Disparities in Vision Testing for Adolescents

Decreased vision testing in primary care and in school settings drove an age-related overall decline in vision testing among adolescents, a review of national data showed.

Data from 2018-2019 showed that three-fourths of adolescents had a vision test in some setting within the previous 12 months, though testing decreased with age (1.3% per year of age), primarily as a result of decreased testing in primary care (2.8% decrease per year of age) and school settings (2.4% per year), reported Isdin Oke, MD, of Boston Children’s Hospital and Harvard Medical School, and co-authors.

Socioeconomic factors also influenced testing, including insurance status, caregiver education, and birth outside the U.S., they said in JAMA Ophthalmology.

“Although most adolescents in the U.S. were reported by their caregivers to have had their vision tested within the previous year, individuals from socioeconomically disadvantaged backgrounds … were less likely to have reported receiving a vision test,” the authors wrote. “Our findings further suggest that language- and education-related barriers may also contribute to differences in caregiver-reported vision testing. Limited access to vision testing may delay the identification and treatment of ocular conditions and contribute to the inequities in visual function … in the adolescent population.”

Noting that socioeconomically disadvantaged adolescents were not less likely to have school-based vision testing, the authors concluded that “consideration should be given to strategies that expand the role of school-based vision testing for older children who are not otherwise receiving vision care.”

The study shows that “we have a long way to go toward overcoming disparities in vision testing for adolescents in the U.S.,” according to the authors of an invited commentary. Identifying the problem is not enough; innovative solutions are need to ensure equitable access to care.

“Expanding the role of schools is one viable pathway,” wrote Megan E. Collins, MD, and Bani Antonio-Aguirre, MD, of Johns Hopkins University in Baltimore. “Establishing relationships with federally qualified healthcare centers should be another priority. Simultaneously, we need to better educate primary care physicians about the crucial link between vision and the health and well-being of adolescents.

“Finally, we need efforts to build better coordinated care — across schools, primary care, and eye care settings — to ensure children have access to needed vision services through adolescence and into adulthood.”

A multivariable analysis adjusted for age and sex showed that odds of vision testing were significantly lower among adolescents with these characteristics:

• Uninsured: OR 0.81, 95% CI 0.76-0.87
• Caregiver did not have high school education: OR 0.89, 95% CI 0.84-0.95
• Family born outside the U.S.: OR 0.90, 95% CI 0.82-0.98

Adolescents with those characteristics (plus low-income household) were less likely to be tested in an eye clinic or primary care clinic but just as likely to be tested in a school-based setting as compared with adolescents without those characteristics.

Refractive error is the most common cause of visual impairment in adolescents and may interfere with academic and social development and negatively impact future career trajectories, Oke and co-authors noted in their introduction. Vision testing can help identify children with ocular conditions, but few states mandate vision testing in adolescents, as compared with early school-aged children.

The settings where vision testing occurs, the patterns of testing as a function of age, and sociodemographic influences on testing had yet to be described by means of a nationally representative cohort of U.S. adolescents. To address the issue, investigators queried the National Survey of Children’s Health database for the 2018-2019 survey cycles. Caregivers were asked whether a child had vision testing within the past 12 months, by means of pictures, shapes, or letters. Caregivers also were asked about the setting in which vision testing occurred. The primary outcome was reported vision testing within the previous 12 months in any setting.

The data represented 24,752 adolescents who had a median age of 14. Sex distribution was 51% male. Investigators found that 18,621 adolescents had vision testing within the previous 12 months. Testing occurred most often at an eye clinic (13,323), followed by primary care clinics (5,230), school (2,594), and health centers (635).

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