Visual Impairment and Blindness in Spanish Adults: Geographic Inequalities Are Not Explained by Age or Education

doi:10.1016/j.ophtha.2013.07.017

Ophthalmology

Volume 121, Issue 1, January 2014, Pages 408-416

https://doi.org/10.1016/j.ophtha.2013.07.017 Get rights and content

Objectives

The objectives of this study were to examine for the first time the prevalence of visual impairment and blindness among adults in Spain, to explore regional differences, and to assess whether they may vary as a function of sex or be explained by age and individual or regional socioeconomic position.

Design

Data were obtained from the 2008 Spanish Survey on Disability, Personal Autonomy, and Dependency Situations, a cross-sectional survey based on a representative sample of the noninstitutionalized population of Spain.

Participants

The sample was composed of 213 626 participants aged ≥15 years (103 093 men and 110 533 women); 360 were blind (160 men and 200 women), 4048 had near visual impairment (1397 men and 2651 women), and 4034 had distance visual impairment (1445 men and 2589 women).

Methods

The prevalence of near and distance visual impairment was calculated for each region. Multiple logistic regression models were fitted to calculate odds ratios and 95% confidence intervals. All analyses were stratified by sex.

Main Outcome Measures

Visual impairment was based on 3 questions aimed at identifying blindness and near and distance visual impairment.

Results

The prevalence (percentage) of blindness was 0.17 (men, 0.16; women, 0.18): 1.89 for near visual impairment (men, 1.36; women, 2.40), 1.89 for distance visual impairment (men, 1.40; women, 2.34), and 2.43 for any visual impairment (men, 1.81; women, 3.02). Regional inequalities in the prevalence of visual impairment were observed, correlated with regional income, and the prevalence was consistently higher among women than men. The magnitude of the inequalities remained after adjusting for age and educational level, and a north-to-south pattern of increasing prevalence was observed.

Conclusions

Regional and sex inequalities in the prevalence of visual impairment and blindness were observed in Spain, with a north-to-south gradient of increasing prevalence that was not explained by age or individual educational level but was correlated with regional level of economic development. Factors that could be prioritized for future policies and research include differential regional economic development, rural environment, quality of eye care services, diabetes, ultraviolet light exposure, or gender inequalities in diagnostic and therapeutic health care.

Section snippets

Sample

Data were obtained from the 2008 Spanish Survey on Disability, Personal Autonomy and Dependency Situations, a cross-sectional survey based on a representative sample of the noninstitutionalized population of Spain. The questionnaire included self-reported information on visual impairment and sociodemographic data. The sample was selected using a multiple-stage random sample strategy. The first-stage units were census tracts, and the second-stage units were family households. One adult aged ≥15

Description of the Sample and General Prevalence

Descriptive statistics for the entire sample are shown in Table 1. The overall prevalence of blindness was 0.17% (men, 0.16%; women, 0.18%): 1.89% for near visual impairment (men, 1.36%; women, 2.40%), 1.89% for distance visual impairment (men, 1.40%; women, 2.34%), and 2.43% for any visual impairment (men, 1.81%; women, 3.02%). People with visual impairment had a different sociodemographic profile compared with others. Distribution of visual impairment was higher among individuals aged more

Discussion

The study has produced 4 main findings: (1) There are regional inequalities in the prevalence of visual impairment in Spain, an example of a high-income country; (2) the prevalence of visual impairment and blindness among women was consistently higher than among men in most regions; (3) these inequalities remained after adjusting for age and education, and prevalence was correlated with regional GDP; and (4) a north-to-south pattern of increasing prevalence was observed.

This study was based on

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To evaluate visual performance and factors associated with abnormal vision in patients screened for frailty at the Geriatric Frailty Clinic (GFC) for Assessment of Frailty and Prevention of Disability at Toulouse University Hospital.
Retrospective, observational cross-sectional, single-centre study.
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Patients were screened for frailty during a single-day hospital stay between October 2011 and October 2014 (n = 1648).
Collected medical records included sociodemographic data (including living environment and educational level), anthropometric data, and clinical data. The general evaluation included the patient's functional status using the Activities of Daily Living (ADL) scale and the Instrumental Activity of Daily Living (IADL) scale, the Mini-Mental State Examination (MMSE) for cognition testing, and the Short Physical Performance Battery (SPPB) for physical performance. We also examined Body Mass Index (BMI), the Mini-Nutritional Assessment (MNA), and the Hearing Handicap Inventory for the Elderly Screening (HHIE-S) tool. The ophthalmologic evaluation included assessing visual acuity using the Snellen decimal chart for distant vision, and the Parinaud chart for near vision. Patients were divided into groups based on normal distant/near vision (NDV and NNV groups) and abnormal distant/near vision (ADV and ANV groups). Abnormal distant or near vision was defined as visual acuity inferior to 20/40 or superior to a Parinaud score of 2, in at least one eye. Associations with frailty-associated factors were evaluated in both groups.
The mean age of the population was 82.6 ± 6.2 years. The gender distribution was 1,061 females (64.4%) and 587 males (35.6%). According to the Fried criteria, 619 patients (41.1%) were pre-frail and 771 (51.1%) were frail. Distant and near vision data were available for 1425 and 1426 patients, respectively. Distant vision was abnormal for 437 patients (30.7%). Near vision was abnormal for 199 patients (14%). Multiple regression analysis showed that abnormal distant vision as well as abnormal near vision were independently associated with greater age (P < 0.01), lower educational level (P < 0.05), lower performance on the MMSE (P < 0.001), and lower autonomy (P < 0.02), after controlling for age, gender, educational level, Fried criteria, and MMSE score.
The high prevalence of visual disorders observed in the study population and their association with lower autonomy and cognitive impairment emphasises the need for systematic screening of visual impairments in the elderly. Frailty was not found to be independently associated with abnormal vision.
Age-related eye disease and gender
2016, Maturitas
Citation Excerpt :
Several studies have demonstrated lower diagnostic and therapeutic efforts in women [91,92]. Rius et al. demonstrated a higher disparity between diagnosis of cataract and rates of surgery among women than men, indicating that more women were waiting for cataract extraction, thus a lower therapeutic effort [93]. Since cataract is the leading cause of blindness worldwide, gender inequity in access to cataract surgery is a major cause of the higher prevalence of visual impairment and blindness in women [94,95].
Worldwide, the prevalence of moderate to severe visual impairment and blindness is 285 millions, with 65% of visually impaired and 82% of all blind people being 50 years and older. Meta-analyses have shown that two out of three blind people are women, a gender discrepancy that holds true for both developed and developing countries. Cataract accounts for more than half of all blindness globally and gender inequity in access to cataract surgery is the major cause of the higher prevalence of blindness in women. In addition to gender differences in cataract surgical coverage, population-based studies on the prevalence of lens opacities indicate that women have a higher risk of developing cataract. Laboratory as well as epidemiologic studies suggest that estrogen may confer antioxidative protection against cataractogenesis, but the withdrawal effect of estrogen in menopause leads to increased risk of cataract in women. For the other major age-related eye diseases; glaucoma, age-related macular degeneration (AMD) and diabetic retinopathy, data are inconclusive. Due to anatomic factors, angle closure glaucoma is more common in women, whereas the dominating glaucoma type; primary open-angle glaucoma (POAG), is more prevalent in men. Diabetic retinopathy also has a male predominance and vascular/circulatory factors have been implied both in diabetic retinopathy and in POAG. For AMD, data on gender differences are conflicting although some studies indicate increased prevalence of drusen and neovascular AMD in women. To conclude, both biologic and socioeconomic factors must be considered when investigating causes of gender differences in the prevalence of age-related eye disease.
Inequities in visual health and health services use in a rural region in Spain
2018, Gaceta Sanitaria
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Live in rural areas has been shown as a risk factor for certain common eye conditions such as cataracts or diabetic retinopathy compared to urban populations.7 During the last decade, the prevalence of visual impairment is growing in Spain and is unequally distributed among groups with an increased risk in lower-income regions.8 National surveys on the prevalence of blindness and visual disability in Spain show that these problems affect more than 900,000 people, of whom 69% are over age 65 and two thirds are women;9 life expectancy may contribute to this gap as in Spain is greater in women than in men, 86.2 years versus 80.4 years.10
To analyse perceived visual health and health services use in a rural population in relation to socioeconomic characteristics and compared with the general population in Spain.
Cross-sectional study in a rural population using a structured questionnaire including questions comparable to the Spanish National Health Survey (2012). A descriptive analysis was carried out through the calculation of frequencies and prevalence, the χ² test for independent variables, contrasts of proportions and logistic regression to obtain associations between the rural and general populations and socioeconomic variables.
For the rural population studied, the prevalence of poor perceptions of visual health is 40.8% in men and 39.4% in women, and is strongly associated with age, employment situation, income and presence of chronic diseases (p ˂0.001). Compared with the general population, the rural population has a higher risk of presenting with serious difficulties related to farsightedness (OR: 2.56; 95% CI: 1.32-4.95) and make less use of optical correction (OR: 0.57; 95%CI: 0.44-0.74). The use of health services is not sufficient for adequate prevention, particularly in diabetics. For those affected by poor vision, the distance to travel to receive an eye exam, the belief that eyesight problems come with age and the cost of glasses are the principal reasons used to explain why eyesight problems are not resolved.
The rural population presents worse visual health that is influenced by social and economic factors. Improving accessibility and reducing barriers is essential to tackle avoidable visual disability and reduce health inequities.
Analizar la salud visual y el uso de servicios de salud en una población rural periférica en relación a variables socioeconómicas y a la población general española.
Estudio transversal en población rural con administración de cuestionario estructurado incluyendo preguntas comparables a la Encuesta Nacional de Salud en España (2012). Se realizó un análisis descriptivo a través del cálculo de frecuencias y prevalencias, el uso de la prueba χ² para la independencia de variables y el contraste de proporciones y regresión logística para obtener asociaciones entre variables en población rural y general.
En la población rural estudiada, la prevalencia de mala salud visual percibida es del 40,8% en los hombres y del 39,4% en las mujeres, y está fuertemente asociada a la edad, la situación laboral, el nivel de ingresos y la presencia de enfermedades crónicas (p ˂0,001). Presentan mayor riesgo de afrontar importantes dificultades en visión lejana (odds ratio [OR]: 2,56; intervalo de confianza del 95% [IC95%]: 1,32-4,95) y hacen un menor uso de corrección óptica (OR: 0,57; IC95%: 0.44-0.74) en comparación con la población general. El uso de los servicios de salud es insuficiente para una adecuada prevención, particularmente en las personas diabéticas. Aquellos/as con dificultades visuales señalaron la distancia al centro de salud, asociarlo a la edad y el precio de las gafas como principales barreras en el acceso a una solución.
La población rural presenta peores indicadores de salud visual, influenciados por factores socioeconómicos. Se requieren acciones que aborden la discapacidad visual por causas evitables y reducir las inequidades en salud.
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Original articleVisual Impairment and Blindness in Spanish Adults: Geographic Inequalities Are Not Explained by Age or Education

Objectives

Design

Participants

Methods

Main Outcome Measures

Results

Conclusions

Section snippets

Sample

Description of the Sample and General Prevalence

Discussion

Lancet

Am J Ophthalmol

Ophthalmology

Gac Sanit

Ophthalmology

Lancet

Soc Sci Med

Global estimates of visual impairment: 2010

Br J Ophthalmol

Global data on visual impairment in the year 2002

Bull World Health Organ

Prevalence of vision impairment in older adults in rural China: the China Nine-Province Survey

Ophthalmology

Prevalence of blindness and visual impairment in Pakistan: the Pakistan National Blindness and Visual Impairment Survey

Invest Ophthalmol Vis Sci

Nigeria National Blindness and Visual Impairment Study Group. Ecological determinants of blindness in Nigeria: the Nigeria National Blindness and Visual Impairment Survey

S Afr Med J

Blindness in the Indian state of Andhra Pradesh

Invest Ophthalmol Vis Sci

Visual impairment and eye care among older adults–five states, 2005

MMWR Morb Mortal Wkly Rep

Blindness registrations and socioeconomic factors in Canada: an ecologic study

Ophthalmic Epidemiol

Prevalence and burden of self-reported blindness, low vision, and visual impairment in the French community: a nationwide survey

Arch Ophthalmol

Socioeconomic status and blindness

Br J Ophthalmol

Social economic development in the prevention of global blindness

Br J Ophthalmol

A conceptual framework for action on the social determinants of health: Social Determinants of Health Discussion Paper 2

Prevalence of visual impairment in relation to the number of ophthalmologists in a given area: a nationwide approach

Health Qual Life Outcomes [serial online]

Original article
Visual Impairment and Blindness in Spanish Adults: Geographic Inequalities Are Not Explained by Age or Education