Introduction

Ophthalmic disorders represent a major global disease burden. In 2020, it was estimated that 1.1 billion people globally are living with vision impairment; this figure is projected to reach 1.76 billion people by 2050 due to an expanding and aging population [1]. Existing studies have thoroughly investigated how ocular disorders such as strabismus, refractive errors, and congenital blindness are associated with significant morbidity, with those diagnosed being more likely to experience academic deficits, mental health disorders, barriers to social interaction, and decreased self-esteem and quality of life [2]. For example, a study conducted by Astle et al. found that adults with strabismus have decreased self-esteem, fewer social relationships, increased prevalence of mental health disorders, and reduced quality of life [2]. These factors are important because they are interconnected and impact an individual’s well-being and overall functioning; for example, a lack of close relationships is strongly linked to depression [3], poor physical health [4], and even higher mortality [5].

Pediatric populations are particularly impacted by ocular diseases due to infancy, childhood, and adolescent periods being critical windows for development, learning, and social growth [6,7]. Studies by Alvarez-Peregrina et al. and Joseph have identified an association between worse visual health and poor academic performance, specifically that of uncorrected refractive errors hindering education, personality development, and career opportunities [8,9]. Thus, it is important that clinical tests properly identify children at risk of underachieving academically and allow clinicians to provide additional support in managing these ocular disorders in pediatric patients [10]. Additionally, Mojon-Azzi et al. found that children with strabismus are invited to fewer birthday parties, specifically that children over six years old with a visible squint are less likely to be accepted by their peers [11]. It can be inferred from this finding that negative social and cognitive biases towards strabismus emerge around age six. There is an abundance of literature that has investigated the impact of ocular diseases on the academic and social development of children, but it is also necessary to include an analysis of how social determinants of health (SDOH) modify neuropsychological development in these pediatric ocular patients.

The United States Department of Health and Human Services defines SDOH as “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks [12].” SDOH can thereby attenuate or exacerbate ocular disease burden, influencing the broad outcomes of these diseases on patients’ lives through a complex interplay between external factors and disease burden. These relationships are exemplified by observations that patients with higher socioeconomic status (SES), better access to quality healthcare and education, better living environments, and/or more supportive communities are better equipped to mitigate the detrimental effects of the disease [13].

While many studies have investigated the impact of ocular diseases on the neuropsychological development of children, these tend to focus primarily on the impact of a specific ocular disease while controlling for SDOH factors to avoid confounding rather than analyzing their potential effect(s) on the association between ocular disease and neuropsychological development [14–16]. Using a scoping review methodology, we plan to investigate the existing literature with an emphasis on the three-way intersectionality between pediatric ophthalmology, neuropsychology, and SDOH.

The concept of a scoping review and its nature as “a form of knowledge synthesis, which incorporates a range of study designs to comprehensively summarize and synthesize evidence” are particularly effective for investigating this complex interaction due to the immense breadth of SDOH factors, ocular diseases, and potential developmental effects that exist in the world [17]. We aim to extract information from a variety of articles analyzing a diverse set of ocular diseases and effects and synthesize this information to inform a complex understanding of how SDOH factors influence the outcomes of pediatric ocular diseases and identify gaps to guide future studies in the growing field of SDOH research. Through a thorough review of the literature, we hope to contribute to a more complete understanding of how diseases do not have definitive outcomes for patients but are instead unique to individual patients based on SDOH factors that they exist within. This information will be crucial for informing and directing future medical and public health efforts to improve the outcomes of our communities.

Methods

In this scoping review, we will conduct a comprehensive review of the literature in accordance with guidelines delineated by the Joanna Briggs Institute [18] and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist [19]. The completed scoping review will be presented to address questions concerning (1) the distribution of modern literature among the five defined domains of social determinants of health, (2) the variety of ocular diseases and neuropsychological impacts that have been investigated in the literature, and (3) the distribution of literature among countries of various resource levels. These research objectives will form a framework for our presentation of data, and we will provide summary tables highlighting the distributions we uncovered. The current document serves as a scoping review protocol, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA-P) can be found in the supporting information. Institutional review board approval was not required for this study because there were no human subjects recruited or involved.

Discussion

Understanding how SDOH modulates the developmental impact of disease processes on children is a growing body of research that is essential for the development of effective public health interventions to address these factors beyond the control of patients and their healthcare providers. This scoping review will investigate the existing medical literature with emphasis on the three-way interactions between ophthalmology, neuropsychology, and SDOH components. In contrast to the previous articles focusing on direct correlations between ocular diseases and neuropsychology, this scoping review will provide a comprehensive analysis of whether these articles address SDOH. The three main components of our results will consist of the following. First, the percentage of articles classified into each ocular, neuropsychological, and SDOH categories will be reported. For each of the five SDOH domains, the quantity and percentage of articles exploring and observing the domains will be reported with sub-classification by domestic or international location, national income levels, and presence of UHC. The comparison between explored and observed SDOH domains will provide insight into finding gaps in the literature and suggest where potential intervention may take place. This identification may guide the effective distribution of resources in promoting education and social awareness to reduce stigma and protect child development within individual and community contexts, while tailored policies and interventions are implemented at organizational and systemic levels. The results of the finalized scoping review will be reported in peer-reviewed publications.

As the influence of SDOH domains is a concept that has garnered research interest in recent years, we foresee potential difficulties with retrieving older articles that are relevant to this scoping review and identifying the SDOH domains involved, as they may not be explicitly defined. We believe that this should not significantly reduce the volume of research that can be included in this scoping review below what we could retrieve in an ideal scenario. As such, this shortcoming should not dramatically modify our findings pertaining to the relevant interest in research into each SDOH domain or future interventional efforts.

Overall, we believe that this scoping review will help identify well-informed areas of SDOH research pertaining to pediatric ophthalmic conditions as well as evidence gaps that can be explored through future research efforts. We hope to use the information gleaned from this review to initiate future research projects and initiatives that can fill in identified gaps in the literature and help spur the development of relevant public health interventions.

Supporting information