{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T05:04:36Z","timestamp":1789535076936,"version":"build-2803163510"},"reference-count":24,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T00:00:00Z","timestamp":1789516800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Public Health"],"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Social determinants of health (SDoH) are increasingly recognized as drivers of population health, but their association with severe vision impairment has not been examined in Puerto Rico, a U. S. territory with a particularly high reported prevalence of severe vision impairment.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We conducted a population-based, cross-sectional analysis of 4,558 noninstitutionalized adults aged \u226518\u202fyears who participated in the 2023 Behavioral Risk Factor Surveillance System (BRFSS) in Puerto Rico. Responses were dichotomized into five SDoH exposure variables representing Healthy People 2030 domains: economic instability, low educational attainment, insufficient social support, limited health care access, and unstable built environment. These were summed to construct a cumulative Social Risk Index (range, 0 to \u22654). Modified Poisson regression with robust variance estimation was used to estimate adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) for the association between each exposure variable and self-reported severe vision impairment, adjusted for age, sex, marital status, and insurance coverage. Analytic weights were incorporated to account for the complex survey design.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Among 4,558 respondents (mean age, 50\u202fyears; 53.3% female), 880 reported severe vision impairment (survey-weighted prevalence, 19.8%). After adjustment, severe vision impairment was more prevalent among individuals experiencing an unstable built environment (aPR, 2.02; 95% CI, 1.70\u20132.40), limited health care access (aPR, 1.95; 95% CI, 1.53\u20132.50), economic instability (aPR, 1.68; 95% CI, 1.40\u20132.01), insufficient social support (aPR, 1.33; 95% CI, 1.10\u20131.61), and low educational attainment (aPR, 1.30; 95% CI, 1.06\u20131.60). A graded increase in prevalence was observed with higher cumulative Social Risk Index scores, from aPR 1.28 (95% CI, 1.03\u20131.59) for one social risk factor to aPR 3.00 (95% CI, 2.13\u20134.23) for four or more factors.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Discussion<\/jats:title>\n                    <jats:p>Self-reported severe vision impairment in Puerto Rico was associated with multiple individual social determinants and increased monotonically with cumulative social risk. Identifying social risk factors associated with severe vision impairment may help direct eye health resources toward the populations in which it is most prevalent. Further research is needed to clarify the mechanisms linking social determinants to vision loss.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fpubh.2026.1907768","type":"journal-article","created":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T04:32:38Z","timestamp":1789533158000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Severe vision impairment is associated with cumulative social risk among adults in Puerto Rico: a population-based study"],"prefix":"10.3389","volume":"14","author":[{"given":"Mariola A.","family":"Busquets","sequence":"first","affiliation":[{"name":"School of Medicine, University of Puerto Rico","place":["San Juan, PR, United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ibrahim D.","family":"Ali","sequence":"additional","affiliation":[{"name":"Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health","place":["Baltimore, MD, United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrea N.","family":"Ponce","sequence":"additional","affiliation":[{"name":"Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health","place":["Baltimore, MD, United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jeremy D.","family":"Keenan","sequence":"additional","affiliation":[{"name":"Francis I. Proctor Foundation, University of California, San Francisco","place":["San Francisco, CA, United States"]},{"name":"Department of Ophthalmology, University of California, San Francisco","place":["San Francisco, CA, United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Luma","family":"Al-Attar","sequence":"additional","affiliation":[{"name":"Department of Ophthalmology, University of Puerto Rico","place":["San Juan, PR, United States"]},{"name":"Retina Center of Puerto Rico","place":["Manat\u00ed, PR, United States"]},{"name":"Johns Hopkins Bloomberg School of Public Health","place":["Baltimore, MD, United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,9,16]]},"reference":[{"key":"ref1","volume-title":"Social Determinants of Health (SDOH)","year":"2024"},{"key":"ref2","volume-title":"Office of Disease Prevention and Health Promotion","year":"2024"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"468","DOI":"10.1001\/jamaophthalmol.2023.0723","article-title":"Association between social determinants of health and examination-based vision loss vs self-reported vision measures","volume":"141","author":"Alfaro Hudak","year":"2023","journal-title":"JAMA Ophthalmol."},{"key":"ref4","doi-asserted-by":"publisher","first-page":"453","DOI":"10.1177\/08901171221132390","article-title":"Social risk factors are associated with disability prevalence \u2013 results from 17 states in the 2017 behavioral risk factor surveillance system","volume":"37","author":"Sharpe","year":"2023","journal-title":"Am J Health Promot"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"1219","DOI":"10.1001\/jamaophthalmol.2022.4566","article-title":"Association of socioeconomic, demographic, and health care access disparities with severe visual impairment in the US","volume":"140","author":"Besagar","year":"2022","journal-title":"JAMA Ophthalmol."},{"key":"ref6","doi-asserted-by":"publisher","first-page":"368","DOI":"10.4103\/0301-4738.100529","article-title":"Social inequalities in blindness and visual impairment: a review of social determinants","volume":"60","author":"Rius Ulldemolins","year":"2012","journal-title":"Indian J Ophthalmol"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"93","DOI":"10.1080\/09286586.2019.1680703","article-title":"Associations of social determinants of health and self-reported visual difficulty: analysis of the 2016 National Health Interview Survey","volume":"27","author":"Su","year":"2020","journal-title":"Ophthalmic Epidemiol"},{"key":"ref8","volume-title":"Puerto Rico Census Profile","year":"2024"},{"key":"ref9","volume-title":"Medicare Advantage in 2024: Enrollment Update and Key Trends","author":"Freed","year":"2024"},{"key":"ref10","volume-title":"2022 BRFSS Modules Used by Category","year":"2022"},{"key":"ref11","volume-title":"BRFSS Overview","year":"2023"},{"key":"ref12","volume-title":"2023 BRFSS Survey Data and Documentation","year":"2025"},{"key":"ref13","volume-title":"BRFSS - BRFSS Frequently Asked Questions (FAQs)","year":"2022"},{"key":"ref14","volume-title":"The BRFSS Data User Guide","year":"2013"},{"key":"ref15","volume-title":"2023 BRFSS Questionnaire","year":"2023"},{"key":"ref16","volume-title":"BRFSS Combined Landline and Cell Phone Weighted Response Rates by State","year":"2023"},{"key":"ref17","volume-title":"Vision and Eye Health Surveillance System (VEHSS)","year":"2025"},{"key":"ref18","doi-asserted-by":"publisher","first-page":"e44552","DOI":"10.2196\/44552","article-title":"Comparing telephone survey responses to best-corrected visual acuity to estimate the accuracy of identifying vision loss: validation study","volume":"9","author":"Wittenborn","year":"2023","journal-title":"JMIR Public Health Surveill"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"959","DOI":"10.1001\/jamaophthalmol.2016.1778","article-title":"Visual function, social position, and health and life chances: the UK biobank study","volume":"134","author":"Cumberland","year":"2016","journal-title":"JAMA Ophthalmol"},{"key":"ref20","doi-asserted-by":"publisher","first-page":"820","DOI":"10.1038\/s41598-020-79760-7","article-title":"Socioeconomic and physical health status changes after visual impairment in Korea using difference-in-difference estimations","volume":"11","author":"Kim","year":"2021","journal-title":"Sci Rep"},{"key":"ref21","doi-asserted-by":"publisher","first-page":"958","DOI":"10.1038\/s41598-022-05003-6","article-title":"A longitudinal study of the association between visual impairment and income change using a national health screening cohort","volume":"12","author":"Choi","year":"2022","journal-title":"Sci Rep"},{"key":"ref22","doi-asserted-by":"publisher","first-page":"1371","DOI":"10.1007\/s40123-022-00531-w","article-title":"Addressing social determinants of vision health","volume":"11","author":"Williams","year":"2022","journal-title":"Ophthalmol Ther"},{"key":"ref23","volume-title":"Integrating Social Care Into the Delivery of Health Care: Moving Upstream to Improve the Nation\u2019s Health","year":"2019"},{"key":"ref24","doi-asserted-by":"publisher","first-page":"453","DOI":"10.1001\/jamaophthalmol.2022.0409","article-title":"Elevating social determinants of health and community engagement in eye care \u2013 the time is now","volume":"140","author":"Elam","year":"2022","journal-title":"JAMA Ophthalmol."}],"container-title":["Frontiers in Public Health"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2026.1907768\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T04:32:50Z","timestamp":1789533170000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2026.1907768\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,16]]},"references-count":24,"alternative-id":["10.3389\/fpubh.2026.1907768"],"URL":"https:\/\/doi.org\/10.3389\/fpubh.2026.1907768","relation":{},"ISSN":["2296-2565"],"issn-type":[{"value":"2296-2565","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,16]]},"article-number":"1907768"}}