D568 Task 1 Social Determinants Comparison Example

The Same Note Sent Home: How Social Determinants Decided Which of Two Composite Nine-Year-Olds Got Eyeglasses After Failing a School Vision Screening

Student Name

Leavitt School of Health, Western Governors University

D568: Health Equity and Social Determinants of Health, Task 1

Course Instructor

Month Day, Year

The Same Note Sent Home: How Social Determinants Decided Which of Two Composite Nine-Year-Olds Got Eyeglasses After Failing a School Vision Screening

Two Children, One Result

In October, the school nurse in a mid-sized city screened every third grader's vision. Two nine-year-olds, Maya and Jaylen, both failed in both eyes, and both families received the same letter recommending a full eye examination. Both children had been squinting at the board, and both were reading below grade level. By the end of the school year, Maya had worn glasses for seven months and her reading had caught up. Jaylen had never seen an eye doctor. Nothing about their eyes explains the difference. What differed was the circumstances in which they live, the social determinants of health, which the World Health Organization describes as the conditions in which people are born, grow, live, work and age, and the forces that shape those conditions (Braveman & Gottlieb, 2014).

This paper compares the two children across the five domains of the Healthy People 2030 framework: economic stability; the access to and quality of education; the access to and quality of health care; the neighborhood and the built environment; and the social and community context (Office of Disease Prevention and Health Promotion, n.d.).

Economic Stability

Maya's mother is an accountant and her father a pharmacist; the household income is about $160,000. Jaylen lives with his mother, who works two part-time jobs, one as a home health aide and one stocking shelves overnight, and earns about $31,000 a year. For Maya's family, the $45 copay for the eye exam and $120 for frames beyond what insurance covered were minor. For Jaylen's mother, taking an unpaid morning off to go to an appointment meant losing a morning's wages, and she did not know whether glasses would cost her anything. Economic instability does not only limit what families can buy; it limits the time they have to navigate a system.

Health Care Access and Quality

Maya has private insurance with a vision rider, and her family has seen the same optometrist since her brother needed glasses. Her mother booked an appointment online the night the letter came home. Jaylen is covered by Medicaid, which includes children's eye exams and glasses, but his mother did not know that. The two optometry practices nearest their home did not accept Medicaid, and the practice that did had a six-week wait for a weekday appointment and no evening hours. When she called, she was put on hold, and her break ended before anyone answered.

Neighborhood and Built Environment

Maya's neighborhood has a shopping center with two optical stores within a mile. Jaylen's neighborhood has neither an eye care practice nor a pharmacy, and the Medicaid optometrist is two bus transfers away, so the trip takes over an hour in each direction. His mother does not own a car. Distance converts an appointment into half a day.

Education Access and Quality

Both children attend public schools, but their schools differ. Maya's school has a full-time nurse who follows up with families by phone two weeks after a failed screening. Jaylen's school shares one nurse with two other schools; she sends the letter but has no time to follow up. Jaylen's teacher noticed his squinting, but with 29 students and no classroom aide, she did not connect it to his reading. Maya's mother, a college graduate, understood that poor vision could explain reading trouble. Jaylen's mother, who left school in 11th grade to work, assumed he would grow out of it.

Social and Community Context

Maya's family has friends who are nurses and teachers, and her grandmother offered to take her to the appointment. Jaylen's family has recently moved, their support network is thin, and his mother has little time to build one. Jaylen also told his mother that a boy in his class had been teased for wearing glasses, and he did not want them. Among children who received glasses through a school program in Baltimore, 20% reported being teased about them (Huang et al., 2019).

The Disparity and Why It Matters

The result is a health disparity: a difference in health and its consequences that follows social disadvantage rather than biology. Uncorrected vision problems affect more than sight. In a cluster randomized trial in Baltimore City Public Schools, students in grades 3 to 7 who received eye exams and eyeglasses through a school-based program improved their reading scores after one year compared with students who had not yet received the program, with the largest gains among girls, students in special education and the lowest-performing students; the effect was not sustained at two years (Neitzel et al., 2021). Consistent use is part of the reason: in the same city's program, 87% of students were observed still wearing their glasses a year later, but fewer than two-thirds reported wearing them as prescribed, and 66% needed replacement glasses during the study (Huang et al., 2019). For Jaylen, a correctable problem is compounding into an academic one, and academic trouble in elementary school is itself linked to later health through education, employment and income.

The comparison also shows how determinants interact. No single barrier stopped Jaylen's family. Medicaid covered the exam, but lack of information, few participating providers, distance, no car, inflexible work hours, an overstretched school nurse and a fear of teasing combined to make the appointment nearly impossible. For Maya, every one of those factors worked in her favor.

Conclusion

Two children with the same need received the same screening result and the same letter. Economic stability, access to care, neighborhood, education and social support decided which one got glasses. The comparison suggests where action would help most: bringing eye exams and glasses to schools, as the Baltimore program did, removes distance, time off work and cost at once, and follow-up by a school nurse with enough time to call families can catch the children for whom a letter is not enough. Medicaid plans could also be held to standards for how many optometrists accept their members and how quickly children are seen, and practices could offer evening and Saturday hours for parents who cannot leave hourly jobs. Each of these steps targets a determinant identified here rather than asking Jaylen's mother to overcome all of them alone.

References

Braveman, P., & Gottlieb, L. (2014). The social determinants of health: It's time to consider the causes of the causes. Public Health Reports, 129(Suppl. 2), 19-31. https://doi.org/10.1177/00333549141291S206

Huang, A. H., Guo, X., Mudie, L. I., Wolf, R., Owoeye, J., Repka, M. X., Friedman, D. S., Slavin, R. E., & Collins, M. E. (2019). Baltimore Reading and Eye Disease Study (BREDS): Compliance and satisfaction with glasses usage. Journal of AAPOS, 23(4), 207.e1-207.e6. https://doi.org/10.1016/j.jaapos.2019.01.018

Neitzel, A. J., Wolf, B., Guo, X., Shakarchi, A. F., Madden, N. A., Repka, M. X., Friedman, D. S., & Collins, M. E. (2021). Effect of a randomized interventional school-based vision program on academic performance of students in grades 3 to 7: A cluster randomized clinical trial. JAMA Ophthalmology, 139(10), 1104-1114. https://doi.org/10.1001/jamaophthalmol.2021.3544

Office of Disease Prevention and Health Promotion. (n.d.). Social determinants of health. Healthy People 2030, U.S. Department of Health and Human Services. https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health