Acquisition and Integration of Low Vision Assistive Devices:
Understanding the Decision-Making Process of Older Adults
With Low Vision
Al Copolillo,
Jodi L. Teitelman
The purpose of this study was to describe how older adults with low vision make decisions to use low vision
assistive devices (LVADs). Analysis of participants’ narratives, from both group and individual interviews,
revealed three topic areas affecting device use. Two are discussed in this paper: Experiences and
Characteristics Leading to Successful LVAD Use Decision Making and Challenges to Successful LVAD Use
Decision Making. The third, Adjustment to Low Vision Disability, is briefly discussed. Of particular importance
to occupational therapy practitioners in the growing field of low vision rehabilitation was the value placed on
low vision rehabilitation services to assist with acquiring devices and integrating them into daily routines.
Occupational therapy services were highly regarded. Participants demonstrated the importance of becoming a
part of a supportive network of people with low vision to gain access to information about resources. They
emphasized the need for systems and policy changes to reduce barriers to making informed decisions about
LVAD use. Results indicate that occupational therapists working in low vision can support clients by facilitating development of a support network, acting as liaisons between clients and other health practitioners, especially ophthalmologists, and encouraging policy development that supports barrier-free LVAD acquisition and
use. These topics should be incorporated into continuing and entry-level education to prepare practitioners for
leadership in the field of low vision rehabilitation.
Copolillo, A., & Teitelman, J. L. (2005). Acquisition and integration of low vision assistive devices: Understanding the decision-making process of older adults with low vision. American Journal of Occupational Therapy, 59, 305–313.
Al Copolillo, PhD, OTR, is Associate Professor,
Department of Occupational Therapy, Virginia
Commonwealth University, 1000 East Marshall Street,
Richmond, Virginia 23219; [email protected]
Jodi L. Teitelman, PhD, is Associate Professor, Department
of Occupational Therapy, Virginia Commonwealth
University, Richmond, Virginia.
Background and Significance
Low vision assistive devices (LVADs), if used effectively by older adults with visual impairments, can increase and sustain engagement in occupation and support
active participation in the community (Scadden, 1997). Low vision assistive
devices are technologies used by people who are partially sighted to enhance performance of everyday tasks such as reading the newspaper, watching television, or
pouring beverages. They are historically classified into optical and nonoptical categories. Optical devices are items such as magnifiers, and microscopic and telescopic lenses. Nonoptical devices are designed to be relatively larger in size or to
reduce glare or increase contrast (Rosenthal & Williams, 2000). To maximize
social participation, employment, self-care, and play and leisure involvement, a
greater understanding of the complexities of incorporating low vision devices into
the daily routine is needed by occupational therapists. Otherwise, opportunities to
facilitate informed decision making for LVAD use may be missed. This paper
describes results of a qualitative research study that examined older adults’ decisions about low vision assistive device use. Two of three major topic areas generated by the findings, Experiences and Characteristics Leading to Successful LVAD Use
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Decision Making and Challenges to Successful LVAD Use
Decision Making are highlighted here, with a third topic
area, Adjustment to Low Vision Disability, briefly discussed.
Topic three is presented elsewhere as the main focus of a
separate article.
In the United States, vision impairment, including low
vision, which is defined as permanent visual impairment
that is not correctable with spectacles, contact lenses, or surgical intervention and interferes with normal everyday
activities, affects approximately 21% of adults 65 years of
age and older (7.3 million persons) (Lighthouse
International, 2001). The aging of the U.S. population and
documented annual rise in low vision incidence indicate
that the number of older adults with low vision impairments will continue to increase over the next half century
(Leat, Fryer, & Rumney, 1994). Chronic visual impairments in the elderly include diagnoses of macular degeneration, diabetic retinopathy, glaucoma, and optic neuropathy (Tielsch, 2000).
Although assistive device use has been examined across
a broad range of devices, age groups, and disabilities, there
are few studies of older adults with visual impairments and
how their concerns affect decisions about incorporating
LVADs into their lives. Researchers have given limited
attention to understanding why some older adults are more
motivated to use and continue using low vision devices than
others.
Literature Review
Making a Decision to Use Low Vision Assistive Devices
Decision making is a special form of problem solving in
which the most satisfying outcomes are chosen from a
number of potential solutions (Yates & Patalano, 1999).
Choosing the most satisfying solutions from a larger number of considerations requires the decision maker to compare and contrast different possibilities, carefully weighing
benefits against barriers. This procedure is complex because
it depends on the problem-solving strategies that are available for use. How one defines a problem, life experiences,
familiarity with the problem, and the context in which the
problem occurs determine strategy selection and ultimate
decision making (Berg, Strough, Calderone, Sansone, &
Weir, 1998).
Although similarities in decision-making processes may
exist across many device types, dependence on the visual
system over the other senses makes experiences surrounding
vision loss particularly salient and decisions related to those
experiences uniquely complex. Fear of vision loss exceeds
several other disabilities (Leonard, 2002). Therefore, this
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study focused specifically on people with low vision to
begin to develop an in-depth understanding of the underlying mechanisms used to make choices about using
LVADs. The principal task of the older adult with low
vision faced with the question of whether to use LVADs is
to consider whether these devices can improve quality of
life. Low vision creates major disruptions in family life,
employment, and social interactions (Lighthouse
International, 2001). These disruptions often lead to functional dependence and depression (Horowitz & Reinhardt,
1998), which have been shown to improve with use of
LVADs (Raasch, Leat, Kleinstein, Bullimore, & Cutter,
1997). However, older adults who may be unfamiliar with
LVADs and the service-delivery systems by which they are
acquired may experience difficulty with decision making
about initial and ongoing use of devices.
Whereas several studies have examined factors that
contribute to use of assistive devices (Chen, Mann, Tomita,
& Nochajski, 2000; Hartke, Prohaska, & Furner, 1998;
Prangrat, Mann, & Tomita, 2000) only a few studies have
included subjective reports of decision-making experiences
by older adults (Copolillo, 2001; Gitlin, Luborsky, &
Schemm, 1998; Gitlin, Schemm, Lansdsberg, & Burgh,
1996; Lund & Nygard, 2003), and none of these subjective
reports have examined assistive device use in older adults
with low vision.
Barriers To Deciding To Acquire and
Use Low Vision Assistive Devices
Cost has been identified as the primary barrier to acquiring
all assistive technology, including LVADs (LaPlante,
Hendershot, & Moss, 1992). Additionally, many older
adults are unaware that they are eligible to receive services.
Limited knowledge about the varieties and types of available LVADs also contributes substantially to either never
acquiring devices or delaying acquisition (Leonard, 2002;
Mann, Hurren, Karuza, & Bentley, 1993). Once solutions
to these barriers are found, older adults face other concerns
in the process of making decisions.
In the midst of altered self-images from disability, older
adults often ask how the presence of assistive devices might
change others’ perceptions of them and their own sense of
roles, responsibilities, and status in their families and communities (Copolillo, 2001; Gitlin, Luborsky, & Schemm,
1998; Verbrugge, 1994). Questions of capability to use a
device arise, and older adults react to them by examining
whether they are young and healthy enough for LVAD use,
sometimes concluding they are “too old and too sick”
(D’Allura, McInerney, & Horowitz, 1995). The perception
that assistive device use is not yet warranted because the
condition is still too mild can also delay a decision to use a
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device (Copolillo). Finally, although the literature does not
document fear of stigmatization as a major concern for
older adults, reports from a variety of studies indicate that
stigma and potential for marginalization is considered in
the process of deciding when and under what circumstances
to use devices (Copolillo; Fine & Asch, 1988; Mann &
Tomita, 1998; Zola, 1985).
In addition to issues related to perceptions of LVADs,
other potential correlates of LVAD use include increases in
dissatisfaction with devices as vision worsens (Mann et al.,
1993); and quality and quantity of training in device use.
Older adults may experience difficulty transferring what
they have learned in a training environment to the community (D’Allura et al., 1995).
What remains unclear is how individual factors,
including those demonstrated to have an impact on LVAD
use, combine to increase the likelihood of seeking and
acquiring LVADs and encourage incorporation of LVADs
into the daily routine. The detailed descriptions of low
vision experiences provided by the participants in this study
give further insights into this process.
Research Design and Methods
Participants
For the purposes of this study, 15 participants were recruited from two low vision rehabilitation centers. The sites were
selected to provide a larger participant pool, inclusive of
people of varying backgrounds living in urban, rural, and
suburban settings.
Occupational therapy and optometry staff identified
and referred persons who met the sampling frame criteria to
the principal investigator. A brief telephone interview
screening was then conducted to finalize selection. People in
varying stages of LVAD use and with a variety of device
types were selected for participation and reflected varying
ages and levels of experience with LVADs. Initial inclusion
criteria were: (1) 55 years of age or older; (2) diagnosis of
low vision impairment (worse than 20/70 but no worse
than 20/400 visual acuity in the best eye); (3) no evidence
of severe cognitive deficits or dementia as evidenced by
Mini Mental Status Exam (MMSE) scores of 24 or higher
(Folstein, Folstein, & McHugh, 1975); (4) no evidence of
language disorder or problems with verbal communication;
(5) English language fluency; and (6) potential or current
use of low vision assistive devices.
From its onset, the overarching epistemology of this
study was applied ethnography in that its purpose was to
elicit the point of view of older adults with low vision as
they made decisions about acquiring and using assistive
technology, and to understand the meaning of that decision
making (Chambers, 2000; Krefting, 1989). Charmaz
(2000) discusses how grounded theory strategies can be
used with a variety of theoretical perspectives to organize
and systematize data collection and analysis. We applied
this perspective in our research design to provide a basis for
thematic analysis and establish rigor while using principles
of ethnography to explore the culture of older adults with
low vision and give voice to participants’ views of their
experiences. Because the results of the study indicate a need
for social action and advocacy, future research studies using
participatory action and other, in-depth ethnographic
approaches may be beneficial.
All participants engaged in an informed consent process approved by the affiliated university’s institutional
review board. Each participant was paid $50.00 to defray
transportation and other costs of participation.
Data Collection and Management
The researchers engaged in in-depth interviews, in both
group and individual formats. A total of 4 initial and 2 final
focus groups and 15 individual interviews were conducted.
By meeting the participants in familiar clinical settings and
then in their homes, we were able to gradually enter and
become a part of their experiences with low vision and
LVADs. We had the opportunity to observe them among
peers and family members, and in marginally and fully
familiar environments with and without the use of their
devices. Research assistants accompanied the co-investigators and, directly following each interview, participated in
general discussions about its content and meaning.
The objectives of the interviews were to understand
how one formulates a plan to acquire LVADs and then integrate them into daily life. The interviews provided participants an opportunity to describe both satisfying and dissatisfying components of LVAD decision making, express
appreciation for and frustration with those involved in the
process, and share concerns for themselves and others with
low vision. Participants demonstrated the relevance of
LVADs by discussing device use within the larger context of
adjusting to low vision.
Initially, the co-investigators played the role of facilitators of group discussion, mostly remaining in the background and allowing the participants to interact with one
another. In individual interviews, we had the opportunity
to explore each participant’s experience in greater depth
and express empathy for her or his situation. In the process,
we began to reflect upon our own experiences with low
vision, one of us through her own, age-related vision
changes superimposed on a corneal degenerative disease.
The other focused his reflections on his recent experience
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with his 86-year-old father who developed low vision and
continued to experience vision-related functional losses
during the course of this study. By relating the information
the participants shared to personal experiences, we gained
a greater appreciation for the participants’ struggles and
accomplishments.
The focus group interviews were included to seek general reactions to current or potential LVAD use. Each group
was followed by individual narrative interviews that sought
more in-depth exploration of LVAD use, views of disabling
conditions, and the process of incorporating LVADs into
routines. Interviews usually lasted 1 hour and ranged from
45 minutes to 2 hours. Two doctorally prepared occupational therapy faculty with gerontology training and experience in qualitative research design conducted all groups and
interviews. All focus groups and narrative interviews were
tape recorded.
Data management and analysis consisted of transcription of audiotapes and reading the transcribed narratives.
We analyzed and interpreted the content of each interview
independently at first and then came together to reconcile
our interpretations, revise our codes, and examine underlying meanings in greater depth. Interpretation of the data
was a collaborative consensus-building process requiring
persuasive dialogue and conflict resolution between investigators and final confirmation from participants.
We named codes by using words or phrases that we
found in the transcripts. For example, we named one code
partial success but too much energy to describe participants’
experience with devices that, although somewhat useful,
required too much effort to learn to use. Further analysis
of the content of the initial codes raised our awareness of
what participants were describing and consequently resulted in new categories that were better representations of the
content.
Findings
The study’s participants included 10 men and 5 women.
The mean age was 75.7 years with a range of 56 to 90 years.
One participant was black; all others were white. Although
2 lived in remote, rural areas, most lived in small urban or
suburban settings. Seven participants lived independently
in the community, and 8 lived with a spouse. The youngest
participant in the study was still employed; all others were
retired. Eleven participants had a diagnosis of adult-onset
macular degeneration, 2 diabetic retinopathy, 1 multiple
sclerosis, and 1 Stargardt’s disease.
One hundred fifty-four codes were identified and then
collapsed into larger categories, resulting in three primary
topic areas: (a) Experiences and Characteristics Leading to
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Successful LVAD Use Decision Making; (b) Challenges to
Successful LVAD Use Decision Making; and (c) Adjustment to Low-Vision Disability. This paper primarily explores the first two components, with psychosocial aspects
of adjusting to vision loss explored elsewhere. These two
topic areas describe the benefits and challenges that are
experienced in the process of acquiring and incorporating
low vision devices.
Experiences and Characteristics Leading to Successful
Low Vision Assistive Device Use Decision Making
This content area consists of four subcategories: (1) positive
health care experiences, (2) benefits of low vision assistive
devices, (3) resource exchange, and (4) savvy consumerism.
Positive Health Care Experiences describes the value of positive interactions with low vision health care service personnel. Participants emphasized the key role of low vision
professionals (i.e., ophthalmologists, optometrists, occupational therapists, and other rehabilitation specialists) in simplifying the process of acquiring and incorporating devices.
Participants’ statements indicated that low vision professionals were relied upon to provide solutions to low vision
device needs. The main expectations participants had of
their primary low vision physicians were to accurately diagnose and manage low vision impairments, properly prepare
them for what their low vision experience would be, and
refer them to resources for low vision rehabilitation. One
participant said:
He (ophthalmologist) told me everything. He said you will
not go blind, and he said you’ll be deprived of personal
writing checks, and pertinent things in your home, he said.
So I have gone to him ever since. He’s a very fine man.
Satisfactory service from occupational therapists and
other low vision service providers depended, in part, on
assistance with acquiring useful devices and successful training. When such provisions were made, the process of
acquiring and incorporating devices was simplified. A participant stated the following:
They were very helpful and introduced me to a lot of the
technology, A [occupational therapist] in particular. She
had a pretty good grasp of the technology and was fairly
abreast of what was available. . . . A done more about getting that thing than the VA. did. She communicated with
them. It wasn’t, wasn’t me . . . I . . . take my hat off to her
. . . give her the credit for it.
In Benefits of Low Vision Assistive Devices participants
provided positive appraisals of devices and related experiences of discovering unexpected advantages. Of specific
interest was the enthusiasm with which participants discussed closed-circuit televisions (CCTV), print enlarging
devices that project larger sized print onto a monitor. They
frequently referred to them as a “Godsend” and conveyed a
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feeling that the device was the key to satisfactory low vision
management: “This is my big Godsend, right here. . . . Yes,
big, big, probably most valuable single tool I’ve got.”
Resource Exchange demonstrated the extent of and
reliance on a well-established, informal network of people
with low vision and their friends, families, and acquaintances. Word-of-mouth conveyance about low vision
devices and services was a primary method by which people
with newly diagnosed low vision impairments began to
acquire resources and learn how to access low vision care.
Participants received information from a variety of sources,
on which they then followed up to determine whether the
recommended devices or services were suitable. One participant stated:
It’s funny. People know that you’ve got this problem and if
they come across something in a magazine or something,
they’ll tell you about it. . . . They at least let you know
what’s going on. So a lot of people do that, even now. I
mean they’ll read an article in the paper and call you up.
Word-of-mouth suggestions were appreciated, and, as
each person became more knowledgeable about resources
for managing low vision, they assumed a more active role by
reciprocating with those who had provided valuable information and sharing resources with others with newly
acquired low vision impairments. They created a resource
exchange network, which grew and replenished itself continuously. As more human resources joined the network,
greater varieties and types of LVADs were made known.
Focus groups served participants with another mechanism for accessing this network. Participants often brought
devices for others to try out. They exchanged names, phone
numbers, and Web pages of low vision clinics, physician
contacts, and low vision device sources. People who lived in
older adult communities or had relatively broader support
systems were more likely to be actively engaged in the
resource exchange process because the exchange network
was more easily accessible.
The final subcategory, Savvy Consumerism, describes an
advanced level of expertise and comfort with negotiating
the purchase of low vision devices. This expertise developed
over time but was more quickly achieved by people who, for
employment, skill, or interest purposes, had a predisposition to using technology. They became adept at judging the
quality, versatility, and cost-benefit of devices, thereby
increasing confidence in managing low vision and making
them less vulnerable to purchasing relatively useless equipment. One participant, an engineer, described his experience with purchasing an expensive, high technology system:
I mean most people would say: “OK, here is the package
and here is the price. Do you want it (monitor) or not.”
Instead of asking the question, “Can I get it small?” Oh, by
the way (supplier) will give you a smaller monitor, a 20-
inch monitor, for a $299 up-charge. I said wait a minute I
can go buy a TV for $100. What do I need to pay you an
extra $300 for, on top of the $2,700 you are already charging me?
Challenges To Successful Low Vision Decision Making
This topic area provides information about those features
that detracted from or slowed the process of acquiring and
incorporating low vision devices. It consists of two large
subcategories, Barriers to LVAD Use and Limits of LVADs.
The former describes difficulties with acquiring devices,
which sometimes led to difficulties with devices themselves;
the latter describes how the devices failed to assist the user.
Barriers To Low Vision Assistive Device Use
This subcategory derived from comments on negative
health care experiences and unmet assistive technology
needs. Negative health care experiences were both salient
and widespread. Eight of the 15 participants described
experiences in which their ophthalmologists, frequently
upon informing them that no further medical interventions
were available to improve their vision, did not discuss low
vision devices or make a referral to low vision rehabilitation
services. Participants were both respectful and appreciative
of these physicians while also being frustrated and angry
with them. They recognized that failure to refer to low
vision rehabilitation was not out of malice but rather the
physicians’ lack of awareness of this as a treatment alternative. Five participants stated that they lost confidence in
their ophthalmologists and sought new physicians to provide low vision medical care. This occurred when they
became aware that low vision rehabilitation services, and
potential direct access to assistive device options, had been
available but not recommended. One participant stated:
One gal I had was an ophthalmologist . . . that just told me,
bang, “You’re blind.” That’s it, so long, didn’t give me any
recommendation to go down and talk to (optometrist) or
to tell me anything about (low vision service) . . . it was just,
bang, that was it. And that was frustrating. So, since, I’ve
changed doctors in fact.
Another participant exemplified the relevance of this issue
for people with low vision:
Unfortunately, that would be the one area that I would be
critical of (physician) was that he had not offered this up as
an alternative. Of course, he was aware of the (low vision
service), but it took a referral . . . from a doctor. When I
asked him about it he said, “Oh, well of course, I’ll send
you down there.” I was a little taken back that it was something that wasn’t done proactively. Like, let’s see what we
can do to try to help you out. Since we tried all these surgical things and nothing’s worked, here are some other
opportunities you might want to investigate.
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Other unmet needs included limited access to information, lack of and limited knowledge of available services,
and delays in getting self-ordered or prescribed devices. For
example, one participant stated:
You simply couldn’t find them (low vision services). If you
go to the Internet for example and put in, low vision clinics or low vision optometrist, or things like that, you will
get no answer. . .
Limits of Low Vision Assistive Devices
Once devices were acquired, their limitations became
apparent. Occasionally, devices purchased in haste were
found to be of little use. One participant, who had been
searching for a device for a long time expressed his disillusionment as follows:
I bought, in a moment of weakness, the [CCTV], which is
their bottom of the line 14-inch monitor. . . . it was, you
know, it was only so big and you could take it with you. . . .
I thought you could at any rate. It does not have an XY
table. It just has a flat table, and that’s not very nice, and it’s
not really very clear.
In describing device limitations, participants often
expressed how cumbersome they were. Devices were perceived as too big, heavy, or awkward, or as taking up too
much space. Illustrative descriptions include the following:
• . . . this one’s so heavy my arm gets tired.
• They’re all right for spotting one person on a stage
or something, but if you don’t get a wide vision, it’s
not worthwhile.
• The only thing I can take with me that I can read
with is this thing (magnifier). And you know, here I
am like this, reading one letter at a time. You can’t
even remember what the first letter was by the time
you get to the end of the word.
Adjustment to Low Vision Disability
This overarching theme described the perspective from
which participants discussed the benefits and challenges of
making decisions about device use. Because it represents
about half of the study’s data, it is beyond the scope of this
paper to describe this theme in detail. Rather, an overview
of its content is provided here.
The theme contains poignant content, including negative emotional aspects of adjusting to low vision. It extends
beyond the process of making decisions to use low vision
devices into employment of other mechanisms for coping
with lifestyle changes. Participants described emotional
reactions to having to relinquish desired activities, make
psychological and logistic adjustments, and struggle to
maintain self-sufficiency.
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Discussion
Several limitations were considered in interpreting the
results of the study. The need for participants to discuss
LVAD use in focus groups required them to find transportation to participate in the study. A number of people
with low vision impairments recruited for the study
declined to participate because of difficulties with transportation. Although participants indicated that transportation was an ongoing concern, they may still be most representative of older adults with more resources for
transportation than the typical low vision population.
Results of this study must be carefully applied with consideration of the similarities between the participants in this
study and those of the clients in any particular practice.
Despite these limitations however, the study provides compelling implications for occupational therapy practice and
education.
Participants regarded LVADs and low vision services as
major mechanisms for managing disability. Because reliance
on the sense of vision is so great, the need for low vision
devices appeared urgent. Consequently, acquisition of function-enhancing LVADs was highly valued, and provision of
services that made this possible was greatly appreciated.
Adequate training and choice of the appropriate
devices assured continuous use. Positive reactions to low
vision devices were primarily related to the practical applicability of LVADs. Therefore, devices that provided substantial solutions to serious problems, such as reading or
driving, were more highly regarded than devices that only
slightly enhanced usable vision. For example, closed-circuit
televisions (CCTV), although expensive and therefore more
difficult to obtain, were still regarded enthusiastically
because they offered a substantial solution to a variety of
needs, including reading, writing, and money management.
Devices regarded as cumbersome, (e.g., large, portable magnifiers), requiring unreasonable amounts of energy to use
and providing only limited solutions to functional loss,
were more likely to be discarded.
Positive interactions with low vision health care personnel were considered essential for adequate adjustment to
low vision and, when provided, aided the process of acquiring and incorporating low vision devices. Many participants
stated that they only began to feel capable of managing
their disabilities when they finally gained access to the low
vision clinic. Occupational therapy low vision services were
a highly relevant part of this positive experience. On the
other hand, inadequate low vision services deterred participants from successful decision making and delayed the
adjustment process. Participants frequently described
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receiving insufficient services, especially from first-encountered ophthalmologists who did not refer them to low
vision rehabilitation. This moved some of the participants
toward advocacy for improved low vision services. These
participants encouraged us to assist them in the process.
Participants clearly recognized the essential contribution ophthalmologists make to low vision care. Approximately half had positive experiences with ophthalmologists
who referred them to low vision rehabilitation services or
recommended devices and provided information on how to
acquire them. However, although participants perceived
referral to low vision rehabilitation services as a responsibility of the primary low vision physician, especially under circumstances where no further medical care was available,
some felt they had not received this. Occupational therapy
practitioners in low vision care have strong potential and
responsibility for working with ophthalmologists as team
members and thereby, influencing the low vision system to
eliminate this concern.
A rich, informal network of older adults with low
vision, and their friends, family, and acquaintances, seems
to have developed and continues to expand. A major purpose of this network is to exchange resources, including services and devices that aid and benefit people with low
vision. Participants relied on this network, sometimes out of
frustration with traditional health care systems that did not
seem to provide needed information. They expressed appreciation for this network although advocating for a more
user-friendly, formal system for accessing information about
LVADs and related services. Without assistance from this
network, participants felt desperate to find low vision
devices, consequently making uninformed purchases,
which they later regretted. Over time, they became more
sophisticated in their abilities to make appropriate device
choices, and then could make expert recommendations to
others in the network.
Although they usually spoke in terms of device limitations, participants seemed to recognize that the real source
of limitations came from an inefficient system made up of
themselves, assistive devices, and the context in which they
used devices. Their hopes for and expectations of devices
were high, but they remained realistic about what they
could expect devices to achieve given their level of vision
loss and the complexity of the tasks for which they wished
to use devices. Therefore, they were usually able to judge the
feasibility of resuming certain desired activities and the
inevitability of abandoning others. However, some also
described experiences, usually early in the process of losing
vision, in which they made unsafe decisions and misjudged
their visual capacities, the complexity of the task, and the
potential of the assistive device.
Adjustment to low vision disability is the overarching
theme under which low vision assistive device use falls.
Therefore, participants provided rich descriptions of the
adjustment process, including negative emotional reactions
to vision loss and mechanisms for managing and coping
with it. Further insights into the values, attitudes, strengths,
and challenges of older adults with low vision and the
meaning LVADs have in their lives are presented elsewhere.
Clinical Relevance and Application of
Concepts for Occupational Therapy
Practitioners
The clinical relevance of this study is that it provides
insights into the decision making of people with low vision
that occupational therapists typically encounter in practice.
The findings bridge research and practice and provide
information to begin to develop practice guidelines but are
not guidelines themselves.
Participants indicated that provision of low vision services that assist them with obtaining LVADs contributes
substantially to managing and adjusting to disability. As
part of a physician or therapist team, the occupational therapy practitioner was highly regarded by participants, provided satisfactory low vision training within her scope of
expertise, and made careful, timely referrals to other low
vision specialists when necessary.
Of importance to the participants was the availability
of a variety of devices in one setting, a type of “one-stop
shopping” for LVADs, which provided an opportunity for
trial use and on-the-spot training. Participants were grateful
for lists of Web sites that allowed them to conduct independent computer searches for devices. Guidance and
direction through what otherwise could be a confusing and
frustrating health care system simplified the process of
choosing and using low vision devices and consequently,
managing low vision. Participants emphasized willingness
to do the majority of the work to locate, purchase, and learn
to use suitable devices once given the means to gain access
to services and devices. Over time, when positive low vision
services were consistently provided, health care practitioners
became a part of a larger network of supportiveness, which
participants relied on and to which they contributed.
Problems with low vision devices occurred when participants made impulsive purchases and failed to use devices
on a trial basis. This confirms findings of D’Allura et al.
(1995), who emphasized the importance of transferring
learning from the clinic to the home when attempting to
incorporate LVADs into the daily routine. Encouraging use
of LVADs on a trial basis before purchase, in the appropriate context for use, may yield better outcomes. Therapists
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can encourage trial use of devices by setting up a system
whereby patients are allowed to return undamaged items
within a designated time and receive full refunds or
exchanges for them. Therapists can also direct patients to
vendors and manufacturers who offer 30-day trial options
on devices. Those participants who were predisposed to use
technology seemed to derive greater satisfaction and get
more use out of their devices than those who were not. A
recent study demonstrated better functional outcomes for
high technology device use for frail elderly with good attitudes toward computer use (Tomita, Stanton, Russ, Tung,
& Mann, 2003). Older adults with low vision may benefit
when training in use of high technology devices such as
computers, increases a client’s sense of competence by
demonstrating the feasibility of using such devices.
This study showed the value of bringing older adults
with low vision together for social support and resource
exchange purposes. Recognizing that transportation is not
easily available for older adults with low vision, even infrequent meetings or inconsistent group membership may have
value in helping older adults with low vision make connections with peers. Encouraging support groups and social
interaction among older adults with low vision, and identifying volunteers with low vision who are interested in talking with peers, can provide more isolated individuals with
opportunities to gain access to a rich network for resource
exchange. Using this strategy in conjunction with individualized occupational therapy intervention is likely to make
acquisition and use of appropriate LVADs a more efficient
process with more satisfying and beneficial outcomes.▲
Acknowledgments
The authors wish to thank Mary Bullock, OTR/L; Jeffrey
Michaels, OD, FAAO; and research assistants, Robert Fix
and Stephanie Weiseman, for their assistance.
This project was funded through a Mary Switzer
Distinguished Fellowship, U.S. Department of Education:
National Institute for Disability and Rehabilitation
Research #H133F020028.
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