Delivering eye care to homeless and marginally housed populations during the COVID-19 pandemic: a pilot study.

OBJECTIVE: Homeless and marginally housed populations experience a higher prevalence of visual impairment relative to the general population. The aim of this pilot study is to present a novel model for conducting ocular screening clinics for homeless individuals during a pandemic and to describe the status of ocular health in this population during this time. METHODS: In this cross-sectional study, 3 outdoor tent-based ocular screening clinics were held in a park in Toronto. Most participants were recruited from local shelters, but additional spots were allocated for homeless individuals on a drop-in basis. Prior to enrolment, each participant underwent COVID-19 screening via a questionnaire and temperature measurement. Those who screened negative received a comprehensive eye examination, including vision testing, dilated fundus examination, and autorefraction. RESULTS: Eleven individuals completed all assessments. The mean age of participants was 54.5 years, and 11 of the participants were male. Visual impairment was found in 5 individuals. Refractive error via pinhole testing was found in 1 patient. Ocular pathology in this sample was found in 4 participants. Two patients required a referral to an ophthalmologist. From a psychosocial perspective, 4 participants reported significant difficulties. CONCLUSIONS: This novel tent-based ocular screening program provides a viable option for screening in a pandemic.

Ophthalmic findings in marginally housed women in a Canadian city.

OBJECTIVE: To assess the prevalence and common causes of ocular pathology experienced by vulnerable women with marginalized housing and/or a history of abuse, violence, and trafficking. METHODS: Using a stratified random sampling technique, we recruited 93 women living in 10 randomly selected women's shelters in Toronto, Canada between May and November of 2018. All English-speaking females older than the age of 18 were eligible to participate. Data on demographics, medical or ocular history, subjective visual acuity, and access to eye care were obtained. Comprehensive visual screening and dilated fundoscopy were performed for each participant. RESULTS: The median age was 40 years (interquartile range, 30.5-54 years) and the median duration of homelessness was 8 months (interquartile range, 2.25-20.5 months); 63.4% of participants reported a history of abuse, 44.9% experienced head trauma, 15.9% experienced eye trauma, 22.5% identified as refugees, and 2.17% (2 of 92) had been victims of human trafficking. The above variables were not significantly related to vision problem severity on univariate analysis. Based on the presenting visual acuity, 27.8% of participants (95% CI [18.9-38.2]) were found to have visual impairment. Visual impairment was mainly related to refractive error (54.8% [51 of 93]), however, nonrefractive pathology was also observed. Of all the participants, 64.5% had one or more abnormal findings during the vision screening, and 40.9% needed follow-up by an ophthalmologist. Most participants (96.7%) expressed interest in accessing free eye examinations. CONCLUSIONS: Visual impairment is highly prevalent among homeless women living in Toronto. Routine vision-screening programs present an opportunity to improve the ocular health of this vulnerable population.

The Attitudes of Canadian Ophthalmology Residents and Pre-Clerkship Medical Students at an Ontario Medical School Towards Homeless Individuals: A Cross-Sectional Study.

Purpose: This cross-sectional study assessed the attitudes of Canadian ophthalmology residents (PGY1-5) and pre-clerkship medical students (year 1 and 2) at the University of Toronto towards individuals experiencing homelessness.Methods: Residents and students were invited to complete the Health Professionals' Attitudes Towards the Homeless Inventory (HPATHI) tool to assess attitudes, interests and confidence in working with the homeless population on a 5-point Likert scale. Comparisons were made between residents and pre-clerkship learners and between junior and senior residents using the Fisher exact test and Mann-Whitney U test.Results: Responses were received from 114 of 220 ophthalmology residents (52%) and 315 of 534 (59%) pre-clerkship medical students. Ophthalmology residents had significantly more negative overall attitudes (pre-clerk median = 4.4, resident median = 4.1, both still indicating positive attitudes) and interests (pre-clerk median = 4.0, resident median = 3.3, residents with more neutral interests) towards working with the homeless population compared to pre-clerkship medical students. Using both statistical methods, beliefs were significantly more negative in 7 of 9 'Attitude' items, 5 of 5 'Interest' items and 1 of 4 'Confidence' items. Ophthalmology residents were only more positive in 1 of 4 of the 'Confidence' items. Attitudes were similar across PGY1-5 training years, except PGY4 and PGY5 residents were more negative than PGY1-3 residents on 1 of 5 'Interest' items.Conclusions: Ophthalmology residents have an at least neutral perception of individuals experiencing homelessness, while medical students have a more positive opinion. Studies exploring optimal ways to advocate for this population are needed for Canada's eye-care trainees.

Visual impairment and the prevalence of ocular pathology in homeless children and adults globally: a systematic review.

BACKGROUND: Homelessness is a global issue in developing and developed countries. This article is the first systematic review to explore its impact on visual health globally. METHODS: A systematic literature search was conducted on OVID MEDLINE, EMBASE, and Cochrane CENTRAL. Peer-reviewed English-language studies with a focus on homeless children or adults that reported on ocular outcomes were included. Primary outcomes and secondary endpoints were reported via weighted averages. Primary outcomes between homeless children and homeless adults were compared using the Fisher exact test. RESULTS: There were 5774 individuals across 23 full-text articles included in the review. For studies reporting primary outcomes, 36.8% of homeless individuals self-reported dissatisfaction with their vision, 26.8% self-reported a previous ocular pathology, 26.3% had uncorrected refractive error, 25.6% were functionally visually impaired, 9.2% had at least one previous eye surgery or procedure, and 4.0% had nonrefractive visual impairment. Upon screening, 25.1% of homeless individuals had some type of ocular pathology, which included cornea and external eye diseases (13.4%), glaucoma (7.4%), cataracts (6.3%), retinal diseases (5.3%), ocular motility disorders (4.7%), trauma (2.3%), neuro-ophthalmological conditions (1.7%), and oculoplastic conditions (0.7%). Homeless adults had significantly more visual impairment (p < 0.001), uncorrected refractive error (p < 0.001), ocular pathology (p < 0.001), cataracts (p < 0.001), retinal pathology (p < 0.001), and neuro-ophthalmological conditions (p < 0.001) relative to children. CONCLUSIONS: Visual impairment in homeless individuals is higher than the general population. Uncorrected refractive error is a leading cause of visual impairment in this population. Additionally, homeless adults have significantly more visual impairment and ocular pathology than homeless children. Future studies should also explore if these differences are consistent in developing countries and investigate ways to increase eye care access for homeless individuals.

Hearing loss and hearing needs in an adult homeless population: a prospective cross-sectional study.

BACKGROUND: Given that hearing loss is associated with increased social isolation, reduced earning potential and neurocognitive disease, findings of uncorrected hearing loss in the homeless population have important policy implications. We sought to estimate the prevalence of hearing impairment in an adult homeless population. METHODS: We recruited adult (age ≥ 18 yr) homeless people across 10 homeless shelters in Toronto between April and June 2018 using a 2-stage sampling technique. Participants were interviewed by 1 interviewer using a modified survey that had been used in previous studies looking at other health needs in homeless populations. A comprehensive head and neck examination and audiometric evaluation were performed in each participant by an otolaryngologist and an audiologist. Descriptive statistics were estimated. Audiometric data were standardized directly for age and sex to facilitate direct comparisons with the general Canadian population. RESULTS: Of the 132 people invited, 100 (75.8%) agreed to participate. The median age was 46 (interquartile range [IQR] 37-58) years. The median duration of homelessness was 24 (IQR 6-72) months. Although most participants (78) had some form of extended health care benefits through social assistance, only 22/78 (28%) were aware that hearing tests and hearing aids were covered through these programs. After direct standardization for age and sex, the proportions of participants with a speech-frequency and high-frequency hearing loss were 39.5% (95% confidence interval [CI] 30.4%-49.3%) and 51.9% (95% CI 42.2%-61.4%), respectively. Nineteen participants were hearing aid candidates, only 1 of whom owned functional hearing aids. Rates of speech-frequency hearing loss (39.5%, 95% CI 30.4%-49.3% v. 19.2%, 95% CI 16.9%-21.7%) and high-frequency hearing loss (51.9%, 95% CI 42.2%-61.4% v. 35.5%, 95% CI 33.1%-37.7%) were substantially higher than in the general Canadian population. INTERPRETATION: Our results suggest that homeless adults have a high prevalence of hearing impairment, even when living within a system of universal health insurance; awareness of health care benefits through social assistance programs was poor. Results from this study may prompt initiatives surrounding homeless outreach and health screening.

Prevalence and impact of eye disease in an urban homeless and marginally housed population.

OBJECTIVE: Homeless and marginally housed (HMH) populations have a higher prevalence of visual impairment than the general population. This study is the first to conduct a comprehensive ophthalmic examination using portable equipment at various homeless shelter locations in an urban population to identify objective ocular pathologies in a randomly selected sample. METHODS: Ten adult shelters were randomly selected in Toronto, Ontario, Canada, and 143 individuals were randomly selected based on their shelter bed numbers at each shelter, in proportion to the shelter's bed capacity. Participants completed a sociodemographic survey and clinical eye examination. Finally, a dilated ocular examination was performed using a portable slit lamp, autorefractor, tonometer, indirect ophthalmoscope, and fundus camera. RESULTS: The median age of participants was 53.3 years; 82.5% were male and 17.5% female. The age-standardized prevalence of visual impairment was 27.4% (95% confidence interval [CI], 20.6-35.1) for study participants. Refractive error was present in 48% of participants, 34% with myopia and 11% with hyperopia, and 37.8% (95% CI, 32.2-45.9) of this study population were diagnosed with at least one nonrefractive ocular pathology. Low income and low educational attainment were associated with increased odds of being diagnosed with nonrefractive ocular pathologies. CONCLUSIONS: A clear health care gap exists between the ophthalmological disease burden of the HMH population and the amount of resources allocated directed toward their needs. Addressing risk factors such as low income and education, as well as increasing access to free eye examinations and visual aids, may be an effective method of attending to this lack of health equity.

Visual impairment and unmet eye care needs among a Syrian adult refugee population in a Canadian city.

OBJECTIVE: To assess the prevalence of visual impairment and unmet eye care needs of the Syrian adult refugee population in Canada. DESIGN: Cross-sectional descriptive study. PARTICIPANTS: Enrolment was offered to all Syrian refugees 18 years or older, with 248 patients enrolled. METHODS: Five clinics were organized from July 2016 to November 2017 in Toronto, Ontario. A vision screening and dilated retinal examination was performed on all participants. Prevalence of visual impairment and nonrefractive pathologies as well as information on sociodemographics and subjective visual acuity were obtained. RESULTS: The mean age of participants was 36 years (interquartile range, 30-35) and 53% were females. The prevalence of reported uncorrected vision problems was 22.2% for distance vision, 6.5% for near vision, and 5.6% for both distance and near vision, including loss of vision. Compared with the Canadian population, Syrian adult refugees were 19.04 times more likely to report uncorrected vision problems (34.4% vs 1.8%, p < 0.01). The presenting visual acuity in the better-seeing eye was 20/50 or worse in 19.4%. Pinhole improved this to 12.5% (95% confidence interval [CI], 8.7%-17.3%). Compared with the Canadian population (0.95%), Syrian adult refugees were 13 times more likely to have 20/50 vision or worse (p < 0.01). The most common finding was refractive error in 46.0% (95% CI, 39.6%-52.4%) followed by nonrefractive error in 30.2% (95% CI, 24.9%-36.2%). CONCLUSIONS: This is the first study to assess ocular health in a refugee population in Canada. Syrian adult refugees have a high prevalence of visual impairment, even when living within a system of universal health care.

Visual impairment and unmet eye care needs among a Syrian pediatric refugee population in a Canadian city.

OBJECTIVE: To assess the ocular health status of Syrian pediatric refugees in Canada and report the prevalence of vision impairment within this population. DESIGN: Cross-sectional descriptive study. PARTICIPANTS: Syrian refugees 18 years old or younger. METHODS: Five clinic days were organized from July 2016 to November 2017 in Toronto, Ontario. A total of 274 patients were enrolled. Data collection involved surveys, vision screening, and ocular examinations. χ2 was used for statistical analysis. RESULTS: The prevalence of uncorrected vision was 17.2% for distance, 4.7% for near, and 0.7% for both distance and near vision, including loss of vision. Of these, 95.3% had not visited an eye specialist in the past year, and 25.2% of parents were dissatisfied with their children's vision. The presenting visual acuity in the better-seeing eye was 20/50 or worse in 5.8% (95% confidence interval [CI] 3.6%-9.3%), and this did not correct with pinhole. This rate is 32 times (p < 0.01) higher than the prevalence rate in the average Canadian pediatric population (0.17%). Uncorrected refractive error prevalence was 26.3% (95% CI 21.2%-31.9%), with the most common etiology being myopia (19.7% CI 15.2%-24.9%). Myopia was 17.9 times (p < 0.0001) more prevalent among our Syrian refugee children compared with the average Canadian pediatric population (1.1%). CONCLUSION: Syrian pediatric refugees residing in Canada have a high prevalence of vision problems. Comprehensive vision screening, improved access to eye clinics, and developing evidence-based guidelines may help address the unmet eye care needs of this vulnerable population.

Identifying the ophthalmic needs of families living in Toronto shelters.

OBJECTIVE: To assess the ophthalmic needs of families with children residing in Toronto shelters. DESIGN: Cross-sectional study. PARTICIPANTS: Forty-nine families, including 86 children (age 0-16 years) and 55 adult and youth family members (AYFM) (age >16 years), randomly selected from 5 family shelters in Toronto, Ont. METHODS: Ten families with at least 1 child aged 16 years or younger were randomly recruited from each shelter. Data on sociodemographics, medical history, ocular history, and access to eye care were collected through a structured interview. Eye examinations were performed in the shelters for all children and AYFM. RESULTS: The mean age for AYFM was 34.9 ± 9.3 years (range, 17-60 years), and the mean age for children was 6.1 ± 4.3 years (range, 1 month-16 years). Thirty-nine percent of parents reported dissatisfaction with their vision, and 6.7% of children had parents who perceived that their child had eye problems. Overall, fewer parents had accessed care for their own eye problems in the last year than for their children (parents 36.4%, children 81.8%). Examination revealed abnormal ocular findings in 47.3% of AYFM and 24.4% of children. The commonest finding in AYFM was refractive error (30.9%); among children, it was refractive errors (16.3.%) and strabismus (3.5%). CONCLUSIONS: We found that a significant percentage of families living in shelters had eye problems that required treatment. We propose a proactive approach to identify these families and their dependent children in order to expedite access to appropriate eye care in a timely fashion for this vulnerable population.

Unmet eye care needs among a homeless youth population.

OBJECTIVE: To assess the rate of visual impairment and quantify the unmet eye care needs within Toronto's homeless youth community. DESIGN: Prospective and cross sectional. PARTICIPANTS: Ninety randomly selected homeless youth aged 16-24 years. METHODS: From each of 9 participating homeless youth shelters and drop-in centres in Toronto, 10 English-speaking youths between ages 16 and 24 were randomly recruited. Information regarding sociodemographics, medical history, subjective visual acuity, and access to eye care was collected. Comprehensive visual screening and undilated direct fundoscopy were also performed. RESULTS: The median age of participants was 21 years (interquartile range = 19-23 years), and 62.2% were male. Most participants were homeless for less than 5 years (90%) and earning less than $500 monthly (57.8%). Despite 51.1% of participants having previously owned corrective lenses, only 20% of participants currently owned them when assessed/at study time. When analyzing the better-seeing eye, presenting visual acuity was 20/50 or worse in 18.9% (95% CI 10.8%-27.0%) of participants. Pinhole occlusion decreased the number to 2.2% (95% CI 0%-5.3%). The most common cause of visual impairment was uncorrected refractive error. Ocular pathology was observed in 8 participants. Compared to adults, youth have similar functional visual impairment (adults 24.0%, youth 18.9%) but less impairment uncorrectable by pinhole occlusion (adults 11.0%, youth 2.2%) and are less dissatisfied with their vision (adults 70.0%, youths 36.7%). Although a higher proportion of homeless youths have visited an eye specialist in the past year (adults 14.0%; youths 17.8%), neither group is visiting as frequently as the Canadian average (41%) (p < 0.01). CONCLUSIONS: Homeless youth have a high prevalence of visual impairment, even when living within a system of universal health insurance. Ongoing vision-screening programs, readily accessible free eye clinics, and particularly low-cost glasses may help address this need.

Visual impairment and unmet eye care needs among homeless adults in a Canadian city.

IMPORTANCE: The ocular status of homeless populations remains largely unknown. Given that visual acuity has been shown to be heavily correlated with reduced well-being and decreased earning potential, findings of poor vision could have important health implications for people experiencing homelessness. OBJECTIVES: To assess the prevalence of visual impairment and to identify unmet eye care needs in an adult homeless population. DESIGN, SETTING, AND PARTICIPANTS: For this cross-sectional study, we recruited 100 homeless persons using a stratified random sampling technique from January to March 2014. Recruitment took place at 10 randomly selected adult shelters in Toronto, Ontario, Canada. All English-speaking persons older than 18 years of age were eligible to participate. Information was obtained on sociodemographic characteristics, ocular history, and subjective visual acuity. A comprehensive vision screening and an undilated retinal examination were performed for each participant. MAIN OUTCOMES AND MEASURES: Rates of functional visual impairment and prevalence of nonrefractive eye pathology. RESULTS: The median age of participants was 48 years (interquartile range, 36-56 years), and 62% were men. The median lifetime duration of homelessness was 12 months (interquartile range, 5-36 months). Based on the participants' presenting visual acuity, the age-standardized rate of visual impairment was 25.2% (95% CI, 16.7%-33.7%). After pinhole occlusion, this number decreased to 15.2% (95% CI, 7.7%-22.7%). In total, 13.0% (95% CI, 7.8%-20.0%) of participants experienced visual impairment secondary to a correctable refractive error. Although the major problem for this demographic was limited access to refractive correction, a large degree of nonrefractive pathology was also observed. Of all the participants, 34.0% (95% CI, 24.7%-43.3%) had 1 or more abnormal findings during the vision screening, and 8% (95% CI, 2.7%-13.3%) required urgent referral to an ophthalmologist. A large majority of participants (89.0%) indicated interest in accessing free eye examinations. CONCLUSIONS AND RELEVANCE: These data suggest that homeless adults have a high prevalence of visual impairment, even when living within a system of universal health insurance. Given the high level of interest in eye care among homeless persons, ongoing vision-screening programs and readily accessible free eye clinics may help address this need.