To examine the association of health-related quality of life (HRQoL) with severity of visual impairment among people aged 40–64 years.
We used cross-sectional data from the 2006–2010 Behavioral Risk Factor Surveillance System to examine six measures of HRQoL: self-reported health, physically unhealthy days, mentally unhealthy days, activity limitation days, life satisfaction, and disability. Visual impairment was categorized as no, a little, or moderate/severe. We examined the association between visual impairment and HRQoL using logistic regression accounting for the survey’s complex design.
Overall, 23.0% of the participants reported a little difficult seeing, while 16.8% reported moderate/severe difficulty seeing. People aged 40–64 years with moderate/severe visual impairment had more frequent (≥14) physically unhealthy days, mentally unhealthy days, and activity limitation days in the last 30 days, as well as greater life dissatisfaction, greater disability, and poorer health compared to people reporting no or a little visual impairment. After controlling for covariates (age, sex, marital status, race/ethnicity, education, income, state, year, health insurance, heart disease, stroke, heart attack, body mass index, leisure-time activity, smoking, and medical care costs), and compared to people with no visual impairment, those with moderate/severe visual impairment were more likely to have fair/poor health (odds ratio, OR, 2.01, 95% confidence interval, CI, 1.82–2.23), life dissatisfaction (OR 2.06, 95% CI 1.80–2.35), disability (OR 1.95, 95% CI 1.80–2.13), and frequent physically unhealthy days (OR 1.69, 95% CI 1.52–1.88), mentally unhealthy days (OR 1.84, 95% CI 1.66–2.05), and activity limitation days (OR 1.94, 95% CI 1.71–2.20; all
Poor HRQoL was strongly associated with moderate/severe visual impairment among people aged 40–64 years.
A number of investigations have demonstrated that people with visual impairment report poorer quality of life than those without visual impairment.
In this study, we examined HRQoL among people aged 40–64 years reporting no, a little, and moderate/severe visual impairment. This age cohort represents adults in their most economically productive years; consequently, identifying disparities in HRQoL may inform health and public health interventions to improve health and productivity in this age group.
We used data from the 2006–2010 Behavioral Risk Factor Surveillance System, a state-based, random-digit-dialed telephone survey of the non-institutionalized civilian population aged ≥18 years in the United States. The BRFSS data are de-identified and publicly available. The CDC Institutional Review Board reviewed and approved the BRFSS protocol. Details on survey methods, questionnaires, data, and relevant reports appear at
For this study, we analyzed responses from 101,079 adults aged 40–64 years in the 22 states (Alabama, Arizona, Arkansas, Colorado, Connecticut, Florida, Georgia, Indiana, Iowa, Kansas, Maryland, Massachusetts, Missouri, Nebraska, New Mexico, New York, North Carolina, Ohio, Tennessee, Texas, West Virginia, and Wyoming) that used the Vision Module at least once during the 2006–2010 BRFSS surveys. Sample sizes varied by state, ranging from 13,691 people in Alabama to 1812 in Arkansas. Annual median state response rates, the percentages of persons who completed the BRFSS interview among all eligible persons in these states during that period, ranged from 50.6% to 54.6%; median state cooperation rates, the percentages of persons who completed the interview among all eligible persons who were contacted, ranged from 75.2% to 79.7%.
Consistent with previous investigations, we measured HRQoL in six areas; life satisfaction, disability, self-rated health, physically unhealthy days, mentally unhealthy days, and activity limitation days.
We dichotomized the responses to the life satisfaction question, “In general, how satisfied are you with your life?” into satisfied (including very satisfied and satisfied) and dissatisfied (including dissatisfied and very dissatisfied). We defined disability by responses to two questions, “Are you limited in any way in any activities because of physical, mental, or emotional problems?” and “Do you now have any health problem that requires you to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone?” and classified those responding “yes” to either question as having a disability. We dichotomized responses to the self-rated health question into fair/poor health and good/very good/excellent health. Three questions asked about self-assessed health referencing the previous 30 days, “Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?”, “Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?”, and “During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?”. Responses to these questions were dichotomized into <14 days (infrequent) and ≥14 (frequent) unhealthy days in each domain. This dichotomized approach has been used consistently in multiple investigations of these HRQoL measures.
We assessed self-reported visual impairment by using two questions from the Vision Module; “Regardless of whether or not you currently wear glasses or contact lenses, 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 newspapers, magazines, recipes, menus, or numbers on the telephone?”. Response categories were “no difficulty,” “a little difficulty,” “moderate difficulty,” “extreme difficulty,” “unable to do because of eyesight,” and “unable to do because of other reasons.” We defined no visual impairment as a response of no difficulty to both the distance (recognize a friend across the street) and the near (read newspaper print) questions; we defined a little visual impairment as a response of “a little difficulty” to either question; and we defined moderate/severe visual impairment as a response of “moderate difficulty,” “extreme difficulty,” or “unable to do because of eyesight” to either question. “Moderate difficulty,” “extreme difficulty” and “unable to do” were collapsed into one category “moderate/severe difficulty.” A response of “unable to do because of other reasons” was omitted from the analyses.
Based on previous studies,
We used chi-square statistics to test for differences in background characteristics and HRQoL among people by severity of self-reported visual impairment. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) from multiple logistic regression were used to assess the association between severity of visual impairment and each HRQoL outcome. All the models were based on analyzing the 101,979 respondents with complete information about visual impairment, HRQoL outcomes, and the potential confounders. We excluded 24,296 (19.24%) respondents due to missing information; income contributed the most missing values. We adjusted all analyses for the following potential confounders; demographic variables (age, sex, marital status, race/ethnicity, education, and household income), chronic conditions (diabetes, heart disease, stroke, and heart attack), BMI, health behaviors (physical activity and smoking), access to care (regular health care provider, medical care cost as problem), year, insurance, and state of residence.
We analyzed these data using Stata version 12.0 (StataCorp LP, College Station, TX, USA) survey procedures (svy commands) to account for the complex sampling design of the BRFSS by weighting estimates for individual selection probabilities, nonresponse, and post-stratification. Regression analyses were performed using the svy: logistic command. Because some states used the Vision Module in more than 1 year during 2006 to 2010, we adjusted the state-specific respondent sampling weights to represent an average annual population for each state. This adjustment prevents over-representation of respondents in the model. We considered p-values ≤0.05 statistically significant.
Among our study population, two-thirds (67.7%) were aged 40–54 years, 50.8% were female, 9.9% were non-Hispanic black, and 9.7% were Hispanic (
Compared to those with no visual impairment, those with a little visual impairment reported a similar, though less pronounced, pattern to those with moderate/severe visual impairment. More younger persons, women, unmarried persons, non-Hispanic blacks, Hispanics, those with less education, and those with lower household income reported a little difficulty seeing. Those with a little visual impairment generally reported more chronic conditions, especially diabetes and stroke; however, those reporting a little visual impairment did not significantly differ from those with no visual impairment with respect to either heart disease or heart attack. While those with little visual impairment did not significantly differ from those with no difficulty seeing with respect to access to a regular health care provider, those with a little visual impairment reported greater medical care cost issues and less insurance coverage.
Across the six HRQoL measures, poorer outcomes were associated with increased severity of visual impairment (
After controlling for potentially confounding variables in our model, severity of self-reported visual impairment was still associated with poorer HRQoL outcomes among the six measures we investigated (
In this population-based survey of 22 US states, 16.8% of respondents aged 40–64 years reported moderate/severe visual impairment, and 23.0% reported a little visual impairment. Those with self-reported moderate/severe visual impairment were approximately twice as likely as people with no visual impairment to indicate poorer HRQoL across the six indicators employed in this study; fair/poor health, life dissatisfaction, disability, frequent physically unhealthy days, frequent mentally unhealthy days, and frequent activity limitation days. People aged 40–64 years reporting a little visual impairment were about 1.3–1.5 times as likely to report poorer HRQoL outcomes using these six measures.
These findings are consistent with other investigations that have employed other measures of quality of life to gauge the status of people with visual impairment and blindness,
In a population-based sample of Latinos aged 40 years and older in the Los Angeles Latino Eye Study,
In data from 44- and 45-year-olds from the 1958 British birth cohort study,
Finally, a review of 29 studies addressed the psychosocial impact of visual impairment among working-age adults.
In a companion paper, we examined these same HRQoL measures among people aged ≥65 years.
The purpose of the CDC HRQoL measures, to inform service needs and intervention outcomes, helps to define particular implications of these findings, namely poorer outcomes associated with increasing visual impairment. Moriarty and colleagues asserted “The Healthy Days surveillance data are particularly useful for finding unmet health needs, identifying disparities among demographic and socioeconomic subpopulations, characterizing the symptom burden of disabilities and chronic diseases, and tracking population patterns and trends.”
HRQoL is subjective, and individuals may report better or worse results for many reasons. Multiple pathways may contribute to overall poorer or better HRQoL. One pathway may involve access to health care. Working-age people with visual impairment report difficulty getting access to and failure to use eye care, citing cost or no reason to go as major reasons for lack of care.
Our findings draw attention to the role of chronic disease management among people with visual impairment that may lead to poorer HRQoL. We show that among working-age people with visual impairment, poorer HRQoL is associated with increased prevalence of chronic conditions (stroke, heart disease, and diabetes) and poorer health behaviors (increased smoking, decreased physical activity, and overweight and obesity). Chronic disease management may prove to be an avenue for improved HRQoL among individuals reporting visual impairment. Better understanding of the underlying modifiable factors and innovative strategies to address them may improve health and HRQoL.
The findings of this investigation are subject to several limitations. First, the findings are population-based for the 22 states in the sample, but may not be representative of the entire US population. Second, because BRFSS data are cross-sectional, we cannot tell whether visual impairment preceded the reported HRQoL issues, whether these issues preceded visual impairment, or whether both result from other potential confounding factors. However, after controlling for major potentially confounding factors, the association remained. Third, BRFSS data are self-reported and responses may be affected by recall bias, social desirability, or other factors. The BRFSS vision questions represent perception of visual function rather than objectively measured visual impairment. Furthermore, these questions neither provide information regarding duration of visual impairment, nor do they distinguish bilateral from unilateral visual impairment.
In conclusion, poorer HRQoL among people aged 40–64 years is strongly associated with severity of self-reported visual impairment. These findings suggest that research should address the underlying causes of poorer HRQoL among people who report visual impairment as well as potential interventions to improve both health and HRQoL.
This study was supported by the Centers for Disease Control and Prevention.
The authors report no conflicts of interest. The authors alone are responsible for the writing and content of this article.
The findings and conclusions in this paper are those of the authors and do not necessarily reflect the official position of the Centers of Disease Control and Prevention.
Characteristics of study sample aged 40–64 years by visual impairment status in 22 States
| Total % (95% CI) | No difficulty seeing % (95% CI) | A little difficulty seeing % (95% CI) | Moderate/severe difficulty seeing % (95% CI) | |||
|---|---|---|---|---|---|---|
| Age group, years | 0.002 | |||||
| 40–54 | 58,849 | 67.7 (67.2–68.3) | 67.1 (66.3–67.8) | 69.6 (68.5–70.6) | 67.7 (66.3–69.1) | |
| 55–64 | 43,130 | 32.3 (31.7–32.8) | 32.9 (32.2–33.7) | 30.4 (29.4–31.5) | 32.3 (30.9–33.7) | |
| Female | 62,588 | 50.8 (50.1–51.5) | 48.2 (47.3–49.1) | 54.1 (52.8–55.4) | 55.6 (54.0–57.2) | <0.001 |
| Married | 63,100 | 71.7 (71.2–72.3) | 74.7 (73.9–75.3) | 70.1 (69.0–71.2) | 63.6 (62.1–65.1) | <0.001 |
| Race/ethnicity | <0.001 | |||||
| Non-Hispanic white | 81,942 | 75.9 (75.3–76.5) | 77.4 (76.6–78.2) | 76.4 (75.2–77.5) | 70.1 (68.6–71.6) | |
| Non-Hispanic black | 10,353 | 9.9 (9.5–10.2) | 9.3 (8.8–9.7) | 10.1 (9.4–10.8) | 11.9 (11.0–12.8) | |
| Hispanic | 5376 | 9.7 (9.2–10.2) | 8.8 (8.2–9.5) | 9.4 (8.5–10.3) | 13.5 (12.3–14.8) | |
| Other | 3578 | 4.5 (4.2–4.8) | 4.6 (4.2–5.0) | 4.1 (3.7–4.6) | 4.5 (3.9–5.3) | |
| Educational level | <0.001 | |||||
| <High school | 7789 | 8.4 (8.0–8.9) | 6.6 (6.1–7.1) | 8.0 (7.4–8.8) | 15.6 (14.2–17.0) | |
| High school graduate | 30,145 | 26.8 (26.2–27.3) | 25.0 (24.3–25.7) | 27.5 (26.4–28.6) | 32.3 (30.9–33.7) | |
| >High school | 63,951 | 64.8 (64.2–65.4) | 68.4 (67.6–69.2) | 64.5 (63.3–65.7) | 52.2 (50.6–53.7) | |
| Annual household income >$35,000 | 61,204 | 71.3 (70.7–71.9) | 75.9 (75.1–76.6) | 70.6 (69.4–71.7) | 55.7 (54.1–57.3) | <0.001 |
| Employed | 68,918 | 71.6 (71.0–72.2) | 75.0 (74.3–75.8) | 71.5 (70.4–72.6) | 59.3 (57.8–60.9) | <0.001 |
| Diabetes | 11,654 | 10.3 (9.9–10.7) | 8.7 (8.3–9.2) | 10.8 (10.1–11.6) | 15.2 (13.9–16.5) | <0.001 |
| Heart disease | 3572 | 4.1 (3.9–4.3) | 3.3 (3.1–3.6) | 3.9 (3.5–4.4) | 6.8 (6.2–7.4) | <0.001 |
| Stroke | 3025 | 2.6 (2.4–2.8) | 1.8 (1.6–2.0) | 2.6 (2.2–3.0) | 5.3 (4.5–6.2) | <0.001 |
| Heart attack | 3453 | 3.9 (3.7–4.1) | 3.1 (2.9–3.4) | 3.7 (3.4–4.2) | 6.8 (6.2–7.5) | <0.001 |
| Body mass index, kg/m2 | <0.001 | |||||
| Normal, <25 | 30,567 | 31.5 (30.8–32.1) | 32.0 (31.1–32.8) | 31.5 (30.3–32.7) | 29.6 (28.1–31.1) | |
| Overweight, 25–<30 | 35,879 | 38.0 (37.4–38.7) | 38.9 (38.0–39.8) | 36.8 (35.5–38.1) | 36.6 (35.1–38.2) | |
| Obese, ≦30 | 31,169 | 30.5 (29.9–31.1) | 29.1 (28.3–29.9) | 31.7 (30.5–32.9) | 33.8 (32.2–35.3) | |
| Leisure-time physical activity | 74,205 | 74.8 (74.2–75.4) | 77.7 (76.9–78.4) | 74.7 (73.7–75.7) | 64.7 (63.2–66.2) | <0.001 |
| Smoking status | <0.001 | |||||
| Current smoker | 21,927 | 20.8 (20.3–21.4) | 18.3 (17.7–19.0) | 20.8 (19.7–21.9) | 30.1 (28.6–31.5) | |
| Former smoker | 28,160 | 27.4 (26.8–28.0) | 27.2 (26.4–28.0) | 27.4 (26.3–28.6) | 27.9 (26.5–29.4) | |
| Never smoker | 51,579 | 51.8 (51.1–52.4) | 54.5 (53.6–55.4) | 51.8 (50.5–53.1) | 42.0 (40.5–43.6) | |
| Regular health care provider | 88,916 | 85.4 (84.9–85.9) | 86.0 (85.2–86.6) | 85.2 (84.2–86.2) | 83.8 (82.7–84.9) | 0.001 |
| Medical care cost issues | 14,213 | 13.8 (13.4–14.3) | 10.2 (9.7–10.7) | 14.7 (13.8–15.7) | 25.7 (24.2–27.1) | <0.001 |
| Health insurance coverage | 88,819 | 86.5 (86.0–86.9) | 88.1 (87.5–88.7) | 86.4 (85.4–87.3) | 80.7 (79.5–81.9) | <0.001 |
The 22 states using the BRFSS vision module at least once in the years 2006–2010 include Alabama, Arizona, Arkansas, Colorado, Connecticut, Florida, Georgia, Indiana, Iowa, Kansas, Maryland, Massachusetts, Missouri, Nebraska, New Mexico, New York, North Carolina, Ohio, Tennessee, Texas, West Virginia, and Wyoming.
P value is from chi-square test of the null hypothesis for equality of covariate levels across the levels of visual impairment.
CI, confidence interval.
Unadjusted health-related quality of life among those aged 40–64 years by visual impairment status in 22 States
| Health-related quality of life measure | Total % (95% CI) | No difficulty seeing % (95% CI) | Little difficulty seeing % (95% CI) | Moderate/severe difficulty seeing % (95% CI) | ||
|---|---|---|---|---|---|---|
| Life dissatisfaction | <0.0001 | |||||
| Yes | 6915 | 5.8 (5.6–6.1) | 3.7 (3.5–4.0) | 6.0 (5.6–6.5) | 13.3 (12.3–14.3) | |
| Disability | <0.0001 | |||||
| Yes | 27,991 | 24.8 (24.3–25.4) | 19.3 (18.6–19.9) | 27.4 (26.2–28.5) | 41.2 (39.7–42.8) | |
| Self-reported health | <0.0001 | |||||
| Fair/poor | 19,182 | 17.1 (16.6–17.6) | 12.4 (11.8–13.0) | 17.8 (16.9–18.7) | 33.0 (31.4–34.5) | |
| Physical unhealthy days | <0.0001 | |||||
| 14–30 days | 14,196 | 12.4 (12.0–12.8) | 9.2 (8.7–9.7) | 12.7 (12.0–13.5) | 23.7 (22.4–25.1) | |
| Mental unhealthy days | <0.0001 | |||||
| 14–30 days | 12,386 | 11.0 (10.6–11.4) | 7.7 (7.3–8.2) | 11.7 (11.0–12.4) | 21.7 (20.4–23.1) | |
| Activity limitation days | <0.0001 | |||||
| 14–30 days | 9571 | 8.2 (7.9–8.6) | 5.5 (5.2–5.9) | 8.5 (7.9–9.1) | 17.8 (16.6–19.1) |
The 22 states using the BRFSS vision module at least once in the years 2006–2010 include Alabama, Arizona, Arkansas, Colorado, Connecticut, Florida, Georgia, Indiana, Iowa, Kansas, Maryland, Massachusetts, Missouri, Nebraska, New Mexico, New York, North Carolina, Ohio, Tennessee, Texas, West Virginia, and Wyoming.
Chi-square test of the null hypothesis for equality of covariate levels across the levels of visual impairment.
CI, confidence interval.
Health-related quality of life among those aged 40–64 years in 22 States
| Visual impairment status | Fair/poor health | Life dissatisfaction | Disability | Physically unhealthy days | Mentally unhealthy days | Activity limitation days |
|---|---|---|---|---|---|---|
|
| ||||||
| OR (95% CI) | OR (95% CI) | OR (95% CI) | OR (95% CI) | OR (95% CI) | OR (95% CI) | |
| No difficulty seeing | 1 (reference) | 1 (reference) | 1 (reference) | 1 (reference) | 1 (reference) | 1 (reference) |
| A little difficulty seeing | 1.32 | 1.59 | 1.58 | 1.29 | 1.45 | 1.60 |
| Moderate/severe difficulty seeing | 2.88 | 3.28 | 2.94 | 2.47 | 2.77 | 3.30 |
| No difficulty seeing | 1 (reference) | 1 (reference) | 1 (reference) | 1 (reference) | 1 (reference) | 1 (reference) |
| A little difficulty seeing | 1.45 | 1.35 | 1.46 | 1.33 | 1.35 | 1.38 |
| Moderate/severe difficulty seeing | 2.01 | 2.06 | 1.95 | 1.69 | 1.84 | 1.94 |
The 22 states using the BRFSS vision module at least once in the years 2006–2010 include Alabama, Arizona, Arkansas, Colorado, Connecticut, Florida, Georgia, Indiana, Iowa, Kansas, Maryland, Massachusetts, Missouri, Nebraska, New Mexico, New York, North Carolina, Ohio, Tennessee, Texas, West Virginia, and Wyoming.
The adjusted model is adjusted for age, sex, marital status, race/ethnicity, education, annual household income, smoking status, leisure-time physical activity, body mass index, regular health care provider, medical care cost issues, health insurance coverage, self-reported history of chronic diseases (diabetes, heart disease, heart attack, and stroke), year, state.
CI, confidence interval; OR, odds ratio.