The AOA's Healthy Eyes Healthy People^® Program 6-Year Evaluation Report (2004-2009)

Article Outline

• Background
• Method for program review
• Results of program review
• Discussion
• Strengths and weaknesses
• Collaboration
• Outcome measure
• Future evaluation planning
• References

It has been 10 years since the U.S. Department of Health & Human Services (HHS) established America's first set of national vision care objectives as part of its Healthy People 2010 program. The inclusion of vision objectives in Healthy People 2010, which effectively constitutes the nation's official public health agenda, would mean greater emphasis on eye and vision care as a critical element in overall health. It would also focus new attention on a range of specific eye and vision issues including the growing threat of age-related (cataract, glaucoma) and diabetes-related eye conditions, the need for better eye and vision care among children and adolescents, preventing debilitating eye injuries through protective eyewear, and simple refractive errors as major causes of visual impairment.

Having worked to include vision objectives in the national public health agenda, the American Optometric Association (AOA), more quickly than virtually any other health profession organization in America, set out to make sure those urgent objectives would be addressed across the country.

The AOA Healthy Eyes Healthy People® (HEHP) project, established by the association as part of a formal Memorandum of Understanding with the HHS, would provide an innovative ongoing program for the development of community-based eye and vision care outreach initiatives centered around Healthy People 2010 vision care objectives and custom tailored to the needs of local, underserved populations. Each HEHP community outreach program would be developed by a participating state optometric association in conjunction with a local partner to ensure the program would meet the needs of local residents as well as be sufficiently accessible. Volunteer optometrists and their staffs would provide high-quality eye and vision care services through the project. Corporate grants would be secured to defray costs.

Since 2004, the HEHP program has provided $1 million in grants for a total of 279 innovative projects addressing diabetes, glaucoma, children's vision, eye safety, low vision, and other issues. The program is nearing its primary goal; the underwriting of HEHP projects in all 50 states. (To date, projects have been approved in 48.) Local partners have ranged from hospitals and health departments to churches and schools.

The program has been most active in providing eye and vision care for children with $358,700 (36%) of the funds allocated to date spent on children's vision projects; $269,500 (27%) on diabetes related eye problems; $65,000 (13%) on age-related vision problems (equally divided between vision impairment and glaucoma); and $241,500 (24%) on others.

The HHS is now preparing to issue a new set of vision care priorities as part of its Healthy People 2020 health objectives—covering the time period Congress has officially designated as “The Decade of Vision.” With that in mind, the AOA Clinical and Practice Advancement Group (AOA CPAG) conducted a formal study of the HEHP program's first half-dozen years of operation to determine how effective optometry has so far been in addressing the nation's top eye and vision care priorities at the local level.¹

The report finds HEHP has clearly been effective in reaching numerous underserved populations and has provided both vision care and public education in a highly cost-effective manner. As the program has broadened throughout the optometric community, it has helped improve the visual well being of communities across the nation. However, the report also concludes that greater input from local partners and targeted patient groups may be necessary to ensure HEHP projects coincide with the objective of collaborators and meet the needs of patients.

In assessing the program, the AOA CPAG noted that the HEHP program is intended to directly provide benefits and improve the overall health of residents in a community. However, it is also intended to identify and document unmet need for eye and vision care, thereby providing data and demonstration projects that may be useful in shaping pertinent public policy at the state or local level. The HEHP program effectively serves to identify, educate, and promote awareness of visual disorders, systemic diseases, and ocular diseases, as well as public health policy that can impact the visual health of a community. Through this program, AOA and affiliate optometric associations collaborate with non-optometry groups to eliminate health disparities and improve the eye and visual health of the nation. Not only does the initiative continue to provide optometrists the tools necessary to succeed, but it acts as a supporter for patient rights and educates patients as to the role healthy eyes play in a healthy lifestyle. The overall good health of the general public will increase as a result of increased access to care and early detection and intervention for general health issues, diseases, and disorders of the visual system. Although participating optometrists are not compensated for their services, they may find incidental benefit in terms of community relations.

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Background 

Robert N. Kleinstein O.D., Ph.D., outlined the Healthy People vision objectives in a 1994 Optometry: Journal of the American Optometric Association guest editorial.² “The Healthy People 2000 objectives represent a major opportunity for optometry to expand its scope of practice, enhance its quality of patient care, and become involved in making policies and programs that will directly affect the services and patient care it provides,” Dr. Kleinstein wrote. “If optometrists take advantage of this opportunity they will: (1) increase the visibility of optometry and enhance our image as the primary eye and vision care provider; (2) increase the number of patients seen by optometrists; (3) expand the number of organizations, policy makers, and third-party providers who understand the services optometrists provide and their importance in achieving the Healthy People 2000 objectives; (4) increase the number of referrals from nontraditional sources; (5) enhance the overall health of their patients; and (6) be recognized as the leader of health promotion and disease prevention activities involving eye and vision care.”

“The question is,” Dr. Kleinstein continued, “Will optometrists become involved and use this opportunity? We must look back from the perspective of the year 2000 and be able to answer this question with a definite YES!”

The HHS began setting goals for health objectives for the nation in 1979. The first group of 10-year objectives for the nation was set forth in 1980 in its Promoting Health/Preventing Disease: Objectives for the Nation report.³ Vision objectives were first included in the 2010 version of Healthy People, grouped with hearing as one of 28 focus areas. In 2001, the AOA Board of Trustees approved the formation of the Healthy Eyes Healthy People committee to stimulate optometric involvement in community initiatives for health promotion and disease prevention that supported the vision objectives of Healthy People 2010. In 2002, the AOA was one of only 7 national associations to have a Memorandum of Understanding (MOU) with HHS. This MOU reflected the intent of AOA and HHS to work together toward the following:

Specific goals included:

The strategy would be to address these goals by using the vision objectives from the Healthy People 2010 document. Those vision objectives are:

As Alden N. Haffner, O.D., Ph.D., observed in a September 2000 Optometry guest editorial, these 10 objectives are well within the abilities of optometrists to address.⁴, ⁵, ⁶ Dr. Haffner also suggested the policy implications for optometry were huge. The blueprint for the AOA, and for all of the state associations, should be the dissemination and enactment, by statues, regulations, and program initiatives, to institutionalize the vision objectives of Healthy People 2010, he said. Dr. Haffner believed that if properly executed, the initiatives leading to 2010 would provide momentum to the next (2010-2020) decade that could produce remarkable results and offer extraordinary opportunities for the optometric profession to increase its responsibilities to the American public and extensively improve its well-being. In the same issue of Optometry, Dr. Kleinstein and Norma K. Bowyer, O.D., M.P.H., formally introduced optometry to the Healthy People 2010 vision objectives. “These objectives address many important areas, including regular dilated eye examinations; vision screening for preschool children; uncorrected visual impairment due to refractive errors; blindness and visual impairment in children and adolescents; visual impairment due to diabetic retinopathy, glaucoma, and cataracts; occupational eye injury; the use of personal protective eye wear in recreational activities and hazardous situations around the home; and the use of vision rehabilitation services and adaptive devices by people with visual impairments. These new national health goals and objectives will impact optometrists. Therefore, it is important that optometrists understand these objectives and actively work to help implement them at the national, state, and local levels. By doing this, they can help provide the services needed to reduce visual impairments and improve the vision of people in their communities,” Drs. Kleinstein and Bowyer wrote.

One of the strategies of the HEHP committee was to institute a grant program with the support of the ophthalmic industry. Currently, Luxottica and VSP provide funding through state optometric associations to help address the vision needs of communities. These innovative HEHP collaborative community outreach program grants address one or more of the 10 Healthy People 2010 vision objectives. Applicants propose a project that focuses on one or more of the Healthy People 2010 vision objectives and involves cooperation between community-based, nonoptometric organizations and members of the state optometric association. Each award is worth up to a maximum of $5,000. Optometrists may apply through their state optometric associations. Letters of support for collaboration from each participating organization are required with each application form. Collaborations with other state health associations and/or public agencies must reflect broad-based sponsorship. The AOA HEHP Committee evaluates, selects and administers the projects. Recipients may reapply for continued support. The HEHP grants should strengthen the outreach of community-based organizations by providing “seed money” to begin or continue vision-related projects.

HEHP promotes partnerships between government agencies, health care advocates, and optometrists to expand ground-breaking approaches for community outreach to promote good eye health and optimal vision. The HEHP grants are highlighted each year at national HEHP conferences. In the last 7 years, these conferences have included speakers representing the U.S. Department of Health and Human Services, the Centers for Disease Control and Prevention (CDC), the National Eye Institute, the Office of Disease Prevention and Health Promotion, the Health Resources and Services Administration, and state departments of health, to name a few. To promote collaboration in the HEHP grants, there have been speakers from the American Public Health Association, American Association of Diabetes Educators, American Heart Association, National Association of Community Health Centers, National Head Start Association, National Rural Health Association, Academy of General Dentistry, and Community–Campus Partnerships for Health. Representatives from the nation's schools and colleges of optometry have also attended the conferences and submitted HEHP grant applications.

After eight years, the HEHP initiative remains one of the 4 tenets of the AOA Strategic Plan. Each state optometric association has appointed an HEHP consultant to spearhead activities at the state and local level. The goal of the 6-year evaluation of the HEHP program was to examine the general effectiveness of partnership activities across the 10 Healthy People 2010 vision objectives. The primary audiences for the evaluation findings are the HEHP partners, sponsors, collaborators, and the larger vision community. Findings will be used to assist future planning efforts for HEHP by identifying successes and challenges during the last 6 years. The purpose of this review is to evaluate the impact that the HEHP grants have had in helping implement the vision objectives of Healthy People 2010 nationwide.

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Method for program review 

All of the grants that have been awarded through the HEHP program from 2004 to 2009 were assessed. Data analyzed included the state optometric association applying, the types of collaborations they established, the amount of funding received, and the vision objectives addressed.

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Results of program review 

The results from the 6-year data suggest that HEHP has been successful on many levels, though collaboration with partners may need to be re-examined and improved. Partnership collaboration is particularly important given that networking and information exchange are key benefits of HEHP. One of our findings was that goal similarity was an important predictor for increasing collaboration capacity and involvement in HEHP. We are fortunate that our program is based on some of the broader goals of the Healthy People 2010 vision objectives. HEHP may want to consider developing a plan that outlines the reasons and strategies for how to educate or inform its collaborators to incorporate the Healthy People 2010 vision objectives into their organizational/project goals.

Since 2004, when the HEHP grant program began, AOA has distributed $1,000,000 in HEHP grants to 279 state optometric associations for community outreach projects. These grants have funded collaborative community outreach projects, including projects addressing diabetes, glaucoma, children's vision, eye safety, and low vision.

The grants established partnerships with a wide variety of organizations. This included 39% with community-based organizations; 17% with state or county health departments; 28% with educational bodies; 27% with other professional organizations; 15% with hospitals, clinics, or private practices; 10% with health centers; and 7% with various other entities. (The total is greater than 100%, as some projects collaborated with more than one organization.) Projects addressing children's vision issues comprised 38% of the total, whereas diabetes was addressed by 28%, glaucoma by 8%, vision impairment by 7%, and the remaining 19% of projects addressed other issues. The amount allocated in dollars to these project areas is shown in Figure 1.

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• Figure 1 

  Healthy Eyes Healthy People® grants funded in dollars.

The number of grants awarded by year, the number of states represented, and the total dollars awarded by year are shown in Table 1.

Table 1. Healthy Eyes Healthy People® grant awards and funding by year

Per program rules, all of the projects dealt with one or more of the vision objectives of Healthy People 2010. The greatest number of projects addressed Objective 28-5, Reduce visual impairment due to diabetic retinopathy. The objectives regarding occupational injury and protective eyewear were incorporated into the least number of projects. The percentage of projects for each vision objective is provided in Table 2.

Table 2. Percentages of Healthy Eyes Healthy People® projects addressing various Healthy People 2010 objectives

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Discussion 

According to a 2009 CDC report, Improving the nation's vision health: A coordinated public health approach, blindness and vision impairment are major public health problems causing a substantial human and economic toll on individuals and society, including significant suffering, disability, loss of productivity, and diminished quality of life for millions of people.

It has been estimated that at least half of all blindness can be prevented through timely diagnosis and treatment. More than 3.4 million (3%) Americans 40 years and older, are either blind or visually impaired, and millions more are at risk for vision impairment and blindness, according to the CDC report. By 2030, the number of blind and visually impaired people is predicted to double, according to the report. Preparing now to prevent this expected increase in morbidity and its associated costs is imperative. To address this growing concern, the AOA and its partners are focusing on this compelling and urgent challenge. AOA recognizes that vision impairment continues to adversely impact the quality of life for large numbers of individuals nationwide, particularly those most at risk in society.

The AOA is committed to Healthy People 2010. The HEHP program is an initiative led by the AOA, the voice of America's primary eye care profession, which provides optometrists the support and information necessary to make a greater impact on not just the visual health, but the overall health of the general public. This initiative provides optometrists the tools necessary to succeed and acts to educate patients as to the role healthy eyes play in a healthy lifestyle.

Optometrists have the information, tools, and support they need to improve the vision and health of the general public. The HEHP grants are a resource for optometrists to use in establishing community-based programs that recognize the importance of vision services. The overall good health of the general public will increase as a result of increased access to care, and awareness of the importance of early detection and intervention for general health issues, as well as diseases and disorders of the visual system.

Eye and vision care needs to be an integral part of the health care system and plays a major role in improving the quality of life for all Americans. Those involved with HEHP recognize this fact and work to educate optometrists, other health care providers, policy makers, and the public on issues related to disease prevention and health promotion. The program promotes an awareness of visual, ocular, and systemic diseases and an awareness of public policy that impacts the health of communities. A short-term goal of HEHP is to support projects in all 50 states. As the program has spread throughout the optometric community, it has helped improve the visual well being of communities across the country.

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Strengths and weaknesses 

The largest number of projects addressed diabetic retinopathy and children's vision. These 2 areas combined accounted for approximately 2 of every 3 projects. There were 3 years in which no project addressed the reduction of occupational eye injury and 2 years in which no project addressed the use of personal protective eyewear. In 2009, there was no project that addressed cataracts. The HEHP program needs to remind optometrists of the objectives on occupational eye injury, increased use of personal protective eye wear, and reducing visual impairment caused by cataract while working to make the other projects a regular part of optometric practice.

Perhaps efforts related to diabetes and children's vision should have as their emphasis incorporating the results of these projects into a community outreach handbook that looks at the strengths and weaknesses of previous efforts. This could then be utilized by state and local optometric organizations as a roadmap to enhancing their community outreach. Our challenge is to give optometrists the tools and information necessary to continue to bring the goals outlined in this plan to life, and to recognize the roles of doctors of optometry as the primary eye and vision care providers in the American health care delivery system.

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Collaboration 

For many, the motivation to support HEHP is the opportunity to collaborate and network with others in the areas of Healthy People 2010 vision objectives. Thus, an important indicator of HEHP effectiveness is the amount and diversity of collaborations that occur. In terms of increasing collaborations with diverse organizations, more emphasis should be given to creating synergy with groups that have been underrepresented. This kind of progress has been seen in the large number of collaborations with hospitals and clinics. Partnerships with community organizations should still be encouraged, but future efforts should emphasize collaborations with CHCs and departments of health.

As with the objectives addressed, the HEHP program must strive for both depth and breadth in this area. As the program moves forward, HEHP should prioritize funding for programs that create new networks of collaboration. A breakdown by HEHP projects by collaborating partners is provided in Figure 2.

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• Figure 2 

  Percentage of HEHP projects by collaborating partners.

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Outcome measure 

One of the main reasons for the existence of HEHP is to increase collaboration with its partners. That is, the HEHP program should assist its community partners to improve access to eye care that doctors of optometry provide to their constituents. Optometrists' collaboration with hospitals and clinics has been increased from 2.38% in 2004 to 40.35% in 2009. The HEHP program developed strong collaborations with community organizations (28.57% in 2004 to 52.63% in 2009), professional organizations (19.05% in 2004 to 29.82% in 2009), and health departments (9.52% in 2004, 22.81% in 2009).

Projects involving CHCs went from 11.90% in 2004 to 7.02% in 2009. There has been a relatively consistent collaboration with educational institutions throughout the program. An implication from this finding might be that HEHP needs to align its goals closely with HEHP collaborators and increase the perceived value of the 10 Healthy People 2010 vision objectives.

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Future evaluation planning 

Although this 6-year evaluation provided useful insights for assessing the program, a more comprehensive evaluation plan should be developed for the future. The plan may use an evaluation framework to examine the inputs and outputs of the program and should incorporate a methodology for gaining input from various stakeholders, including target audiences. This will assist the HEHP program in conducting future assessments. The AOA HEHP program acts as a vehicle for bringing vision health into the public health arena, and to aid the public health community in its efforts to improve the nation's vision health.

Table 3. Percentages of Healthy Eyes Healthy People® projects involving major categories of collaborators

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References 

1. Zumbrink U, Frazier M, Visker J, et al. The AOA Healthy Eyes Healthy People^® Program: 6-Year Evaluation Report 2004-2009. American Optometric Association internal report. March 2010;
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2. Kleinstein RN. Healthy People 2000—health promotion and disease prevention, a new opportunity for optometrists. J Am Optom Assoc. 1994;65:88–91
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3. U.S. Public Health Service . Promoting Health/Preventing Disease: Year 2000 Objectives for the Nation. Washington, D.C.: U.S. Government Printing Office; 1980;
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4. Haffner AN. Optometrists in the mainstream—2010 and 2020. Optometry. 2000;71:551–552
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5. Bowyer N, Kleinstein RN. Healthy People 2010—vision objectives for the nation. Optometry. 2000;71:569–578
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6. U.S. Centers for Disease Control and Prevention. Improving the nation's vision health: A coordinated public health approach. Available at: www.cdc.gov/visionhealth/pdf/improving_nations_vision_health.pdf. Last accessed December 22, 2009.
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