impairment to achieve greater health equity.

Relationship to Existing APHA Policy Statements

There are no existing policy statements that explicitly and comprehensively relate to the public health problem identified in this statement. Some policy statements approved prior to 1999 that are expected to be automatically archived in the coming year do relate to parts of this statement, but only in very limited ways. This statement is relevant to but does not contradict or supersede the following statements:

• APHA Policy Statement 200028: Ensuring Optimal Vision Performance in Visually At Risk Drivers
• APHA Policy Statement 20002: Reducing the Incidence of Blindness, Lower Extremity Amputation, and Oral Health Complications in Minority Populations Due to Diabetes
• APHA Policy Statement 20011: Improving Early Childhood Eyecare
• APHA Policy Statement 20016: Global Campaign to Eliminate Avoidable Blindness
• APHA Policy Statement 200312: Increasing Access to Vision Rehabilitation
• APHA Policy Statement 20067: Promoting the Use of Protective Eyewear For Children In Sports
• APHA Policy Statement 20071: Preventing Vision Loss Through Smoking Cessation
• APHA Policy Statement 200713: Eye Care in Disaster Preparedness
• APHA Policy Statement 200910: Improving Access to Vision Care in Community Health Centers
• APHA Policy Statement 201118: Preventing Injuries by Banning Consumer Use of Fireworks
• APHA Policy Statement 201112: VISION 2020: Global Campaign to Eliminate Avoidable Blindness
• APHA Policy Statement 20116: Reducing Barriers and Increasing Access to Children’s Vision Care Services

Problem Statement

Problems related to vision and eye health represent a significant health and economic burden in the United States and have a profound impact on the lives of those affected. The sheer numbers show a real and growing public health issue that is even greater when considering the additional effects of poor vision and eye health on education, quality of life, social participation, and other arenas.

Current status of vision and eye health in the United States: While calculating precise estimates regarding the burden of vision impairment in the United States is challenging because nationwide epidemiological data are limited, we do know that at least 6 million Americans suffer from uncorrectable vision impairment or blindness.[1] About 48 million Americans are affected by refractive errors that can be readily corrected, but almost 16 million of them are undiagnosed or otherwise uncorrected.[2] While not all vision loss can be corrected, a set of simple interventions can prevent many Americans from suffering associated decreased independence and quality of life, reduced performance in school, lower wages and job attainment, and increased health costs. Cataracts, glaucoma, age-related macular degeneration, and other diseases affect almost 30 million Americans older than 40 years.[3] Diabetic retinopathy is the leading cause of new cases of blindness among working-age adults.[4] Many of the conditions just described can be prevented or mitigated with early detection and treatment.

As our nation’s population ages, the numbers outlined above are expected to grow. Because eye diseases and conditions become more common in the later years of life, the number of blind and visually impaired people will double by the year 2050 as the U.S. population ages.[1] In the elderly, vision loss is a significant contributor to falls; moreover, it can increase social isolation, reduce an individual’s ability to age in place, and increase the risk for depression.[5] In fact, vision impairment is an independent contributor to earlier mortality.[6]

Americans treasure their ability to see; research consistently reports that loss of vision is among our greatest health fears.[7] As a cornerstone of daily life, the ability to see well strongly impacts everything people do: from a child’s chances for a quality education to an adult’s pursuit of employment and hopes for an independent and enjoyable retirement. Consequently, loss of vision carries a heavy toll for both individuals and society. People encountering vision loss face a future more likely to be burdened by depression, a higher risk of falls, loss of driving privileges, social isolation, and poverty.[8]

Access and utilization: Data on the percentage of people undergoing eye examinations, the gold standard in eye care for prevention, diagnosis, and treatment of diseases and conditions, are limited. Medicare claims show that about 45% of Medicare beneficiaries had an eye exam in 2015.[9] Because the risk of eye problems increases with age, it might be expected that use of services is highest in this population; however, existing data are not sufficient to confirm such a hypothesis.

Among patients with limited access to health care or low socioeconomic status, such as those primarily served by federally qualified health centers, access to comprehensive eye care can be limited. According to the Uniform Data System, health centers employed only 407 full-time-equivalent optometrists and ophthalmologists (the professionals qualified to provide comprehensive eye care) in 2018. In that same year, less than 1% of health center patients received vision care services. Comparatively, health centers employed approximately 5,000 full-time-equivalent dentists in 2018, and about 14% of patients received dental care.[10]

Medical insurance plans, including Medicare, typically do not cover comprehensive eye exams for asymptomatic patients who are not in a specific high-risk category, although many patients do not realize that they are experiencing symptoms of a vision or eye health problem until they receive a comprehensive exam. Twenty-three percent of privately insured Americans had access to vision care benefits in 2017.[11] In comparison with adults, children have relatively high rates of insurance coverage for vision and eye care. In 2017, 98.7% of children were insured.[12] Among almost all children, medical insurance coverage includes vision coverage. In Medicaid, Early and Periodic Screening, Diagnosis, and Treatment includes screening, diagnosis, and treatment for vision conditions, including eye examinations and eyeglasses. Children receiving insurance through CHIP (Children’s Health Insurance Program) have access to comparable eye care services. Finally, the essential health benefits provision of the Affordable Care Act required that qualified health plans include pediatric vision services; in many states, this benefit was defined according to what was available through CHIP. Among most children with private insurance, that means coverage for one comprehensive eye examination and one pair of glasses per year, although associated cost sharing is not dictated. In addition, whether in the case of private insurance or public insurance, cost sharing, the exact details of the benefit, and related limitations vary from plan to plan and state to state.[13]

Children and vision: Vision and eye health problems affect children as well. An estimated one out of five preschool children in the United States have vision problems,[14–17] and more than one in four school-aged children wear corrective eyewear.[18] Left unidentified and uncorrected, vision problems can challenge a child’s general development,[19] school performance,[20] social interactions, and self-esteem.[21] Visual skills are the foundation for nearly all tasks a child performs in the classroom.

Childhood vision disorders, especially those that remain untreated, often manifest as problems well into adulthood, affecting an individual’s level of education, employment opportunities, and social interactions.[22] In some cases, students with undiagnosed vision impairment may be misdiagnosed with learning disabilities because of undetected vision problems.[23,24] As children have only a few short years to learn to read before they read to learn, early diagnosis and treatment of vision impairments is crucial. Early intervention is critical to preserve vision and can bolster a child’s self-esteem, elevate reading comprehension, boost test scores, and reduce behavior problems.

Economic burden: Economically, vision loss and eye disease were estimated to cost the United States $145 billion in 2014, making them (in combination) the fifth most expensive health condition. The country’s aging and changing demographics could quintuple this economic toll to $717 billion a year by 2050.[25] The financial well-being of each individual who experiences vision loss is likely to deteriorate as well. Early intervention, diagnosis, and treatment can often prevent vision loss and could reduce the economic burden resulting from preventable chronic visual impairment.[26]

Disproportionate impact: The effects of vision and eye health issues are widespread across the American population, but they are not distributed equally. Race, ethnicity, sex, age, socioeconomic status, and insurance status all have an impact on an individual’s risk of vision problems and eye disease. Race/ethnicity and sex can increase an individual’s risk for specific eye diseases, but socioeconomic status and insurance status can also affect any resulting visual impairment. For example, the prevalence of cataracts is consistently highest in older White populations. However, vision impairment from untreated cataracts occurs more frequently in minority populations.[27] Diabetic retinopathy disproportionally impacts minority populations[1] and is more common in males.[28]

For public health purposes, it may be more useful to assess the disproportionate effects of vision impairment and blindness that result from vision problems and eye diseases than the varying prevalence rates of individual conditions. The resulting vision impairment or blindness is the factor with the greatest practical impact on individuals. African Americans older than 40 years have a higher prevalence of uncorrectable vision impairment and blindness than all other groups. However, non-Hispanic White females make up the largest portion of Americans with vision impairment and blindness.[1] Minority populations are at risk for poorer health overall,[29] and many of the factors that relate to overall health have similar effects when considering eye and vision health. Vision impairment and blindness have a disproportionate impact on female and minority racial/ethnic groups, although there are variations within subpopulations.

Socioeconomic status is an important determinant of visual impairment.[30] No matter their age, Americans who are poor, have less education, or are unemployed have a greater risk of developing eye disease and vision impairment.[31] Individuals with lower incomes and a lower level of educational attainment have been shown to be less likely to report having an eye care visit in the preceding 12 months.[32] This risk is also clear for children; children in low-income homes have a greater risk of vision loss and untreated vision impairment. A child living below the federal poverty line has almost double the risk of being visually impaired relative to a child living at 200% of the federal poverty line or higher.[33]

A diverse workforce improves access to care among underserved populations. African American, Hispanic, and Native American physicians have been shown to be more likely to practice in underserved communities and to serve minority patients, and African American and Hispanic physicians, as well as women, are more likely to care for the poor and those with Medicaid coverage.[34] The fields of both optometry and ophthalmology struggle with a lack of diversity, and African American, Hispanic, and Native American providers in these disciplines represent 5% or less of the total number.[13]

The disproportionate impact of vision problems and eye disease is consistent with that of overall health status, health outcomes, and use of health services. APHA has long recognized the imperative of promoting health equity, and this must include eye and vision health.

The scope of vision problems in the United States is large and demands a coordinated approach to ensure efficient use of available resources. The federal government bears a significant portion of the burden of vision and eye health problems, largely though not exclusively through direct health costs. It also has the capacity to coordinate a nationwide strategy. However, it has not yet done so. At the Centers for Disease Control and Prevention (CDC), perhaps the most likely agency to coordinate a population health approach, vision and eye health consistently fail to reach the list of agency-wide priorities. In fact, the CDC addresses vision and eye health primarily through a program within the Division of Diabetes Translation—the Vision Health Initiative—with a dedicated budget of $1 million and control of an additional $4 million dedicated to glaucoma.[35] The CDC also has a small team within the Waterborne Disease Prevention Branch to address safe contact lens wear. Various programs at the Health Resources and Services Administration (HRSA) have an impact on vision and eye health, and the National Eye Institute at the National Institutes of Health is dedicated to research related to vision and eye health. However, these fragmented and mostly small programs do not represent a coordinated strategy.

Evidence-Based Interventions and Strategies

Addressing vision and eye health at a population level requires the use of fundamental public health strategies that have been unavailable or not used at a sufficient scale in the past. As noted in the National Academies of Sciences, Engineering, and Medicine (NASEM) report Making Eye Health a Population Health Imperative: Vision for Tomorrow, “the long-term goal of a population health approach for eye and vision health should be to transform vision impairment from a common to a rare condition, reducing associated health inequities.”[13] For individuals, eliminating or minimizing vision impairment or blindness means taking proper preventive measures and receiving timely comprehensive eye care including diagnosis, treatment, and management of eye disease or visual conditions, as well as appropriate correction of refractive errors or visual dysfunction.[13] At the population level, reducing vision impairment and associated health inequities requires a more expansive health model that aims to improve vision and eye health across the life span.

This population health model, as described in the NASEM report, includes facilitating public awareness, generating evidence to guide policy decisions and evidence-based actions, expanding access to appropriate clinical care, enhancing public health capacity to support vision-related activities, and promoting community action to encourage vision- and eye-healthy environments.

Facilitating public awareness: Vision and eye health, as described in the problem statement, present a clear public health challenge that affects a large number of people, with significant impacts on morbidity, quality of life, and cost that have been and will continue to grow as the population ages. Americans surveyed in 2016 indicated that vision impairment and blindness were substantial personal concerns.[7] However, vision and eye health are unrepresented on major national health priority lists and do not appear to have reached the level of national priority they deserve.

Public awareness campaigns are a long-standing way to increase public visibility and priority for specific health issues. When structured properly, using the right resources to reach the right audiences (considering, for example, literacy skills and unequal access to resources), public awareness campaigns have been shown to improve awareness of specific issues.[36] These campaigns can include a variety of activities, including mass media and social media initiatives and targeted calls to action by federal officials. A call to action by the U.S. Department of Health and Human Services, usually by the surgeon general, is a science-based means of stimulating nationwide action to solve a major public health problem.

Increasing public knowledge about eye and vision health, common risk factors, early signs of disease, and what steps can be taken to reduce the risk of vision conditions or eye disease and decrease the impact of vision impairment is an effective but not independently sufficient step in enhancing population knowledge as part of a population health approach to improving national vision and eye health.

Generating evidence: Evidence-based policy-making and decision making rely on the existence of reliable, accepted evidence. Unfortunately, basic epidemiological data regarding rates of vision impairment and eye disease in the United States are unavailable in the peer-reviewed literature.[13] Surveillance is one of the foundations of public health and the basis for policy-making and decision making.[37] The development of a comprehensive eye and vision health surveillance system that relies, where possible, on existing national surveys could provide a wealth of useful data to inform the clinical practice of eye and vision health as well as population health. Relying on currently available data, the CDC has engaged in a collaborative effort to develop the Vision and Eye Health Surveillance System, and it is in the early years of making these data publicly available.[13] However, current data are limited, in part because national health surveys do not address vision and eye health or gather only very limited information that does not allow for monitoring the prevalence of or trends in eye health indicators. Better incorporation of eye-related questions into major national health surveys and inclusion of eye examinations in routine surveillance programs would produce large quantities of usable data that could enrich the CDC’s efforts.

The limitations of existing epidemiological data related to vision and eye health have in turn limited research on public health approaches to improving vision and eye health, health services research (particularly among high-risk populations), and long-term studies on risk factors and causes of vision impairment. Although the development of a surveillance system is a prerequisite for the kind of research needed, the conception of a research agenda by national leaders in eye and vision health could guide the conduct of research in the future to best inform policy, population health, and clinical care.

Currently, research into vision and eye health is performed by several different federal agencies and partners.[38] However, coordination across agencies is limited, which contributes to inefficient use of resources. Better coordination, steered by a holistic research agenda that addresses gaps in knowledge and information, could result in better care and improved health at the individual and population levels.

Expanding access: Access to high-quality, timely, and appropriate care is key to individuals’ overall health. Access to care has consistently been shown to improve health outcomes.[39] In terms of eye and vision care, reliable access to care can lead to earlier detection of eye diseases and vision impairment and better visual and health outcomes.[40] Access to care assumes that, in addition to the availability of a health care provider and the ability of the patient to pay for care, the care delivered is consistent with the best available research and delivered at the right time.

One of the common ways health care providers receive guidance on the most current best practices is through clinical practice guidelines. According to NASEM, “Clinical Practice Guidelines (CPGs) are intended to provide a systematic aid to making such complex medical decisions. When rigorously developed using a transparent process that combines scientific evidence, clinician experiential knowledge, and patient values, CPGs have the potential to improve many clinician and patient healthcare decisions, and enhance healthcare quality and outcomes.”[41] The vision and eye care provider community does not operate on a consistent set of clinical practice guidelines establishing agreed-upon standards of care. Such guidelines could facilitate not only clinical care but also policy decisions (e.g., population health policies and insurance coverage).

The availability of eye care providers is one component of access to eye care. According to recent research, only 12% of U.S. counties, home to 1% of the U.S. population, do not have a practicing optometrist or ophthalmologist.[42] Further research has shown that 90% of Medicare beneficiaries live within a 15-minute drive of a doctor of optometry and a 30-minute drive of an ophthalmologist. As a result of data limitations, these numbers may underestimate the overall supply of eye doctors.[43] In addition, the HRSA no longer calculates the Vision Health Professions Shortage Area designation, which could provide an authoritative assessment of workforce sufficiency based on number of providers, population density, and other factors. Overall, it seems that the eye care workforce in the United States might be adequate to provide sufficient care if all providers were practicing to full capacity, but additional data could provide clarity on this question. However, rates of undiagnosed or untreated eye and vision problems confirm the fact that workforce adequacy alone would not guarantee access to or receipt of care.

Not all patients have access to transportation, and many are not aware of their eye care needs. Insurance coverage has a documented relationship to overall health and to eye and vision health.[13] Increasing the percentage of the population with insurance coverage and vision coverage is a necessary but not sufficient step in improving access to and receipt of care for patients. Even among patients with insurance coverage for comprehensive eye care, out-of-pocket costs can make receipt of care nearly impossible. Expanded access to Medicaid and other federally supported health insurance options has been shown to reduce the overall uninsured rate, which can improve access to medical eye care.

Transportation can be a barrier to routine medical care for any health condition. Patients with existing visual impairments may have greater struggles. Medicaid offers nonemergency medical transportation for beneficiaries who meet certain criteria. This service has been shown to increase the number of completed recommended visits for chronic conditions among Medicaid beneficiaries.[44] A growing number of Medicare Advantage beneficiaries also have access to this benefit, although availability is limited among the privately insured.

Community health centers have been shown to reduce health care costs for populations they serve and to decrease acute care episodes among their patients.[45] As noted in the problem statement, the availability of comprehensive vision care services in community health centers is quite low. Additional investment in health center expansion with a priority on vision services could drive health centers to invest in increasing the number of on-site eye care providers.

Among both individuals and communities, access to care is improved by the development of a diverse workforce that reflects the background and experiences of the American population. A diverse workforce is more likely to be a culturally competent workforce, although cultural competence must also remain a component of health professional education.[34] A culturally competent workforce has been shown to reduce health care disparities among minority populations.[46]

Enhancing public health capacity: Although national and federal leadership often directs population health efforts, that work would be unsuccessful without collaboration with state and local public health departments. Public health departments “serve as key community conveners to coordinate responses that address multiple determinants of health and chronic conditions, such as vision impairment.”[13] Coordinating with state and local public health departments is a common way to improve the health of a community and can build on an effective medical care system to undertake preventive efforts connecting people to care, to measure the quality of care, and to take action on social determinants of health.[47]

However, limited and shrinking investments in public health departments mean that many such entities struggle to meet core requirements and state mandates.[48] Increased investment in public health departments could allow them to take on evidence-based vision and eye health activities that are appropriate for their communities.

Promoting community action: Eye and vision health are determined by more than just an individual’s genetics and medical care. Social determinants of health and environmental factors are among the variables that change from one community to the next and can greatly affect eye and vision health. For example, tobacco use can increase the risk of age-related macular degeneration and cataracts, among other health effects.[49] The quality of life of individuals with uncorrectable vision impairment can also be greatly improved by increasing and improving public transportation to accommodate their needs.[50] Engaging communities in the development of policies to address these factors in their own environments can improve policy quality and targeting, increase community buy-in and long-term success, and enhance the reach of educational programs.[51]

Opposing Arguments/Evidence

The most substantial opposition to tackling eye and vision health at the population level comes from those who would support other priorities. This is not to oppose efforts to improve vision and eye health, but to elevate other priorities for limited funding and attention. The opposing argument assumes that vision and eye health do not present a public health problem on the same scale as other acute or chronic diseases or conditions. Although vision and eye health lack the obvious impact on population mortality of, for example, opioid overdoses or infectious disease, vision impairment has in fact been shown to increase risk of death even after adjustment for other factors.[6] The problem statement clearly articulates the scope of vision and eye health problems as a serious issue at the population health level.

Past public health efforts to improve vision and eye health have been limited at the most basic level by inadequate and incomplete epidemiological data resulting from a lack of comprehensive data collection. This policy statement recommends, among other elements, the creation of a comprehensive surveillance system for eye and vision health, which would offer the basic level of data required to assess the impact of other policies and initiatives to improve vision and eye health.

In addition, the vision and eye health community has failed to unite around cohesive messaging and priorities related to vision and eye health.[13] Although this is not necessarily a prerequisite for implementation of the action steps below, unified stakeholders could facilitate progress. Some of the stakeholders in the vision and eye health community do hold opposing views on specific issues, but they share many common goals that could be implemented more easily.

Action Steps

Significant leadership in the area of public health and eye and vision health comes from the 2016 NASEM report Making Eye Health a Population Health Imperative: Vision for Tomorrow. The following action steps are consistent with the recommendations of NASEM and widely supported by others in the eye and vision health community. They support the achievement of the strategies described here and would contribute to improvements in eye and vision health at the population and individual levels.

APHA recommends that:

1. The secretary of the U.S. Department of Health and Human Services issue a call to action to motivate nationwide efforts toward achieving a reduction in the burden of vision impairment across the life span of people in the United States.
2. The secretary of the U.S. Department of Health and Human Services, in collaboration with other federal agencies and departments, nonprofit and for-profit organizations, professional organizations, employers, state and local public health agencies, and the media, launch a coordinated, evidence-based public awareness campaign to promote policies and practices that encourage eye and vision health across the life span, reduce vision impairment, and promote health equity. This campaign should target various stakeholders including the general population, care providers and caretakers, public health practitioners, policymakers, employers, and community and patient liaisons and representatives.
3. The Centers for Disease Control and Prevention continue to build on and develop the Vision and Eye Health Surveillance System. The CDC should encourage the development, deployment, and standardization of needed questions about vision and eye health and care in major health surveys to provide robust data for the system.
4. The U.S. Department Department of Health and Human Services create an interagency workgroup, including a wide range of public, private, and community stakeholders, to develop a common research agenda and coordinated eye and vision health research and demonstration grant programs that target leading causes, consequences, and unmet needs with respect to vision impairment.
5. The U.S. Department of Health and Human Services convene one or more panels— comprising members of professional organizations, researchers, public health practitioners, patients, and other stakeholders—to develop a single set of evidence-based clinical and rehabilitation practice guidelines and measures that can be used by eye care professionals, other care providers, and public health professionals to prevent, screen for, detect, monitor, diagnose, and treat eye and vision problems. These guidelines and supporting evidence should be used to drive payment policies, including coverage determinations for corrective lenses and visual assistive devices following a diagnosed medical condition (e.g., refractive error).
6. To enable the health care and public health workforce to meet the eye care needs of a changing population and to coordinate responses to vision-related health threats, professional education programs proactively recruit and educate a diverse workforce and incorporate prevention and detection of visual impairments, population health, and team care coordination as part of core competencies in applicable medical and professional education and training curricula. Individual curricula should emphasize proficiency in culturally competent care for all populations.
7. Eye care services also be incorporated into settings that provide care for underserved patients, such as community health centers. The Health Resources and Services Administration should ensure that expansion grant funding offered to community health centers and any other programs intended to develop additional capacity for care in underserved settings is available for eye care services. State and local public health departments should partner with health care systems to align public health and clinical practice objectives, programs, and strategies about eye and vision health.
8. To build state and local public health capacity, the Centers for Disease Control and Prevention prioritize and expand its vision grant program in partnership with state-based chronic disease programs and other clinical and nonclinical stakeholders.
9. Communities work with state and local health departments to translate a broad national agenda promoting eye and vision health into well-defined actions. These actions should encourage policies and conditions that improve eye and vision health and foster environments that minimize the impact of vision impairment, considering the community’s needs, resources, and cultural identity.
10. Federal and state insurance authorities encourage coverage of comprehensive eye care services for all beneficiaries in both public and private insurance programs.

References

1. Varma R, Vajaranant T, Burkemper B, et al. Visual impairment and blindness in adults in the United States: demographic and geographic variations from 2015 to 2050. JAMA Ophthalmol. 2016;134:802–809.

2. Vitale S, Ellwein L, Cotch M, Ferris F, Sperduto R. Prevalence of refractive error in the United States, 1999–2004. Arch Ophthalmol. 2008;126:1111–1119.

3. National Eye Institute. Prevalence of adult vision impairment and age-related eye diseases in America. Available at: https://nei.nih.gov/. Accessed December 17, 2019.

4. Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Available at: http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf. Accessed December 17, 2019.

5. Choi HG, Lee MJ, Lee SM. Visual impairment and risk of depression: a longitudinal follow-up study using a national sample cohort. Sci Rep. 2018;8:2083.

6. Siantar RG, Cheng C-Y, Gemmy Cheung CM, et al. Impact of visual impairment and eye diseases on mortality: the Singapore Malay Eye Study (SiMES). Sci Rep. 2015;5:16304

7. Scott AW, Bressler NM, Folkes S, Wittenborn JS, Jorkasky J. Public attitudes about eye and vision health. JAMA Ophthalmol. 2016;134:1111–1118.

8. Crews JE, Chou CF, Zack MM, et al. The association of health-related quality of life with severity of visual impairment among people aged 40–64 years: findings from the 2006–2010 Behavioral Risk Factor Surveillance System. Ophthalmic Epidemiol. 2016;23:145–153.

9. Centers for Disease Control and Prevention, Vision Health Initiative. Vision and Eye Health Surveillance System. Available at: https://www.cdc.gov/visionhealth/vehss/project/index.html. Accessed December 17, 2019.

10. Health Resources and Services Administration. Table 5: staffing and utilization. Available at: https://bphc.hrsa.gov. Accessed December 17, 2019.

11. Bureau of Labor Statistics. Vision care plans available to 23 percent of private industry workers in March 2017. Available at: https://www.bls.gov. Accessed December 17, 2019.

12. Berchick E, Hood E, Barnett J. Health Insurance Coverage in the United States: 2017. Washington, DC: U.S. Government Printing Office; 2018.

13. National Academies of Sciences, Engineering, and Medicine. Making Eye Health a Population Health Imperative: Vision for Tomorrow. Washington, DC: National Academies Press; 2016.

14. Multi-Ethnic Pediatric Eye Disease Study Group. Prevalence of myopia and hyperopia in 6- to 72-month-old African American and Hispanic children: the Multi-Ethnic Pediatric Eye Disease Study. Ophthalmology. 2010;117:140–147.

15. Wen G, Tarczy-Hornoch K, McKean-Cowdin R, et al. Prevalence of myopia, hyperopia, and astigmatism in non-Hispanic White and Asian children: Multi-Ethnic Pediatric Eye Disease Study. Ophthalmology. 2013;120:2109–2116.

16. Multi-Ethnic Pediatric Eye Disease Study Group. Prevalence of amblyopia and strabismus in African American and Hispanic children ages 6 to 72 months: the Multi-Ethnic Pediatric Eye Disease Study. Ophthalmology. 2008;115:1229–1236.

17. McKean-Cowdin R, Cotter SA, Tarczy-Hornoch K, et al. Prevalence of amblyopia or strabismus in Asian and non-Hispanic white preschool children: Multi-Ethnic Pediatric Eye Disease Study. Ophthalmology. 2013;120:2117–2124.

18. Centers for Disease Control and Prevention. Percentage of children aged 6–17 years who wear glasses or contact lenses, by sex and age group—National Health Interview Survey, 2016. MMWR Morb Mortal Wkly Rep. 2017;66:917.

19. Roch-Levecq AC, Brody BL, Thomas RG, Brown SI. Ametropia, preschoolers’ cognitive abilities, and effects of spectacle correction. Arch Ophthalmol. 2008;126:252–258.

20. Goldstand S, Koslowe KC, Parush S. Vision, visual-information processing, and academic performance among seventh-grade schoolchildren: a more significant relationship than we thought? Am J Occup Ther. 2005;59:377–389.

21. Mojon-Azzi SM, Kunz A, Mojon DS. Strabismus and discrimination in children: are children with strabismus invited to fewer birthday parties? Br J Ophthalmol. 2011;95:473–476.

22. Davidson S, Quinn GE. The impact of pediatric vision disorders in adulthood. Pediatrics. 2011;127:334–339.

23. DeCarlo DK. ADHD and vision problems in the National Survey of Children’s Health. Optom Vis Sci. 2016;93:459–465.

24. Solé Puig M. Attention-related eye vergence measured in children with attention deficit hyperactivity disorder. PLoS One. 2015;10:e0145281.

25. Wittenborn J, Rein D. The Future of Vision: Forecasting the Prevalence and Cost of Vision Problems. Chicago, IL: University of Chicago; 2014.

26. Wittenborn J, Rein D. The potential costs and benefits of treatment for undiagnosed eye disorders. Available at: http://www.nationalacademies.org. Accessed December 17, 2019.

27. Zambelli-Weiner A, Crews J, Friedman D. Disparities in adult vision health in the United States. Am J Ophthalmol. 2012;154(suppl 6):S23–S30.

28. Zetterberg M. Age-related eye disease and gender. Maturitas. 2016;83:19–26.

29. Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press; 2003

30. Sommer A, Tielsch J, Katz J, et al. Racial differences in the cause-specific prevalence of blindness in East Baltimore. N Engl J Med. 1991;325:1412–1417.

31. Ko F, Vitale S, Chou C, Cotch M, Saaddine J, Friedman D. Prevalence of nonrefractive visual impairment in US adults and associated risk factors, 1999–2002 and 2005–2008. JAMA. 2012;308:2361–2368.

32. Zhang X, Saaddine J, Chou C, et al. Vision health disparities in the United States by race/ethnicity, education, and economic status: findings from two nationally representative surveys. Am J Ophthalmol. 2012;154(suppl 6):S53–S62.

33. Cotch M, Klein R, Brett K, Ryskulova A. Visual impairment and use of eye-care services and protective eyewear among children—United States, 2002. MMWR Morb Mortal Wkly Rep. 2005;54:425–429.

34. Cohen J, Gabriel B, Terrell C. The case for diversity in the health care workforce. Health Aff. 2002;21:90–102.

35. Centers for Disease Control and Prevention. FY2019 operating plan. Available at: https://www.cdc.gov. Accessed December 17, 2019.

36. Snyder LB, Hamilton MA, Mitchell EW, Kiwanuka-Tondo J, Fleming-Milici F, Proctor D. A meta-analysis of the effect of mediated health communication campaigns on behavior change in the United States. J Health Commun. 2004;9(suppl 1):71–96.

37. Lee L, Teutsch S, Thacker S, Louis M, eds. Principles and Practice of Public Health Surveillance. 3rd ed. New York, NY: Oxford University Press; 2010.

38. Centers for Disease Control and Prevention. Vision Health Initiative. Available at: http://www.cdc.gov/visionhealth/about/index.htm. Accessed December 17, 2019.

39. Guttmann A. International perspectives on primary care access, equity, and outcomes for children. Pediatrics. 2016;137:1–3.

40. Gilbert C. The importance of primary eye care. Community Eye Health. 1998;11:17–19.

41. Institute of Medicine Committee on Standards for Developing Trustworthy Clinical Practice Guidelines. Clinical Practice Guidelines We Can Trust. Washington, DC: National Academies Press; 2011.

42. American Optometric Association Health Policy Institute. County data demonstrate eye care access nationwide. Available at: https://www.aoa.org. Accessed December 17, 2019.

43. Lee CS, Morris A, Van Gelder RN, Lee AY. Evaluating access to eye care in the contiguous United States by calculated driving time in the United States Medicare population. Ophthalmology. 2016;123:2456–2461.

44. Thomas L, Wedel K. Nonemergency medical transportation and health care visits among chronically ill urban and rural Medicaid beneficiaries. Soc Work Public Health. 2014;29:629–639.

45. Ku L, Richard P, Dor A, Tan E, Shin P, Rosenbaum S. Using Primary Care to Bend the Curve: Estimating the Impact of a Health Center Expansion on Health Care Costs. Washington, DC: George Washington University; 2009.

46. Betancourt JR. Improving Quality and Achieving Equity: The Role of Cultural Competence in Reducing Racial and Ethnic Health Disparities in Health Care. New York, NY: Commonwealth Fund; 2006.

47. Improving the Nation’s Vision Health: A Coordinated Public Health Approach. Atlanta, GA: Centers for Disease Control and Prevention; 2007.

48. Jacobson P, Wasserman J, Wu H, Lauer J. Assessing entrepreneurship in governmental public health. Am J Public Health. 2015;105(suppl 2):S318–S322.

49. Ye J, He J, Wang C, et al. Smoking and risk of age-related cataract: a meta-analysis. Invest Ophthalmol Vis Sci. 2012;53:3885–3895.

50. Montarzino A, Robertson B, Aspinall P, et al. The impact of mobility and public transport on the independence of visually impaired people. Vis Impairment Res. 2007;9:2–3.

51. Rifkin SB. Examining the links between community participation and health outcomes: a review of the literature. Health Policy Plann. 2014;29::ii98–ii106.