Health Related Quality of Life among Older People with Vision Impairment John E. Crews, DPA CDC’s...

Health Related Quality of Life among Older

People with Vision Impairment

John E. Crews, DPACDC’s Vision Health Initiative

November 6, 2015

National Center for Chronic Disease Prevention and Health Promotion

Vision Health Initiative

Quotidian

Outline

Describe public health model Populate model with vision examples Surveillance Introduce WHO ICF Framework Vision & eye health disparities Vision and Health-Related Quality of Life Implications of findings for Vision Rehab Intervention & intervention design Begins to tell the complex story of aging

and vision impairment

Public Health MonitoringSurveillance

Public Health ResearchRisk/Disparity

Public Health InterventionWhat works?

Public Health ImpactImplementation

Problem Response

Public Health Model

Surveillance

• Surveillance is the foundation of public health

• Population based• Driven by rigor and science• Cannot underestimate or over estimate a

problem• Without sound surveillance, all other

decisions may be incorrect

6

How many people experience vision impairment??

7

Population Estimates

• Prevalence and estimated population of people who are visually impaired remains problematic

• 3.3 million (40+) (Eye Diseases Prevalence Research Group, 2004)

• 5.7 million (65+) (Crews, Jones, & Kim, 2006)• 14 million (12+) (Vitale, Cotch, & Sperduto,

2006)• 21.2 million (18+) (Pleis & Lethbridge-Cejku,

2007) • Desire to have large numbers

Estimate depends on what you ask

• Disease: macular degeneration, cataract (cataract removed), glaucoma – Self report vs clinical examination

• Impairment: difficulty seeing• Activity performance: read newspaper print,

recognize friend across the street• Environment: Can you drive at night in unfamiliar

neighborhoods?• No gold standard question for vision surveys

9

Surveillance Gap

• No vision surveillance system in the US.• Therefore, no systematic effort to

harmonize questions, create conceptual clarity, or establish comparability.

• Consequences:– Vision public health research appears

fragmented.– Creates distinct disadvantage to inform

decision making.

10

Supplement to American Journal of Ophthalmology

Convened national/international panel of experts

Identified strategies to improve vision surveillance in US

Papers address disparities

Guide investigators and encourage harmonization of vision data

Forecasting studies

• Cases of cataract expected to increase from 20.5 million to 30.1 million from 2010 to 2020.

• Glaucoma is expected to increase from 2.2/2.7 million to 7.3 million in 2050.

• Cases of early macular degeneration expected increase from 9.1 million in 2010 to 17.8 million in 2050.

• Diabetic retinopathy will triple from 5.5 million cases in 2005 to 16 million in 2050.

Status of Vision Surveillance

• Recall surveillance is foundation of public health.

• Substantial knowledge base, but, perhaps, not organized in way to move a public health agenda.

• Existing knowledge makes case for the magnitude of the problem.

13





Problem Response

Public Health Model

Are people with vision impairment different from the general population?

15

Risk/ Disparity/ Effects of Vision Impairment

Second step in the public health model is to determine whether or not a problem is evenly distributed across the population

Age group, gender, race/ethnicity , co-morbidity, health behaviors, health outcomes, SES Status, social outcomes, quality of life, health-related quality of life.

Accounts for much research in vision Identifies where the action is. Targets

interventions.

Self reported no, little, & moderate/severe difficulty seeing by age

BRFSS, 2006-2010

Severity of Vision Impairment by Sexfor People Aged ≥65 Years

BRFSS. 2006-2010

Severity of Vision Impairment by Race/Ethnicity for People Aged ≥ Years

BRFSS, 2006-2010

Vision Impairment and Co-morbid Conditions

• Represents huge emerging issue• Represents another range of

disparities• Vision largely excluded from

initiatives to address multiple chronic conditions (MCCs)

20

Rank Diseases Present % w/ both

1 Arthritis, visual impairment 44

2 Visual impairment, high blood pressure 40

3 Arthritis, high blood pressure 34

4 Any heart disease, visual impairment 17

5 Visual impairment, hearing loss 15

6 Any heart disease, hearing loss 14

7 Any heart disease, HBP 13

8 Arthritis, hearing loss 12

9 Diabetes, visual impairment 12

10 Cancer, visual impairment 10

Comorbid Chronic Conditions Among Women aged 65+

Fried, at al, 1999

Findings from NHIS

NHIS Vision Questions: Do you have any trouble seeing, even when wearing

glasses or contact lenses?

Are you blind or unable to see at all?

14.6% report trouble seeing or blind

Prevalence of eight chronic conditions among people aged ≥65 years

Hyper

tent

ion

Heart

Disea

se

Stro

ke

Arth

ritis

Asth

ma

Cance

r

Kidn

ey

Diabe

tes

0

10

20

30

40

50

60

7061.8

29.9

8.6

50.3

10.7

23.6

4.3

19.8

23

Data source: NHIS, 2007-2011

Prevalence of eight chronic conditions among people aged ≥65 years

Hyper

tent

ion

Heart

Disea

se

Stro

ke

Arth

ritis

Asth

ma

Cance

r

Kidn

ey

Diabe

tes

0

10

20

30

40

50

60

7061.8

29.9

8.6

50.3

10.7

23.6

4.3

19.8

24

Data source: NHIS, 2007-2011

• What is the prevalence of vision impairment among people with chronic diseases?

25

Percent of people age ≥65 years with chronic conditions reporting vision

impairment

Hyper

tens

ion

Heart

Disea

se

Stro

ke

Arth

ritis

Asth

ma

Cance

r

Kidn

ey

Diabe

tes

0

5

10

15

20

25

30

35

16.419.5

25.5

18.3 19.916.4

29.4

19.9

26Data source: 2007-2011 NHIS

Percent of people with chronic conditions reporting vision

impairment

Hyper

tens

ion

Heart

Disea

se

Stro

ke

Arth

ritis

Asth

ma

Cance

r

Kidn

ey

Diabe

tes

0

5

10

15

20

25

30

35

16.419.5

25.5

18.3 19.916.4

29.4

19.9

27Data source: 2007-2011 NHIS

Percent of men & women with chronic conditions reporting vision impairment

0

5

10

15

20

25

30

35

14.616.4

23.4

16.6 16.7 15.3

29.3

17.3

17.8

22.9

27

19.321.7

17.4

29.5

22.2

MenWomen

28

Differences Significant for hypertension, heart disease, arthritis, asthma, & diabetes. Data source: 2007-2011 NHIS

Percent of men & women with chronic conditions reporting vision impairment

0

5

10

15

20

25

30

35

14.616.4

23.4

16.6 16.7 15.3

29.3

17.3

17.8

22.9

27

19.321.7

17.4

29.5

22.2

MenWomen

29

Differences Significant for hypertension, heart disease, arthritis, asthma, & diabetes. Data source: 2007-2011 HNIS

Prevalence of vision impairment among people w/ chronic conditions by age group

Hyper-tension

Heart Dis-ease

Stroke Arthri-tis

Asthma Cancer Kidney Dia-betes

65-74 14.4 17 24 16 18.6 13.4 26.7 19.2

75-85 16.7 19.4 23.9 18.2 20.2 16.7 29 19.5

85+ 24.6 27.1 32.4 27.7 28 26 38 25.8

2.5

12.5

22.5

32.5

65-74 75-85 85+

So . . .

• What are the effects of comorbid conditions among people with vision impairment?

31

Prevalence of self-reported fair/poor health among people with chronic conditions w/ and w/o vision

impairment

Hyper

tens

ion

Heart

Dis...

Stro

ke

Arth

ritis

Asth

ma

Cance

r

Kidn

ey

Diabe

tes

0

10

20

30

40

50

60

70

80

25.8

38.744.5

27.232.8

24.5

57.6

36.8

46.5

61.4 57.8

47.755.6

44.6

72.6

57.5

No VIVI

32

Data source: NHIS 2007-2011

International Classification of Functioning, Disability and Health

33

Historical struggle to understand disablement

Social & policy efforts have struggled to describe and respond to disability (cognitive, sensory, & mobility limitations).

Shame, isolation, removal, institutionalization, discomfort, fear

Civil War and WW-I response—institutional care

WW-II—employment, reintegration Developmental disabilities--removal Vietnam—civil rights

Models of Disablement

Nagi’s disablement model,1960s ADLs—Katz: bathing, toileting, dressing,

eating IADLs—Lawton: housework, meds, money,

shopping Disability as consequence of disease/ injury Linear models; Disability ≠ disease WHO 2001 International Classification of

Functioning, Disability and Health

Experience of Disability led to Social Model of Disability

Disability is dimensional

Disability is dynamic

Disability Research & Interventions must embrace these qualities

Fit between the person and the environment

Goals of public health

Prevent disease, injury, and disability Uneasy relationship with disability People with disabilities, including people

with vision impairment, are largely viewed as a failure of public health

And therefore, not of interest.

Vision’s Place in This Debate

Vision impairment is generally the negative outcome—to be avoided

Much confusion within the discipline regarding what we mean by “vision” or “vision impairment

Disease, function (20/200), activity (read), work disability (participation)

No gold standard vision questions If reframed, I can show place of vision

impairment in public health

Impairment of Structure or

Function

Activity Limitation

Participation Restriction

Disorder/Disease ICD-9/10

Personal Factors

Environmental Factors

ICF Conceptual Model

17

Functioning at Body, Person, and Societal Levels

• Disease/Disorder--ICD 9 • Body Function and Structures

– Impairments focused on body systems• Activities

– Activity limitations —e.g., self care, mobility, communication, controlling behavior

• Participation– Participation restrictions—e.g., friends, family,

work, school, community, & civic engagement• Environmental Factors

– Built, Attitudinal, Policy– May be barriers or facilitators (positive or

negative)

18

Utility of ICF

• Common language• Can be used for international comparisons• Is dimensional• Can track dynamic changes• Can be used at person, group, or

population level• Neutral terms• Classification system—does not replace

survey questions20

Employ ICF

• Want to demonstrate utility of ICF framework to better understand effects of vision impairment and effects of vision impairment and comorbid conditions

42

Back to Public Health Model

• Surveillance—how big is problem• Research—what are the disparities?• Use ICF to understand disparities.

43





Problem Response

Public Health Model

• Remember 19.9% of people age 65+ years report diabetes.

• Of that group, 17.3% of men & 22.2% of women report vision impairment.

45

Moderate/Severe Difficulty Walking ¼ Mile for Adults 65+ w/ & w/o Diabetes and Vision Impairment,

Health Interview Survey, 1997-2004

No Diabetes, No VI VI Only Diabetes Only Both Diabetes & VI

Series1 16.3 NaN NaN NaN

5

15

25

35

45

55

65

Pe

rce

nt

Crews, Jones, & Kim, 2006




Series1 16.3 40.1 NaN NaN

5

15

25

35

45

55

65

Pe

rce

nt





Series1 16.3 40.1 36.6 NaN

5

15

25

35

45

55

65

Pe

rce

nt





Series1 16.3 40.1 36.6 52.8

5

15

25

35

45

55

65

Pe

rce

nt


Moderate/Severe Difficulty Shopping for Adults 65+ w/ & w/o Diabetes and Vision Impairment,




2.5

7.5

12.5

17.5

22.5

27.5

32.5

37.5

42.5

47.5





Series1 6.2 21.6 NaN NaN

2.5

7.5

12.5

17.5

22.5

27.5

32.5

37.5

42.5

47.5





Series1 6.2 21.6 17.2 NaN

2.5

7.5

12.5

17.5

22.5

27.5

32.5

37.5

42.5

47.5





Series1 6.2 21.6 17.2 31.4

2.5

7.5

12.5

17.5

22.5

27.5

32.5

37.5

42.5

47.5


Percent Reporting Worse Health for Adults 65+ w/ & w/o Diabetes and Vision Impairment,




2.5

7.5

12.5

17.5

22.5

27.5

32.5

37.5

42.5

47.5





Series1 10.3 25 NaN NaN

2.5

7.5

12.5

17.5

22.5

27.5

32.5

37.5

42.5

47.5





Series1 10.3 25 19.9 NaN

2.5

7.5

12.5

17.5

22.5

27.5

32.5

37.5

42.5

47.5





Series1 10.3 25 19.9 31.7

2.5

7.5

12.5

17.5

22.5

27.5

32.5

37.5

42.5

47.5


The Effects of Stroke and Vision Impairment

Remember, 8.6% of people age 65+ years report stroke.

But of that group, 25.5% report vision problems.

Moderate/Severe Difficulty Walking ¼ Mile for Adults 65+ w/ & w/o Stroke and Vision

Impairment, Health Interview Survey, 1997-2004

No VI, No Stroke

VI Only Stroke Only

Both VI & Stroke

Series 1 16.4 NaN NaN NaN

5

15

25

35

45

55

65

Perc

en

t



No VI, No Stroke

VI Only Stroke Only

Both VI & Stroke

Series 1 16.4 40.1 NaN NaN

5

15

25

35

45

55

65

Perc

en

t



No VI, No Stroke

VI Only Stroke Only

Both VI & Stroke

Series 1 16.4 40.1 49.6 NaN

5

15

25

35

45

55

65

Perc

en

t



No VI, No Stroke

VI Only Stroke Only

Both VI & Stroke

Series 1 16.4 40.1 49.6 64.6

5

15

25

35

45

55

65

Perc

en

t

Moderate/Severe Difficulty Shopping for Adults 65+ w/ & w/o Stroke and Vision Impairment,


No VI No Stroke

VI Only Stroke Only Both VI & Stroke

Series 1 6 NaN NaN NaN

2.57.5

12.517.522.527.532.537.542.547.5

Perc

en

t

Crews, Jones, Kim, 2006



No VI No Stroke


Series 1 6 21.6 NaN NaN

2.57.5

12.517.522.527.532.537.542.547.5

Perc

en

t




No VI No Stroke


Series 1 6 21.6 27.5 NaN

2.57.5

12.517.522.527.532.537.542.547.5

Perc

en

t




No VI No Stroke


Series 1 6 21.6 27.5 40.6

2.57.5

12.517.522.527.532.537.542.547.5

Perc

en

t


Percent Reporting Worse Health Adults 65+ w/ & w/o Stroke and Vision


No VI No Stroke


Series 1 10.2 NaN NaN NaN

2.57.5

12.517.522.527.532.537.542.547.5

Perc

en

t




No VI No Stroke


Series 1 10.2 25 NaN NaN

2.57.5

12.517.522.527.532.537.542.547.5

Perc

en

t




No VI No Stroke


Series 1 10.2 25 27 NaN

2.57.5

12.517.522.527.532.537.542.547.5

Perc

en

t




No VI No Stroke


Series 1 10.2 25 27 37.9

2.57.5

12.517.522.527.532.537.542.547.5

Perc

en

t


Effects of Vision & Comorbid Conditions

Associated with decreased activity Associated with decreased social roles Associated with poorer health Vision and multiple chronic conditions have

propelling negative effect. An effect that requires attention.

Oral Health & Vision Impairment

Data Set: 2008 National Health Interview Survey

• Established 1957• Samples 35,000 household and 87,500 people

annually • Multistage area probability design permits

representative sample of households • 2008 Oral Health Supplement in Adult File• 2008 Vision Supplement in Adult File

Definition of Vision Impairment

“Do you have any trouble seeing even with glasses or contacts?”

“Have you EVER been told by a doctor or other health professional that you had any of the following conditions: Macular degeneration, diabetic retinopathy, glaucoma, or cataract?”

Outcome variables

Self-reported perceived oral health (very good to good/ fair to poor),

Teeth problems (toothache/sensitive teeth, bleeding gums, crooked teeth, broken/missing teeth, stained/discolored teeth, loose teeth, broken/missing fillings),

Mouth problems (pain in jaw, sores in mouth, difficult eating, bad breath, dry mouth.)

Self-Reported Oral Health Status

How would you describe the condition of your mouth?

Very good, good, fair, poor

Teeth Problems

Question stem: During the past six months, have you had any of the following problems? Toothache/sensitive teethBleeding gums, Crooked teeth,Broken/missing teeth,Stained/discolored teeth, Loose teeth not due to an injury, Broken/missing fillings

Mouth Problems

Question stem: During the past 6 months, have you had any of the following problems that lasted more than a day? (Y/N)Pain in jaw, Sores in mouth, Difficult eating or chewing, Bad breath, Dry mouth.

RESULTS

Oral Health Age ≥ 40 YearsMouth Condition

NHIS, 2008


Visually Impaired No Vision Impairment

Age 40-64

Age 65+ Age 40-64

Age 65+

Fair/Poor

45.0% 36.3% 24.5% 23.5%

Oral Health Age ≥ 40 YearsMouth Condition

NHIS, 2008


Visually Impaired No Vision Impairment

Age 40-64

Age 65+ Age 40-64

Age 65+

Fair/Poor

45.0% 36.3% 24.5% 23.5%

Oral Health Age ≥ 40 YearsProblems with Mouth among those

having teeth., NHIS, 2008

Vision Impairment

No Vision Impairment

Pain in jaw 12.3% 5.1%

Sores in mouth

9.2% 4.1%

Difficulty eating

18.6% 7.0%

Oral Health Age ≥ 40 YearsProblems with Teeth among those

having teeth. NHIS, 2008

Vision Impairment


Toothache/ Sensitive teeth

36.8% 21.2%

Bleeding Gums

17.2% 8.5%

Broken/Missing Teeth

34.9% 18.9%

Loose teeth 9.9% 4.6%

Heath Status among those having teeth.

Age ≥ 40 Years, NHIS, 2008

Vision Impairment


Excellent/ Very good, good

64.6% 84.8%

Fair/ Poor 35.4% 15.2%

Odds Ratio of Oral Health Problems among people with vision impairment ,

Age 40 Years, 2008 NHIS

Vision ImpairmentAge 40-64

years

Vision Impairment

Age ≥ 65 years

Fair/ Poor Oral Health

1.67 1.23

Mouth Problems

2.31 1.58

Teeth Problems

1.79 1.35

Health Related Quality of Life as Outcome Measure

Health Related Quality of Life Disparitiesfrom BRFSS

Health Related Quality of Life Life Satisfaction Disability Self-reported health Physically unhealthy days Mentally unhealthy days Activity limitation days

Vision Questions

• How much difficulty, if any, do you have reading print in newspaper, magazine, recipe, menu, or numbers on the telephone?

• How much difficulty, if any, do you have in recognizing a friend across the street?

• Response categories: No difficulty, little difficulty, moderate difficulty, extreme difficulty, unable to do because of eyesight

HRQoL Questions

• Self-Rated Health (excellent, very good, good, fair, poor)

• Physically Unhealthy Days: “Now thinking about your physical health, which included physical illness and injury, for how many days during the past 30 was your physical health not good?

• Mentally Unhealthy Days: 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?”

HRQoL Questions

Activity Limitation Days: “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?” Life Satisfaction: “In general, how satisfied are you with your life?” Disability: “Are you limited in any way in any activities because of physical, mental, or emotional problems?” and “Do you now have any health problems that requires you to us special equipment, such as a cane, a wheelchair, a special bed, or a special telephone?”

HRQoL Questions

• Valid indicators of service needs• Valid indicators of intervention

outcome

91

Life Dissatisfaction by Severity of Vision Impairment

among people age ≥ 65 years, BRFSS, 2006-2010

No Difficulty Little Duifficlty Severe Difficulty 0

1

2

3

4

5

6

7

8

9

2.4

4.2

8.4

92

Crews, Chou 2014

Disability by Severity of Vision Impairment

among people age ≥ 65 years, BRFSS 2006-2010

No Difficulty Little Difficulty Severe Difficulty0

10

20

30

40

50

60

31.6

41.2

53.6

93Crews, Chou et al 2014

Fair/Poor Health bySeverity of Vision Impairment

among people age ≥ 65 years, BRFSS 2006-2010

No Difficulty Little Difficulty Severe Difficulty0

5

10

15

20

25

30

35

40

45

50

23.5

29.5

43

94Crews, Chou, et al, 2014

Frequent (14+) unhealthy days by severity of vision impairment among people aged ≥65 years, BRFSS

2006-2010

Phys

ical

ly U

nhea

lthy

Days

Men

tally

Unh

ealth

y Day

s

Activ

ity Lim

itatio

ns D

ays

05

1015202530

14.5

4.87.3

18.3

7.39.7

28.3

1115.7

No DifficultyLittle DifficultySevere Difficulty

95

Crews, Chou, et al, 2014

Logistic Regression

Fair/ Poor Health

Life Dissatisfaction

Disability

No VI 1.0 1.0 1.0

Little VI 1.20 1.53 1.47

Moderate/Severe VI

1.80 2.21 2.01

Crews et al, 2012

Potential Solutions

Improved access and utilization of eye care and vision rehabilitation—no “system” of vision care .

Increased engagement of chronic disease providers to address needs of constituents with vision impairment. Stanford Health Promotion materials, for example, are

not accessible to people with vision impairment Improved tailored efforts to promote health

among people with vision impairment Integrate nutrition (low salt, low fat) into meal

preparation Integrate exercise, conditioning, falls prevention into

O&M Health outcomes are measurable

Vision Rehabilitation Outcomes

Using the ICF model, Vision Rehabilitation Intervention occurs at the activity level; outcomes occur at the social participation level.

Given the evidence, vision rehabilitation has potential to address health and can result in measureable health outcomes.

Next steps in public Health Model

• The future: Development and implementation of health promoting interventions targeted to people with vision impairment

99

A Game Changer

100

Institute of Medicine Report on Vision and Public Health

• vision and eye health surveillance• vision health disparities• prevalence & effects of comorbid

conditions • access and utilization of eye care, • health for people with vision impairment. • public and private collaborations at the

community, state, and national levels to elevate vision and eye health as a public health issue

102

Vision and Eye Health Surveillance System

Develop, test, and implement a vision and eye health surveillance system using existing surveys, as well as administrative and electronic data sources.

Provide population estimates of vision loss function, eye diseases, as well as barriers and facilitators to access to eye care at the national, state, and community levels.

National Opinion Research CenterNORC

Establish standardized vision and eye health indicators (expert advisory panel)

Identify data sources

Estimate the prevalence and disparities in vision, eye health, and eye care utilization

Quotidian

105

Man is the only animal that laughs and weeps; for he is the only animal that is struck with the difference between the way things are and the way they ought to be.--William Haslett

Thank you

107

Thank you very much!

108

For more information, please contactJohn E. Crews, DPA

at [email protected] 488 1116

For more information please contact Centers for Disease Control and Prevention

1600 Clifton Road NE, Atlanta, GA 30333Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: [email protected] Web: http://www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

National Center for Chronic Disease Prevention and Health Promotion

Vision Health Initiative

mailto:[email protected]

If no convinced, let me share one more piece of evidence

Health related Quality of Life among people age 40-64.

Used same vision and HRQoL questions from BRFSS

Vocational rehabilitation is big business Outcomes probably not as desirable as we

wish Concerns: education, employer attitudes,

transportation, technology,

Life Dissatisfaction, Disability & Fair/Poor Health among People with no, little & severe

vision impairment, ages 40-64

Life Dissatisfac-tion

Disability Self-Reported Health

No Difficulty 3.7 19.3 12.4

Little Difficulty 6 27.4 17.8

Severe Diffi-culty

13.3 41.2 33

2.5

12.5

22.5

32.5

42.5

Frequent physically unhealthy days, frequent mentally

unhealthy days, and frequent activity limitation days

by severity of vision impairment, BRFSS, 2006-2010

Frequent Physical Unhealthy Days

Frequent Men-tally Unhealthy

Days

Frequent Activity Limitation Days

No 9.2 7.7 5.5

Little 12.7 11.7 8.5

Severe 23.7 21.7 17.8

2.5

7.5

12.5

17.5

22.5

Findings

Given the findings of HRQoL among those over 65 years, these findings are not unexpected.

Mentally unhealthy days and life dissatisfaction is greater among those 40-64.

What if we look at these data by employment status?

Case definitions

Nine employment questions in BRFSS Working: working for wages or self

employed Not working: unemployed less than or more

than one year Excluded: student, homemaker, retired,

unable to work Working: No Difficulty: 75%; Little

Difficulty: 72%; Severe Difficulty: 59%

Fair/Poor Healthby employment status & severity of vision impairment

No Difficulty Little Difficulty Severe Difficulty

Employed 7.6 9.6 17.8

Not Em-ployed

26.7 38.3 55.2

5

15

25

35

45

55

Life Dissatisfaction by employment status & severity of vision impairment


Employed 2.5 3.7 6.5

Not Em-ployed

7.4 12 23.3

2.5

7.5

12.5

17.5

22.5

Frequent Physically Unhealthy Daysby employment status & severity of vision impairment


Employed 4.9 9.6 10

Not Em-ployed

22.1 30.1 44.1

2.57.5

12.517.522.527.532.537.542.547.5

Frequent Activity limitation Daysby employment status & severity of vision impairment


Employed 1.9 2.7 5.1

Not Em-ployed

16.4 23 36.7

2.5

7.5

12.5

17.5

22.5

27.5

32.5

37.5

Disabilityby employment status & severity of vision impairment


Employed 13.1 18.5 23.7

Not em-ployed

31 42.4 58.6

5

15

25

35

45

55

65

119

Frequently Mentally Unhealthy Daysby employment status & severity of vision impairment


Employed 5.5 7.5 12.3

Not Em-ployed

17.9 24.2 37.8

2.5

7.5

12.5

17.5

22.5

27.5

32.5

37.5

120

What to make of these findings

• Healthy Worker Effect• Same factors that predict health, predict work—

education, income• Workers may have access to better food, more

opportunities for exercise, better healthcare• Working may improve mood

121

In addition

• These finding argue for:• Improved access to health care• Improved health promoting activities

(decreased obesity, decreased smoking, increased exercise, improved nutrition)

• Better management of chronic conditions—especially diabetes and depression

122

Date post:	17-Jan-2016
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Health Related Quality of Life among Older People with Vision Impairment John E. Crews, DPA CDC’s...

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