Vision loss in older veterans is greater in rural than urban areas


  • Justin Tyler McDaniel Southern Illinois University
  • David L Albright University of Alabama
  • Juliane P Wallace Southern Illinois University
  • Wiley D Jenkins Southern Illinois University School of Medicine



veteran, veterans, aging, old, older, rural, urban, vision, vision loss, low vision, veterans health administration, va, BRFSS, race, ethnicity, income, msa, generalized linear mixed model, logit link, odds ratio, adjusted odds ratio, aor


Purpose:  Although rurality has been shown to be a risk factor for vision loss in the general population, there are no published studies to evaluate the relative risk of vision loss in older veterans (age greater than 64 years).  Given that veterans have access to a separate healthcare system, the Veterans Health Administration system, this study sought to determine whether older rural veterans had a higher prevalence of vision loss than older urban veterans.

Methods:  Data for this cross-sectional study were obtained from the 2016-2018 Behavioral Risk Factor Surveillance System (BRFSS) surveys.  Older veteran (n = 49,697) self-reported vision loss was regressed on rural-urban area of residence in a mixed logit model, where state of residence served as a random intercept.  This study model controlled for age, race, sex, income, binge drinking behavior, cigarette use, BMI, exercise, diabetes, and mental distress.

Results:  Analysis demonstrated that vision loss among older veterans was more prevalent in rural areas (6.73%, 95% CI = 6.27, 7.22) than in urban areas (5.89%, 95% CI = 5.57, 6.23).  After controlling for all confounders previously described, rurality was independently associated with vision loss among older veterans (aOR = 1.12, 95% CI = 1.02, 1.23).

Conclusions:  In a search of the peer-reviewed medical literature (using MEDLINE and cross-referenced literature, this study is the first to demonstrate a rural-to-urban disparity in vision loss among older veterans in the United States.  The results of this study demonstrate the need for broader access to health care, including evidence-based remote or telehealth eye care screening and rehabilitation programs for rural veterans, especially within the Veterans Health Administration system.

Author Biographies

Justin Tyler McDaniel, Southern Illinois University

Assistant Professor of Public Health

School of Human Sciences

Southern Illinois University

David L Albright, University of Alabama

Professor of Social Work

School of Social Work

University of Alabama

Juliane P Wallace, Southern Illinois University

Associate Professor of Exercise Science

School of Human Sciences

Southern Illinois University

Wiley D Jenkins, Southern Illinois University School of Medicine

Research Associate Professor

Chief, Epidemiology and Biostatistics

Department of Population Science and Policy

Southern Illinois University School of Medicine


Stelmack JA, Tang C, Wei Y, et al. Outcomes of the Veterans Affairs low vision intervention trial II (LOVEIT II): a randomized clinical trial. JAMA Ophthalmology 2017; 135(2): 96-104.

Crews JE, Campbell VA. Health conditions, activity limitations, and participation restrictions among older people with vision impairments. Journal of Visual Impairment and Blindness 2001; 95(8): 453-67.

West SK, Munoz B, Rubin GS, et al. Function and visual impairment in a population based study of older adults: The SEE project. Investigative Ophthalmology and Visual Science 1997; 38(1): 72-82.

Burmedi D, Becker S, Heyl V, et al. Emotional and social consequences of age-related low vision. Visual Impairment Research 2002; 4(1): 47-71.

Mitchell J, Bradley C. Quality of life in age-related macular degeneration: a review of the literature. Health and Quality of Life Outcomes 2006; 4: 97-117.

Leat SJ, Zecevic AA, Keeling A, et al. Prevalence of vision loss among hospital in-patients: a risk factor for falls? Ophthalmic and Physiological Optics 2018; 38: 106-14.

Zhang X, Bullar KM, Cotch MF, et al. Association between depression and functional vision loss in persons 20 years of age or older in the United States, NHANES 2005-2008. JAMA Ophthalmology 2013; 131(5): 573-81.

Siantar RG, Cheng C, Cheung CMG, et al. Impact of visual impairment and eye diseases on mortality: the Singapore Malay eye study (SiMES). Science Reports 2015; 5: 16304-12.

Chan T, Friedman DS, Bradley C, et al. Estimates of incidence and prevalence of visual impairment, low vision, and blindness in the United States. JAMA Ophthalmology 2018; 136(1): 12-9.

Crews JE, Chou C-F, Stevens JA, et al. Falls among persons aged ≥65 years with and without severe vision impairment – United States, 2014. Morbidity and Mortality Weekly Report MMWR 2016; 65(17): 433-7.

Smith SL, Bennett LW, Wilson RH. Prevalence and characteristics of dual sensory impairment (hearing and vision) in a veteran population. Journal of Rehabilitation Research and Development 2008; 45(4): 597-610.

Urosevich TG, Boscarino JJ, Hoffman SN, et al. Traumatic brain injury seen among veterans in non-VA facilities: implications for clinical practice. Military Medicine 2018; 183(11-12): e564-70.

Pogoda TK, Hendricks AM, Iverson KM, et al. Multisensory impairment reported by veterans with and without mild traumatic brain injury history. Journal of Rehabilitation and Research Development 2012; 49(7): 971-84.

Richer S, Stiles W, Statkute L, et al. Double-masked, placebo-controlled trial of lutein and antioxidant supplementation in the intervention of atrophic age-related macular degeneration: the veterans LAST study (lutein antioxidant supplementation trial). Optometry 2004; 75(4): 216-30.

Stevelink SAM, Malcolm EM, Gill PC, et al. The mental health of UK ex-servicemen with a combat-related or a non-combat related visual impairment: does the cause of visual impairment matter? British Journal of Opthalmology 2015; 99(8): 1103-8.

Boyko EJ, Jacobson IG, Smith B, et al. Risk of diabetes in US military service members in relation to combat deployment and mental health. Diabetes Care 2010; 33(8): 1771-7.

Amaral EFL, Pollard MS, Mendelsohn J, et al. Current and future demographics of the veteran population, 2014-2024. Population Review 2018; 57(1): 28-60.

Kirtland KA, Saadine JB, Geiss LS, et al. Geographic disparity of severe vision loss – United States, 2009-2013. Morbidity and Mortality Weekly Report MMWR 2015; 64(19): 513-7.

Hale NL, Bennett KJ, Probst JC. Diabetes care and outcomes: Disparities across rural America. Journal of Community Health 2010; 35: 365-74.

Blumenthal SJ, Kagen J. The effects of socioeconomic status on health in rural and urban America. JAMA 2002; 287(1): 109.

Yip JLY, Luben R, Hayat S, et al. Area deprivation, individual socioeconomic status and low vision in the EPIC-Norfolk eye study. Journal of Epidemiology and Community Health 2014; 68: 204-10.

Holder KA. Veterans in rural America: 2011–2015. American Community Survey Reports, ACS-36, U.S. Census Bureau, Washington, DC, 2016.

Substance Abuse and Mental Health Services Administration. Results from the 2016 national survey on drug use and health: Detailed tables. Available at (Accessed March 23, 2020).

Gudbranson E, Glickman A, Emanuel EJ. Reassessing the data on whether a physician shortage exists. JAMA 2017; 317(19): 1945-6.

Chakravarthy U, Wong TY, Fletcher A, et al. Clinical risk factors for age-related macular degeneration: a systematic review and meta-analysis. BMC Ophthalmology 2010; 10: 31-43.

Cho E, Hankinson SE, Willett WC, et al. Prospective study of alcohol consumption and the risk of age-related macular degeneration. Epidemiology and Biostatistics 2000; 118(5): 681-8.

Sabel BA, Wang J, Cardenas-Morales L, et al. Mental stress as a consequence and cause of vision loss: the dawn of psychosomatic ophthalmology for preventive and personalized medicine. EPMA Journal 2018; 9(2): 133-60.

Centers for Disease Control and Prevention. Behavioral risk factor surveillance system: Survey data and documentation. Available at (Accessed October 10, 2019).

Centers for Disease Control and Prevention. 2016 summary data quality report. Available at (Accessed October 15, 2019).

Centers for Disease Control and Prevention. 2017 summary data quality report. Available at (Accessed October 15, 2019).

Centers for Disease Control and Prevention. 2018 summary data quality report. Available at (Accessed October 15, 2019).

Centers for Disease Control and Prevention. Overview: BRFSS 2018. Available at (Accessed October 15, 2019).

Centers for Disease Control and Prevention. BRFSS data quality, validity, and reliability: BRFSS data quality and national estimates. Available at (Accessed October 15, 2019).

McDaniel JT, Albright DL, Lee HY, Patrick S, McDermott RJ, Jenkins WD, Diehr AJ, Jurkowski E. Rural-urban disparities in colorectal cancer screening among military service members and veterans. Journal of Military Veteran and Family Health 2019; 5(1): 40-8.

Centers for Disease Control and Prevention. Complex sampling weights and preparing 2018 BRFSS module data for analysis. Available at (Accessed October 15, 2019).

Kilmer G, Bynum L, Balamurugan A. Access to and use of eye care services in rural Arkansas. Journal of Rural Health 2010; 26(1): 30-5.

Maa AY, Wojciechowski B, Hunt K, et al. Remote eye care screening for rural veterans with technology-based eye care services: a quality improvement project. Rural and Remote Health 2017; 17(1): 4045-54.

Murchinson AP, Haller JA, Mayro E, et al. Reaching the unreachable: novel approaches to telemedicine screening of underserved populations for vitreoretinal disease. Current Eye Research 2017; 42(7): 963-70.





Original Articles