Barriers to low vision rehabilitation: a qualitative approach.

Structured Abstract: Introduction: This study sought to describe and better understand barriers to accessing low vision rehabilitation services. Methods: A qualitative description research paradigm was employed. Focus group participants were recruited through their involvement in the Montreal Barriers Study in Montreal, Canada. Six focus groups (n = 21 participants) were conducted to assess perspectives (both positive and negative) about accessing low vision rehabilitation services, and in particular the barriers to accessing these services. Interview transcripts were prepared and analyzed using content analysis. Results: Analyses revealed barriers inherent to the person (perceived ability to comfortably engage in activities of daily living and gradual participatory losses); the clinic (inefficiencies in educating clientele about low vision rehabilitation services, and problems and dissatisfaction associated with ophthalmic consultations); and society (fears associated with having stereotypes applied and transportation is the setting where clashes occur). Discussion: The generated themes revealed barriers to low vision rehabilitation services inherent to the individual, to interactions with vision health professionals, and to interactions with the sighted community. A representative model is proposed. The model design highlights three elements arising from the analyses: the time elapsed since the onset of the vision loss; the complex interactions between the individual, the healthcare setting, and the society; and the overall dynamic nature of help-seeking. Implications for practitioners: There is a need for improved communication between consumers and providers to facilitate clients seeking out low vision rehabilitation services. Providers should solicit user perspectives and attempt to achieve a good fit between client needs and services adopted.

**********

Treatments for numerous diseases and injuries require some form of rehabilitation as part of the healing process. For example, during recovery from joint or muscle injury, physical rehabilitation is an integral part of the treatment regimen. In the case of chronic visual impairment, low vision rehabilitation services allow patients to adjust and develop compensatory skills to improve their functional abilities. Vision rehabilitation is most commonly known in the context of blindness, whereby patients acquire skills such as braille reading and cane or dog guide techniques, or are trained to perform essential skills for activities of daily living such as preparing a meal without sight. Nevertheless, the large majority of individuals who are eligible for vision rehabilitation are affected by low vision. These patients have residual vision, but too little to rely on visual information alone in their daily lives. Given the changing demographics within developed countries, the large majority of these individuals are now elderly persons who are affected with late-onset vision loss because of such diseases or conditions as diabetic retinopathy, macular degeneration, or glaucoma (Maberley et al., 2006).

Low vision is generally defined as an untreatable loss of sight that is not correctable with standard eyeglasses and that interferes with the functioning of the individual, thereby creating a disability (Faye, 1984). Within the Province of Quebec, Canada, the legal definition of a visual handicap is a visual acuity of less than 20/70 in the better eye with a best standard correction or a visual field of less than 70 degrees in diameter (Regie de l'assurance maladie du Quebec/RAMQ, 2006). Individuals who fit these standards are eligible for low vision rehabilitation services, which are covered by the RAMQ. However, not all eligible persons with visual impairments avail themselves of this opportunity. The Canadian National Institute for the Blind (CNIB, 2005) reported that only 28% of the surveyed seniors knew how to access vision rehabilitation services. Furthermore, 17% indicated that the distance they had to travel to the service delivery agency posed a problem of access. In the Province of Quebec, it is estimated that only 20% of eligible clients access vision rehabilitation services (Gresset & Baumgarten, 2002). Awareness of these services was generally low, and eye care professionals were not always supportive of the patients' search for additional information, a finding that has been reported at the national level as well (Gold, Zuvela, & Hodge, 2006). These numbers are comparable to a population-based study conducted in West Virginia, in which only 19% of individuals with symptoms of low vision were aware of vision rehabilitation, and only 12% had received these services (Walter, Althouse, Humble, Leys, & Odom, 2004).

These statistics provide the rationale for the investigation of barriers to low vision rehabilitation services. Frequently, studies about barriers to rehabilitation access utilize quantitative methodologies, whereby eye care professionals are surveyed about their referral patterns or clients at rehabilitation agencies are questioned about the barriers they experienced (Adam & Pickering, 2007; Chiang, O'Connor, Le Mesurier, & Keeffe, 2011; Chiang, Xie, & Keeffe, 2011; Gold et al., 2006; Keeffe, Lovie-Kitchin, & Taylor, 1996; Koenekoop & Gomolin, 1995; Overbury, Jackson, & Santangelo, 1987; Overbury & Wittich, 2011; Sundling et al., 2007). There is, however, a notable dearth of research on the barriers to low vision rehabilitation services from the patient's perspective. In Australia, Pollard, Simpson, Lamoureux, and Keeffe (2003) conducted focus group interviews with 17 individuals, ranging in age from 25 to 88, concerning issues related to access barriers. The main topics that emerged were a general perception of rehabilitation, overcoming distance and travel barriers to services, and interaction with eye care professionals as well as service agencies. Pollard et al. described issues of self-identity, such that the participants with low vision did not consider themselves "blind" and were thus reluctant to utilize services that were seemingly geared toward the severely impaired. Another theme that arose from the analyses was transportation to the service agencies. Older individuals reported difficulties traveling independently because of their fear of getting lost. Communication problems with eye care professionals were also reported. The consensus was that ophthalmologists did not provide information about rehabilitation in the referral process. At a point at which nothing more could be done from the medical perspective, information was finally provided about low vision rehabilitation services, but not always.

One particular point of interest in Pollard et al.'s (2003) study was the goal of recruiting persons with low vision who had not accessed rehabilitation services. However, only five participants fit this criterion, even though announcements had been made over a local radio station. The study presented here included participants who had accessed low vision rehabilitation services, participants who were aware of these services but chose not to take advantage of them, and individuals who had never heard of low vision rehabilitation services. The aim of the study was to describe and gain a better under standing of why individuals with low vision may not (choose to) access vision rehabilitation services. It was anticipated that the qualitative data would lead to a more in-depth understanding of low vision rehabilitation services, perhaps offer explanations for some frequently referenced quantitative results, and generate new hypotheses for subsequent quantitative testing.

Methodology

QUALITATIVE METHODS

To understand the perspectives of patients of ophthalmology clinics with respect to the barriers to low vision rehabilitation services, we used a qualitative description research paradigm (Sandelowski, 2000). The objective of qualitative description studies is to provide a summary of participants' experiences presented in everyday language without high-level interpretation. This approach has frequently been used to investigate topics related to the delivery of health care services. This study received ethical approval from the Institutional Review Board of the SMBD general hospital, Montreal, Canada.

PARTICIPANTS

The focus group participants were recruited through their involvement in the Montreal Barriers Study (Mwilambwe, Wittich, & Freeman, 2009). Six focus groups were conducted with a total of 21 individuals (F = 14, M = 7), ranging in age from 38 to 92. Each focus group was composed of participants who had not heard of low vision rehabilitation services, had heard of but not accessed these services, and who knew of and accessed these services. Heterogeneous groups were selected so that differences in perspectives on the barriers to low vision rehabilitation services would be most apparent to the investigators during the focus group discussions and subsequent analyses.

DATA COLLECTION

The first author moderated all the audio-recorded focus groups. The participants were informed that the investigators were interested in their perspectives (both positive and negative) about accessing low vision rehabilitation services and, in particular, the barriers to accessing these services. The initial interview guide included three questions: What enabled you to access low vision rehabilitation services? What served as obstacles to you accessing low vision rehabilitation services? and What could be done to make it easier to access low vision rehabilitation services? These questions were designed to generate, and allow for the expression of, a wide range of factors that may serve as barriers to low vision rehabilitation services. Follow-up questions were posed to generate more in-depth information on relevant issues. The focus groups were informal in nature, with an underlying goal of stimulating discussions of experiences among the participants. During the focus groups, field notes were taken by the coinvestigator (Walter Wittich) to identify information that was unlikely to be picked up by the audio-recording (Morse & Field, 1995). This information was used as a secondary data source during the analyses. Proper names were assigned pseudonyms, and other identifiers were removed to ensure confidentiality.

CONTENT ANALYSES

The transcripts of the interviews were analyzed using content analysis (Elo & Kyngas, 2008). Content analysis has three steps: open coding, creating categories, and abstraction. During open coding, the investigators immerse themselves in the data, reading and rereading the transcripts in search of text that answers the fundamental research question (in this case, "What are the barriers to accessing low vision rehabilitation services?") (Polit & Beck, 2004). Once meaningful text is identified, the investigators assign labels in the margin of the interview transcript. The aim is to assign the requisite number of labels so as to describe fully the content of the text (Hsieb & Shannon, 2005). Next, categories of headings are created (Burnard, 1991). The final step of content analysis is abstraction, when the investigators prepare general descriptors of the data (Polit & Beck, 2004). In the present study, abstraction involved uploading the data into ATLAS-ti (2009), a software program that is designed to aid in the analysis of large bodies of text. ATLAS-ti provides an interface whereby researchers can efficiently move about text-based documents to examine how the interviews and assigned categories relate to one another. During this phase of content analysis, meaningful patterns within and across the transcripts of interviews (such as the frequency with which categories appear in proximity to one another in the text) were identified. ATLAS-ti was used primarily as a data management tool. Accordingly, it was the task of the investigators to decide what interview passages were relevant and how to categorize selected excerpts. The data analyses continued until it became evident that extending them would produce no new information (Morse & Field, 1995).

Qualitative findings

The analyses of the transcripts of the focus groups generated three themes that served as barriers to accessing low vision rehabilitation services, namely, barriers inherent in the person, the clinic, and society at large. Excerpts presented in this section were judged representative of patterns across the group discussions. In the presentation of the findings, the participants who did not know about low vision rehabilitation services were referred to as G1s; the participants who knew about low vision rehabilitation services but did not access services were referred to as G2s; and those who knew about low vision rehabilitation services and accessed the services were referred to as G3s.

THEME 1: BARRIERS INHERENT IN THE PERSON

The participants indicated that there is a connection between the subjective severity of vision loss and the readiness to seek low vision rehabilitation services. The more impaired, the more likely it was that they would access these services. It is important to note that the subjective severity of loss and accessing low vision rehabilitation services had important moderating cofactors, such as compensatory responses (for example, relying on a partner--subtheme A) and emotional factors (like denial and acceptance--subtheme B). Theme 1 was divided into two subthemes that served as barriers to low vision rehabilitation services.

A: Perceived ability to engage comfortably in activities of daily living

The participants frequently indicated that they could manage functional limitations associated with their impairment; they had no need to seek rehabilitation services. A G2 participant commented, "I don't go because I don't feel that I have to go.... I can do everything by myself." Thus the ability to engage in everyday valued activities served as a strong inhibitor to seeking help. Similarly, compensatory changes made in daily life (such as relying on a partner for certain tasks) ultimately served as a barrier to services. "I was comfortable in my comfort zone at home. I didn't have to go out." This excerpt was taken from a G3 participant who relied heavily on her partner in some social situations at that time.

B: Participatory losses gradual in nature

Several G3 participants explained that the gradual nature of vision loss meant that early in the onset of the condition, they denied its existence. One participant commented, "Being in denial about what you are going through is the worst thing in the world." It was only by recognizing the consequences of low vision (for example, on everyday activities) that the participants facilitated a gradual acceptance of their visual deficits, which enabled them to search for low vision solutions, including rehabilitation. "I wanted my independence back. I gave up driving. So when I started thinking about the car ... and all the things that I had to give up, I said 'No, I don't have to give up, I have to learn how to do things.'" Thus, for some participants, the realization that participation in valued activities (such as driving) had been compromised prompted their acceptance of their low vision and precipitated their help-seeking behaviors. Many participants indicated that they accessed services only after they had accepted their vision loss. The lack of acceptance is thus a barrier: "It takes a while until you get used to the vision loss and you are not threatened to [seek out rehabilitation]. It's a question of readiness."

THEME 2: BARRIERS INHERENT IN THE CLINIC

The second theme of barriers to low vision rehabilitation services arose out of discussions that centered on health care service settings. This theme was divided into the following two subthemes.

A: Inefficiencies in educating clientele about low vision rehabilitation services One of the most frequently mentioned barriers to low vision rehabilitation services was the lack of awareness of these services. For many participants, the challenge of finding health care solutions was not obvious: "People don't even know where to turn. Where to do their own homework." Other participants identified perceived failings in service delivery, "So if the doctors don't have time to [educate], they have to get somebody. A liaison." A common sentiment was the scarcity of advertising by rehabilitation institutes. Some participants expected institutions to distribute information about low vision rehabilitation services. "Pamphlets. There are no pamphlets out here to give us any information." Another participant stated, "I find that they don't advertise a lot. Maybe it's a lack of funding. I don't know the reasons." A G3 participant commented, "I mean, to be here for 30 years and not know that there is a low vision clinic here, I was shocked when I found out. Where is it exactly? I still don't know. Is it on this floor, and who is using it?"

One issue that polarized the participants was the appropriate role of the ophthalmologist in disseminating information on low vision rehabilitation services. Some participants indicated that information about rehabilitation should come directly from the ophthalmologist. "I know a lot of people who ask me [for information about low vision rehabilitation services], and I'm thinking ... Why can't the ophthalmologist help that person?" Another participant stated, "I think that they [ophthalmologists] should at least point you in [the] right direction." However, other participants defended the ophthalmologists, claiming that they are very busy: "Every one of the doctors [has] 150 patients to look after. Once they diagnose you, they figure you are going to do your homework and to figure out what you are going to do next." Another participant added, "The doctor has the right not to know everything." Often, the participants who defended the ophthalmologists spoke of a personal responsibility to educate themselves about low vision rehabilitation services: "If I can help myself, I don't expect to get help from somebody else."

B: Problems and dissatisfaction associated with ophthalmic consultations

The participants described numerous barriers related to low vision rehabilitation services associated with consultations with healthcare practitioners. Many participants indicated that the short duration of professional-patient consultations was a barrier to low vision rehabilitation services: "They can't spend a lot of time with the patient. I try to leave because I know that there are 10-15 people waiting for him. So I don't want to waste his time with my problems." Another participant described the impacts of being rushed through her ophthalmic consultations, "I walk in. "He says hello how are you?" I am fine." All of a sudden, I am fine! I had all these questions. How does that happen? I think [it's the result] of seeing him rushing." Many participants took exception to the ophthalmologist's "bedside manner": "He is a great doctor. But he walks around. He is not God. I would like a doctor that I could have a little bit of a rapport with." Several respondents indicated that health professionals' lack of tact and professionalism compromised the flow of information about low vision rehabilitation services: "So the resident leaned forward and whispered in my ear. 'You have macular degeneration.' Like cancer 20 years ago! You are not even allowed to say the words." Finally, there was general agreement among the participants that the current procedure of referral lacks structure and coordination. The following is a particularly striking example: "I saw an optometrist. He told me, 'Oh no, I cannot help you. You have to see a doctor [at a local hospital].' I saw Dr. John Doe [altered for reasons of confidentiality]. He referred me on here to the low vision clinic [at the same hospital]. They said, 'We are not equipped here. A local rehabilitation [center] might be better for you.' So I did that."

THEME 3: BARRIERS INHERENT IN SOCIETY AT LARGE

The third theme represents barriers that originate in the participants' communities. This theme is divided into the following two subthemes.

A: Fears associated with having stereotypes applied

A surprising finding was that the participants repeatedly described being devalued in their communities. Interactions with their typically sighted peers served as a barrier. The participants described the relationships between these two groups (individuals with low vision and those with typical vision) as stressful and misinformed. Many participants spoke about prejudicial attitudes associated with low vision: "I function like every other normal person. It's just my eyes. I always tell people, there is nothing wrong with my hearing. There is nothing wrong with [my] brain. If you touch me, you don't get a disease." The participants also explained that the functional manifestations of low vision are often misunderstood by people who have typical sight: "It takes you longer to read. You kind of become a little bit slower, which people don't understand."

For some participants, the decision not to enter rehabilitation institutes for the "blind" arose out of a fear of being stereotyped. One person who had accessed low vision rehabilitation services said: "It's a psychological barrier. One of the doctors talked about [an association for people who are blind] to me. My back went up right away. I don't want anything to do with anything that has ... the letter "B" in it." Another participant added, "You go there, but you are a little reluctant to identify with them." The participants explained that such experiences made them resistant to avail themselves of low vision rehabilitation services. The products and services were like a double-edged sword: beneficial to functioning, but also a discernible symbol of vision loss: "You have a magnifying glass, or have someone else read it to you. When you are with a crowd, it is embarrassing."

B: Transportation: The setting where clashes occur

Modes of transportation were most often mentioned as the setting in which this conflict between groups took place. Although taking a bus or cab to low vision rehabilitation services may be manageable on its own, the participants indicated that this task becomes much more difficult if it involves interacting with others who have typical vision. One G3 participant said: "Transportation is the worst thing. People bump into you on the metro, and they are in a hurry ... they don't care if you can see or not.... It changes your life; it is a struggle every single day for me."

Discussion

The purpose of this study was to describe and gain a better understanding of the barriers to low vision rehabilitation services. The themes that emerged from the focus group analyses revealed barriers to low vision rehabilitation services that are inherent in the individual, in interactions with vision health professionals, and in interactions with the sighted community.

With regard to the first theme (the individual), it is noteworthy how compensatory behaviors can serve as a barrier to low vision rehabilitation services. Some participants structured their environments to maximize participation in valued activities, yet in so doing created an environment in which there was no reason to seek help. These responses to decrements of functional vision gave rise to a catch-22 effect, whereby the participants delayed their first contact with low vision rehabilitation services. Also at the level of the individual, the participants indicated that the typical slow progression of their condition delayed their acceptance of vision loss. Until the participants accepted their visual difficulties (that is, that they were ready for rehabilitation), they were not prepared to seek help for them.

The second theme that arose was barriers inherent in medical and rehabilitation environments. The analyses revealed dissatisfaction with procedures for accessing information about rehabilitation services, including the referrals process, and with the unavailability of any type of print material on rehabilitation services. Moreover, they expressed dissatisfaction with ophthalmic consultations, including the length of time devoted to each client, as well as an aversion to the manners of some doctors. These factors served as barriers to continued contact with low vision rehabilitation services.

The third theme that arose from the analyses was barriers inherent in society at large. For this theme, the analyses revealed that interactions with typically sighted individuals in communities are sometimes affected by stereotypes about vision loss. Individuals may be reluctant to reveal their vision loss to others out of a fear that these persons may be prejudiced or that they will be discriminated against. The one setting in which this clash most often played out was the public transportation system. It is not unreasonable to assume that the mistreatment of individuals with vision loss in the transit system could lead some individuals to decide not to visit a clinic.

The barriers to low vision rehabilitation services remain an underresearched health care topic. In the section that follows, a representative model is proposed that places the themes generated in the present analysis. This model is proposed as a first step toward plotting a comprehensive representation of barriers to low vision rehabilitation services, in the hopes that it will open a dialogue and inspire future research on this important topic. The proposed model is inspired by the recognized assistive technology selection and outcomes frameworks (Fuhrer, Jutai, Scherer, & DeRuyter, 2003; Scherer, Jutai, Fuhrer, Demers, & Deruyter, 2007). These authors have proposed assistive technology frameworks that have received acceptance within the assistive technology community. There are other conceptual frameworks that depict factors that influence rehabilitation help seeking (for example, Gitlin, 1998; Lenker & Paquet, 2004). The proposed model design was selected because, in our opinion, it best highlights three crucial elements arising from the analyses presented here: the time elapsed since the onset of the vision loss; the complex interactions among the individual, the health care setting, and society; and the overall dynamic nature of help seeking.

At the heart of the proposed representative model (see Figure 1) are three categories of barriers to low vision rehabilitation services: within the individual, the health care setting, and society. The individual category represents barriers that are inherent in the individual, including personality, age, gender, financial resources, family and social support, personal knowledge about rehabilitation options, expectations, and priorities. The health care setting category represents barriers that are inherent in the clinic setting, including policies and programs that focus on low vision rehabilitation services, attributes of the ophthalmologist and other staff members (that is, knowledge of low vision rehabilitation services and motivation to pass along information), characteristics of the consultations (that is, the time allocated and receptivity to a question-and-answer period), and motivation to refer clients to rehabilitation. Finally, the society category represents barriers that are inherent in the surrounding community, including the characteristics of the social, demographic, and cultural community; governmental policies on accessing specific rehabilitation services or devices; and the attitudes of others with respect to adopting and using these types of services.

[FIGURE 1 OMITTED]

Three key assumptions affect the progression of individuals through the model toward the prolonged use of low vision rehabilitation services. First, the categories of individual, healthcare setting, and society are presumed to interact with one another to create a unique set of barriers for each individual. On the basis of the current analyses, it seems apparent that these categories of factors do not exist as distinct entities. Rather, there are likely to be complex interactions among these three areas.

Second, the proposed model is time dependent. Similar to other assistive technology outcome models (Gitlin, 1998; Lenker & Paquet, 2004), it is assumed in the proposed framework that accessing and utilizing rehabilitation are determined, in part, by the amount of time that has elapsed since the initial exposure to low vision rehabilitation services. The left side of the model represents events that occur prior to the individual first accessing services. During this time, the individual becomes aware of functional changes in vision loss, may acquire some information about the available programs and services, and would presumably develop some attitudes toward people with vision loss (that is, stereotypes). Preconsultation awareness of rehabilitation services is dependent on societal conditions, such as cultural and legislative considerations and attitudes of key other people (Scherer et al., 2007). The middle section of the model depicts first accessing of services in the health care setting, initial outcomes, and relative satisfaction with these services. The right-hand portion of the model represents the longer-term use of low vision rehabilitation services. This design was selected to acknowledge the differences in barriers encountered by new versus more experienced clientele.

Finally, as a complement to the time-dependent aspect of the model, it is assumed that individual-level characteristics, including functional vision loss, are in a state of flux. This instability or unpredictability is attributable to various factors and may include the onset and progression of comorbidity, changes in marital status, financial considerations, and living arrangements. These moderating factors all contribute to the inclination to seek help and personal resources devoted to help seeking.

The proposed model sufficiently integrates the findings arising from the analyses presented here. Prior to initial contact with health care professionals, some people may demonstrate a reluctance to access low vision rehabilitation because they are simply not ready. There is seemingly a coming-to-terms barrier associated with the onset of a new chronic age-related health condition (Charmaz, 1983; Pollard et al., 2003; Whitbourne & Sneed, 2002). Some individuals with low vision may delay help-seeking (Heine & Browning, 2002) until such time that valued activities of daily living (such as driving an automobile or reading to a grandchild) are put in jeopardy of being terminated.

The awareness of rehabilitation services is an important predictor of the use of these services (Roelands, Van Oost, Buysse, & Depoorter, 2002). Although it is an obvious point, it warrants mention; it is impossible to avail oneself of low vision rehabilitation services if one is not aware of these services. Crucial to the short-term phase are interactions with health care professionals and gathering information about low vision rehabilitation services. In the present and other studies, individuals with low vision indicated that the procedures used to disseminate information about low vision rehabilitation services could be improved (Gold et al., 2006; Gresset & Baumgarten, 2002; Pollard et al., 2003). This barrier may be associated with patient-doctor consultations that are reportedly short in duration. After medical procedures have been completed, little time is left for questions. More troublesome were the participants' complaints that hospital staff do not demonstrate basic respect for patients. It is plausible to suggest that this could also serve as a barrier to rehabilitation.

A key assumption of Fuhrer et al.'s (2003) framework is that users make and remake decisions to continue to use rehabilitation services. A critical element of these ongoing evaluations is the relationship between the user and the professional. In the assistive technology literature, some studies have highlighted the importance of this relationship (Kraskowsky & Finlayson, 2001; Wessels, Dijcks, Soede, Gelderblom, & De Witte, 2003). Health care professionals are advised to consider carefully how they communicate with clients, because these strategies strongly influence the clients' adherence to interventions (Wessels et al., 2003).

The final category, society, is linked to barriers that originate in their communities' response to individuals' adaptation and modifications to their lives after they have received low vision rehabilitation services. After individuals have accessed low vision rehabilitation services, the barriers to taking up and using prescribed regimens and adaptive technologies and strategies persist. Many conventional rehabilitation interventions (such as the use of a cane) serve to notify the general public that an individual is in some ways different and may incite discrimination. Yet, an increasing body of literature in the health sciences has suggested that responses to marginalization that occur in social settings vary greatly (Shih, 2004). Critical here is the ease by which adaptations and modifications requisite to the intervention are made in the individual's environment. In the assistive technology literature, this is referred to as fit. Fit refers to the user's subjective evaluation of how easily and naturally the intervention plan is integrated into the user's life. Several authors (Gitlin, 1998; Kraskowsky & Finlayson, 2001; McCreadie & Tinker, 2005) have emphasized the importance of accessing and incorporating the user's perspective when seeking a good match among the individual, the proposed intervention, and the environment. Kraskowsky and Finlayson (2001) cautioned that a lack of fit has a strong negative impact on the adoption of a prescribed intervention plan. The characteristics and preferences of users, including the type and design of housing and a felt need for assistance, interact to influence the acceptability of an intervention (McCreadie, Wright, & Tinker, 2006). In the assistive technology literature, the subjective evaluation of fit appears to be a good predictor of the use of rehabilitation services and arguably warrants a more prominent mention in the design and implementation of low vision rehabilitation services.

Conclusion

A review of the literature indicated that barriers to low vision rehabilitation services are a complex, multifactor phenomenon. Help-seeking behaviors vary dramatically, particularly for older adults whose health status is constantly changing. One may think that symptoms of illness or disease would be reliable predictors of accessing health care. Yet, on the basis of the analyses presented here, the factors that influence accessing low vision rehabilitation services extend beyond symptomology. The barriers to low vision rehabilitation services are rooted in an interaction of personal, clinical, and societal factors. It is crucial to acknowledge this interaction when investigating older populations, for whom these factors are constantly changing. Thus, a more comprehensive approach to the consideration of barriers to the use of low vision rehabilitation services is required. The number of adults who access these services remains low. This situation is troublesome because individuals who are unaware of services and programs are unable to benefit from them. The present analyses highlight the need for research on suitable and effective forms of disseminating information on services and programs for this population. Moreover, these findings underscore the need for research on barriers to the use of low vision rehabilitation services that are intrinsic to the ophthalmologic consultation.

In this article, we proposed that it may he beneficial to examine other theoretical conceptualizations to aid in the recognition and consideration of barriers to low vision rehabilitation services. In so doing, it becomes apparent that these barriers likely change over time and likely exist prior to the first consultation (Ripat & Strock, 2004; Roelands et al., 2002). Factors that may serve as barriers in the short term may be different from those that confront people in the long term. In fact, there are likely numerous decisions to seek services. The need for effective communication between consumers and providers is emphasized to encourage and help clients seek low vision rehabilitation services. Finally, it is vital to seek the user's perspective and attempt to achieve a good fit between the client's needs and the services that are adopted. This is an area of research that warrants more emphasis.

[check] EARN CEUs ONLINE by answering questions on this article. For more information, visit: <http://jvib.org/CEUs>.

The authors thank Dr. Olga Overbury for her support in the completion of the study. The Montreal Barriers Study is funded by the Reseau Vision of the Fonds de recherche en sante du Quebec, the Institut Nazareth et Louis-Braille, and the MAB-Mackay Rehabilitation Centre. Funding for the postdoctoral fellowship of Walter Wittich is provided by the Canadian Institutes of Health Research.

References

Adam, R., & Picketing, D. (2007). Where are all the clients? Barriers to referral for low vision rehabilitation. Visual Impairment Research, 9(2-3), 45-50.

Burnard, P. (1991). A method of analysing interview transcripts in qualitative research. Nurse Education Today, 11, 461-466.

Canadian National Institute for the Blind. (2005). VOICE in health policy: The impact of health policy gaps on low vision services in Canada. Toronto: Author.

Charmaz, K. (1983). Loss of self: A fundamental form of suffering in the chronically ill. Sociology of Health & Illness, 5, 168-195.

Chiang, P., O'Connor, P., Le Mesurier, R., & Keeffe, J. (2011). A global survey of low vision service provision. Ophthalmic Epidemiology, 18, 109-121.

Chiang, P., Xie, J., & Keeffe, J. (2011). Identifying the critical success factors in the coverage of low vision services using the classification analysis and regression tree methodology. Investigative Ophthalmology & Visual Science, 52, 2790-2795.

Elo, S., & Kyngas, H. (2008). The qualitative content analysis process. Journal of Advanced Nursing, 62, 107-115.

Faye, E. E. (1984). Clinical low vision (2nd ed.). Boston: Little, Brown.

Fuhrer, M. J., Jutai, J. W., Scherer, M. J., & DeRuyter, F. (2003). A framework for the conceptual modelling of assistive technology device outcomes. Disability and Rehabilitation, 25(22), 1243-1251.

Gitlin, L. (1998). From hospital to home: Individual variations in experience with assistive devices among older adults. In D. Gray, L. A. Quatrano, & M. L. Lieberman (Eds.), Designing and using assistive technology: The human perspective (pp. 117-136). Baltimore, MD: Brookes Press.

Gold, D., Zuvela, B., & Hodge, W. G. (2006). Perspectives on low vision service in Canada: A pilot study. Canadian Journal of Ophthalmology, 41, 348-354.

Gresset, J., & Baumgarten, M. (2002). Prevalence of visual impairment and utilization of rehabilitation services in the visually impaired elderly population of Quebec. Optometry & Vision Science, 79, 416-423.

Heine, C., & Browning, C. (2002). Communication and psychosocial consequences of sensory loss in older adults: Overview and rehabilitation directions. Disability and Rehabilitation, 24(15), 763-773.

Hsieh, H. F., & Shannon, S. E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15, 1277-1288.

Keeffe, J. E., Lovie-Kitchin, J. E., & Taylor, H. R. (1996). Referral to low vision services by ophthalmologists. Australian and New Zealand Journal of Ophthalmology, 24, 207-214.

Koenekoop, R. K., & Gomolin, J. E. (1995). The management of age-related macular degeneration: Patterns of referral and compliance in seeking low-vision aids. Canadian Journal of Ophthalmology, 30, 208-210.

Kraskowsky, L. H., & Finlayson, M. (2001). Factors affecting older adults' use of adaptive equipment: Review of the literature. American Journal of Occupational Therapy, 55, 303-310.

Lenker, J. A., & Paquet, V. L. (2004). A new conceptual model for assistive technology outcomes research and practice. Assistive Technology, 16(1), 1-10.

Maberley, D. A., Hollands, H., Chuo, J., Tam, G., Konkal, J., Roesch, M., et al. (2006). The prevalence of low vision and blindness in Canada. Eye, 20, 341-346.

McCreadie, C., & Tinker, A. (2005). The acceptability of assistive technology to older people. Ageing & Society, 25, 91-110.

McCreadie, C., Wright, F., & Tinker, A. (2006). Improving the provision of information about assistive technology for older people. Quality in Ageing, 7(2), 13-22.

Morse, J., & Field, P. A. (1995). Qualitative research methods' for health professionals (2nd ed.). Thousand Oaks, CA: Sage.

Mwilambwe, A., Wittich, W., & Freeman, E. E. (2009). Disparities in knowledge and use of low vision rehabilitation. Canadian Journal of Ophthalmology, 44, 686-691.

Overbury, O., Jackson, W. B., & Santangelo, M. (1987). Canadian ophthalmologists and low vision: A national survey. Canadian Journal of Ophthalmology, 22(1), 29-31.

Overbury, O., & Wittich, W. (2011). Barriers to low vision rehabilitation--The Montreal Barriers Study. Investigative Ophthalmology & Visual Science, 52, 8933-8938.

Polit, D. F., & Beck, C. T. (2004). Nursing research: Principles and methods. Philadelphia: Lippincott Williams & Wilkins.

Pollard, T. L., Simpson, J. A., Lamoureux, E. L., & Keeffe, J. E. (2003). Barriers to accessing low vision services. Ophthalmic & Physiological Optics, 23, 321-327.

Regie de l'assurance maladie du Quebec/ RAMQ. (2006). Services covered in Quebec--Visual devices. Retrieved from http://www.ramq.gouv.qc.ca/en/citoyens/ assurancemaladie/serv_couv_queb/aides_visuelles_pq.shtml

Ripat, J., & Strock, A. (2004). Users' perceptions of the impact of electronic aids to daily living throughout the acquisition process. Assistive Technology, 16(1), 63-72.

Roelands, M., Van Oost, P., Buysse, A., & Depoorter, A. (2002). Awareness among community-dwelling elderly of assistive devices for mobility and self-care and attitudes towards their use. Social Science & Medicine, 54, 1441-1451.

Sandelowski, M. (2000). What ever happended to qualitative description? Research in Nursing & Health, 23, 334-340.

Scherer, M., Jutai, J., Fuhrer, M., Demers, L., & Deruyter, F. (2007). A framework for modelling the selection of assistive technology devices (ATDs). Disability and Rehabilitation: Assistive Technology, 2(1), 1-8.

Shih, M. (2004). Positive stigma: Examining resilience and empowerment in overcoming stigma. Annals of the American Academy of Political and Social Science, 591, 175-185.

Sundling, V., Gulbrandsen, P., Bragadottir, R., Bakketeig, L. S., Jervell, J., & Straand, J. (2007). Optometric practice in Norway: A cross-sectional nationwide study. Acta Ophthalmologica Scandinavica, 85, 671-676.

Walter, C., Althouse, R., Humble, H., Leys, M. J., & Odom, J. g. (2004). West Virginia survey of visual health: Low vision and barriers to access. Visual Impairment Research, 6(1), 53-71.

Wessels, R., Dijcks, B., Soede, M., Gelderblom, G. J., & De Witte, L. (2003). Nonuse of provided assistive technology devices, a literature overview. Technology & Disability, 15, 231-238.

Whitbourne, S. K., & Sneed, J. R. (2002). The paradox of well-being, identit3, processes, and stereotype threat: Ageism and its potential relationships to the self in later life. Cambridge, MA: MIT Press.

Kenneth Southall, Ph.D., early researcher-new career scientist, Institut de recherche Elisabeth-Bruybre Research Institute, affiliated with the University of Ottawa, 60 Cambridge Street North, Ottawa, ON, Canada K1R 7A5; e-mail: <[e-mail]>. Walter Wittich, Ph.D., postdoctoral fellow, Centre de recherche institute universitaire de geriatrie de Montreal, University of Montreal, and research coordinator, MAB-Mackay Rehabilitation Centre, 7000 Sherbrooke Street West, Montreal, Quebec, Canada H4B 1R3; e-mail: <[e-mail]>.