Severe vision impairment is associated with cumulative social risk among adults in Puerto Rico: a population-based study.

Introduction: 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. Methods: We conducted a population-based, cross-sectional analysis of 4,558 noninstitutionalized adults aged ≥18 years 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 ≥4). 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. Results: Among 4,558 respondents (mean age, 50 years; 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, 1.70-2.40), limited health care access (aPR, 1.95; 95% CI, 1.53-2.50), economic instability (aPR, 1.68; 95% CI, 1.40-2.01), insufficient social support (aPR, 1.33; 95% CI, 1.10-1.61), and low educational attainment (aPR, 1.30; 95% CI, 1.06-1.60). A graded increase in prevalence was observed with higher cumulative Social Risk Index scores, from aPR 1.28 (95% CI, 1.03-1.59) for one social risk factor to aPR 3.00 (95% CI, 2.13-4.23) for four or more factors. Discussion: 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.