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A Study Exploring Occupational Therapists’ Current Knowledge and Awareness of Visual Impairment in Older Adults and Potential Interventions which Aim to.

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Presentation on theme: "A Study Exploring Occupational Therapists’ Current Knowledge and Awareness of Visual Impairment in Older Adults and Potential Interventions which Aim to."— Presentation transcript:

1 A Study Exploring Occupational Therapists’ Current Knowledge and Awareness of Visual Impairment in Older Adults and Potential Interventions which Aim to Improve their Quality of Life Gail Fish MSc Occupational Therapy (Pre-Registration) Dissertation Presentation (2011)

2 Background 2 million visually impaired people in UK (RNIB, 2009)
Ageing population will increase demand for vision-related services Services currently provided by opticians, ophthalmologists, local authority visual impairment teams / rehabilitation officers Emerging field of occupational therapy practice in UK (Campion et al, 2010) Occupational therapists are in a prime position to work in this area (Rosenfeld, 2011; Warren, 2011) There are an estimated 2 million visually impaired people in the UK, the majority aged 65+. The ageing population will gradually increase demand for vision-related services, which are currently provided by opticians and ophthalmologists, and often local authority visual impairment teams. Usually when someone registers as blind or partially sighted, they’re referred to a rehabilitation officer within one of these teams, who assesses their daily living needs, and might provide interventions, such as adjusting lighting and contrast in the home, supplying equipment (e.g. magnification devices), reading strategies, working on safe outdoor mobility (e.g. white stick training) – the aim is to maintain independence as far as possible. These interventions are not too dissimilar to the occupational therapy domain, as they aim to maintain independence as far as possible. Visual impairment is an emerging field of occupational therapy practice in the UK, and OTs are in a prime position to become more involved, due to their understanding of how ageing affects the body, and their expertise in providing interventions for other age-related functional impairments. With the imminent ageing population, and the number of rehabilitation officers actually in decline, it’s important to consider future service provision in this area, and what OTs currently know about it.

3 What is Visual Impairment?
“a limitation in one or more functions of the eye or visual system” (Access Economics, 2009, p.2). Normal age-related structural changes Generally correctable using glasses Visual impairment is described as “a limitation in one or more functions of the eye or visual system” (Access Economics, 2009, p.2). The eye undergoes natural structural changes with age which can result in a gradual decline in visual function, although these are generally correctable using glasses and don’t tend to cause significant functional impairment in older adults. However, a more serious type of visual impairment can impact on the sight of older adults – low vision.

4 What is Low Vision? Uncorrectable sight loss caused by age-related eye diseases Up to 90% retain some useful residual sight – potential for vision rehabilitation (Lamoureux et al, 2007) An older person with low vision is therefore described as someone who, “…has impairment of visual functioning even after treatment and/or standard refractive correction…but who uses, or is potentially able to use, vision for the planning and/or execution of a task” (World Health Organisation, 1996, p.4). Low vision is uncorrectable sight loss caused by age-related eye diseases (most commonly age-related macular degeneration, glaucoma, cataracts and diabetic retinopathy). An older person affected by low vision can experience difficulties carrying out their daily occupations, which could lead to a loss of confidence and independence, and even depression, potentially reducing quality of life. Only arthritis and heart disease are ranked more highly than sight loss as causes of functional impairment in adults aged 70+ (Lord et al, 2007). However, up to 90% of those with low vision actually retain some useful sight which could benefit from low vision rehabilitation services. The World Health Organisation (1996) has provided a useful definition of an older person with low vision, as someone who,“…has impairment of visual functioning even after treatment and/or standard refractive correction…but who uses, or is potentially able to use, vision for the planning and/or execution of a task” (World Health Organisation, 1996, p.4).

5 Age-related Eye Diseases
This slide (and the next) shows a simulation of vision affected by the four most common age-related eye diseases: Cataracts Cause reduced visual acuity, and blurred or hazy vision. Age-related macular degeneration, which is the cause of more than half of all cases of low vision in the UK, and results in a loss of the central visual field. - The person is left with just their peripheral or surrounding vision. Cataracts Age-related macular degeneration Adapted from: City and County of San Francisco: SFGOV. 2009, Common causes of low vision [online]. City and County of San Francisco: SFGOV, San Francisco. Available at: [Accessed 6 June 2011].

6 Age-related Eye Diseases
Glaucoma Gradually causes ‘tunnel vision’, because the central visual field is the last area to be affected. Diabetic Retinopathy A complication of diabetes mellitus, can distort vision and cause blind spots around the visual field. Glaucoma Diabetic Retinopathy Adapted from: City and County of San Francisco: SFGOV. 2009, Common causes of low vision [online]. City and County of San Francisco: SFGOV, San Francisco. Available at: [Accessed 6 June 2011].

7 Previous Research Campion et al (2010)
– Carried out survey with members of two COT Specialist Sections to investigate training needs of OTs in relation to sight loss - Also explored pre-registration education in this area, and best ways to deliver post-registration training Copolillo et al (2007) - Conducted survey of OTs working in low vision rehabilitation in USA, to investigate their role Campion et al (2010) Survey carried out with members of Older People and Housing COT Specialist Sections. Representatives of nineteen higher education institutions offering pre-registration OT degrees were also interviewed. Findings include: Visual impairment is afforded inadequate attention in pre-registration programmes. 81% of respondents felt they needed further training in this area. Whilst three quarters routinely considered visual impairment when assessing clients, 88% indicated they would refer them to a VI team, expressing a lack of confidence in assessing and planning interventions for people with sight loss. Copollilo et al (2007) Survey investigating role of OTs working in low vision rehabilitation services. Majority of OTs worked with those age 65+. Most frequently used interventions were those traditional to the OT profession, relating to environmental modifications and ADLs. Majority of respondents had attained several years of practice experience prior to working in LVR, but were keen to pursue specialist LVR qualifications.

8 Aim To investigate occupational therapists’ current knowledge and awareness of visual impairment in older adults and potential interventions which aim to improve their quality of life Main aim of my study: to investigate occupational therapists’ (who work with a variety of client groups across the UK) current knowledge and awareness of visual impairment in older adults, and potential interventions which aim to improve their quality of life. I achieved this aim by surveying members of four of the College of Occupational Therapists specialist sections (Older People, Housing, Trauma & Orthopaedics and Rheumatology).

9 Methods Brief literature search
Contacted four COT Specialist Sections by (Older People, Housing, Trauma & Orthopaedics, Rheumatology) Developed survey → piloted → published online 1043 members invited to participate by Survey available to participants for four weeks My methods: I initially conducted brief literature search to learn more about topic. I contacted four Specialist Sections by to ascertain whether they’d be interested in taking part (I chose the groups most likely to work with older people). I developed the survey based on background reading, previous research, and by consulting with local visual impairment charities (e.g. Visibility, in Glasgow). - I piloted the survey (in Word format) with four OTs I know – to check their understanding of questions, and completion time. I then had the survey published online using Snap survey software. An invitation (containing a hyperlink to the survey) was then sent out to 1043 occupational therapists in total, and the survey was available to complete online for 4 weeks.

10 This is a screenshot of the beginning of the survey.

11 Demographic Results Response rate = 25% (265 / 1043)
92% (n = 242) worked with clients aged 65+ 52% (n = 135) had practised for >16 years 21% (n = 54) had practised for 6-10 years The response rate was 25% (265 / 1043) – which is relatively low, but within a normal range for online surveys. The pie chart shows the breakdown of respondents by specialist section: - 40% were Housing members (green section) and 36% Older People members (pink section). These two groups made up the largest proportion of the sample. The other proportions were 13% Rheumatology members (yellow section) and 10% Trauma and Orthopaedics members (purple section). 92% said they worked with clients aged 65+ Respondents were also likely to have several years of professional experience: 52% said they’d practised for more than 16 years; 21% had practised for 6-10 years. Four main themes of the findings will now be discussed…

12 1. Knowledge of Common Causes of Low Vision in Older Adults
Majority (80%) reported ‘fair’ or ‘good‘ knowledge < 10% = ‘very good’ knowledge of any eye condition < 1% = ‘excellent’ knowledge of any eye condition Poorest knowledge of diabetic retinopathy (23%) 1. I asked participants to rate their knowledge of the four most common age-related eye diseases that cause low vision (i.e. AMD, Glaucoma, Cataracts and Diabetic Retinopathy). The majority (around 80%) reported ‘fair’ or ‘good’ knowledge of all four conditions. However, less than 10% felt their knowledge of any of the four eye conditions to be ‘very good’; And less than 1% felt they had ‘excellent’ knowledge of any of these conditions. Knowledge was poorest in relation to diabetic retinopathy (23% reported poor knowledge of this). - The incidence of diabetes is going to increase with ageing population (from 2.9 million in 2011 to 5 million in 2025 – Diabetes UK, 2011), so it’s important to raise more awareness of this eye condition.

13 2. Awareness of Available Vision-Related Services
77% (n = 201) would refer client to VI team if visual impairment was identified  Housing (87%) > Trauma & Orthopaedics (37%) (Χ2 = 33.85, df = 3, p = 0.00) 81% (n = 213) aware of LA VI services  Housing (92%) > Trauma & Orthopaedics (56%) (Χ2 = 35.87, df = 6, p = 0.00) 2. Awareness of available vision-related services. 77% of participants said they’d refer their older clients to a VI team if they identified sight loss. I used the Chi-Square to test for any significant differences between the specialist groups, in terms of their answers to particular questions. I found that Housing members (87%) were more likely to refer their clients to a VI team than T & O members (37%). Furthermore, 81% of respondents said they were aware of services provided by VI teams. Housing members were most aware of these services (92%), whilst T & O (56%) were least aware. This may be because Housing members work more closely with local authority VI teams, therefore being more aware of them and more likely to refer clients to them.

14 3. Awareness and Use of a Range of Relevant Interventions
Participants most aware of and had most frequently used interventions within ‘traditional’ domain of occupational therapy 96% (n = 251) aware of ‘use of optical devices in daily activities’, but only 58% (n = 153) had used this intervention in practice INTERVENTION PREVIOUSLY USED WITH VISUALLY IMPAIRED OLDER ADULT NUMBER OF RESPONSES % Basic ADL interventions 223 85.1 Indoor functional mobility 204 77.9 Environmental modifications 202 77.1 Instrumental ADL interventions Use of nonoptical assistive devices / compensatory strategies 187 71.4 Use of optical devices in daily activities 153 58.4 3. I asked participants which interventions they were aware of and had previous used with visually impaired older clients, and the table shows that the top 5 previously used were within the ‘traditional’ domain of OT, as would be expected. This also correlates with the research mentioned earlier, conducted by Copollilo et al (2007). Interestingly, the intervention respondents were most aware of (96%) was the use of optical devices in daily activities (magnifiers) – but only 58% had used this intervention in practice, which may indicate a future training need.

15 The participants were also asked how confident they felt in planning the types of interventions just mentioned. The chart shows that: - Just over half (52%) felt ‘relatively confident’ and 23% ‘quite confident’. - Almost a quarter (21%) indicated feeling ‘not very confident’ and only 5 respondents (2%) felt ‘extremely confident.

16 4. Occupational Therapy and Low Vision
81% (n = 211) = practice would be enhanced by learning more about visual impairment 1-5 years (91%) > 16+ years of practice (73%) (rs = 0.21, p = 0.001, n = 262) 87% (n = 228) = OTs could have important future role in this area 50% (n = 131) might want to work in this area in future 4. This theme relates to how the occupational therapists surveyed felt about the profession’s future role in low vision. 81% felt their practice would be enhanced by learning more about visual impairment in older adults (this supports Campion et al’s (2010) identical finding in this area). There was a correlation between years of practice and whether participants felt they needed to learn more: Those most recently qualified (91% of those practising for 1-5 years) were more likely to feel they needed to learn more than those practising for 16 years or more (73%). - [May suggest that knowledge of VI has developed with experience, or it may have been more adequately taught in earlier undergraduate degrees. Some respondents commented that it doesn’t sufficiently feature in today’s pre-registration programmes and that more training opportunities are required.] 87% of respondents felt that OTs could have an important role in future low vision service provision, although only half of the sample said they might want to work in this area in future. [Older People and T & O members most likely to want to work in low vision in future (around a third of each), and Housing least likely (only 16%).]

17 Additional Findings * Awareness of conditions associated with VI: falls (84%), stroke (80%), fractures (63%), depression (63%), dementia (45%) * 65% indicated awareness that anyone with a visual impairment could access services provided by LA VI team, registered or not * 69% unfamiliar with Light for Sight guidelines; 87% unaware of Progress in Sight best practice guidelines The majority of participants were aware of an association between visual impairment and falls (84%) and stroke (80%). However, lower numbers were aware of its association with fractures (63%), depression (63%) and dementia (45%). 65% indicated awareness that anyone with a visual impairment could access services provided by local authority visual impairment teams, whether or not they were registered as blind/partially sighted. This is in fact the case, and those with sight loss can also self-refer if they wish (Adams, 2007; RNIB, 2010a, 2010b; Macular Disease Society, 2011). Awareness of guidelines was very low – 69% were unaware of the Light for Sight guidelines (emphasising the importance of good lighting in the homes of visually impaired older people – produced by Thomas Pocklington Trust in conjunction with concerned professional bodies, including the COT) and 87% were unaware of the Progress in Sight best practice guidelines. This supports Campion et al’s (2010) recognition of the need to more fully address the marketing and communication of such standards and guidelines to occupational therapists in the future.

18 Implications for Practice
Occupational therapists have skills to work in low vision, but knowledge should be developed: Broaden existing knowledge of eye diseases Training on suitable low vision interventions Visual impairment should be a core subject in undergraduate & postgraduate programmes Need for post-registration education Embrace opportunities! (Withers & Shann, 2008) The results of the survey suggest that OTs do have the skills to work in low vision with older adults, but there is scope to develop their knowledge: More awareness of age-related eye diseases, particularly diabetic retinopathy, would be beneficial. Additional training in suitable low vision interventions not so traditional to OT would be useful, e.g. those traditionally delivered by rehabilitation officers, such as use of optical devices, adjustment of lighting and contrast (environmental factors), reading strategies… Many participants said they needed to learn more about visual impairment, and it should really be a core subject in undergraduate and postgraduate OT programmes. In addition, post-registration visual impairment training should be available, to help practising OTs develop their knowledge (such as study days arranged by e.g. COT, internal training, literature/guidelines…). * OTs should also embrace opportunities to develop their profession, in response to the needs of changing society (Withers & Shann, 2008). The ageing population and growing need for vision-related services over the coming years are good examples of such opportunities.

19 Study Limitations Relatively low response rate (25%), although comparable to previous studies mentioned in slide 7 Technical issue with one question may have lowered response rate Not generalisable – four specialist groups were chosen deliberately due to their interest in older adults Voluntary participation may have reduced the study’s representativeness The survey was created solely by the researcher, thus its validity and reliability are not proven It is important to acknowledge some of the study’s potential limitations: - Low response rates are a common weakness of web-based surveys (Evans & Mathur, 2005). However, 25% is comparable to two similar web-based surveys: 28%, described as “low” (Copolillo et al, 2007, p.24) and 27.7%, “within an acceptable range” (Campion et al, 2010, p.416). Response rates of online surveys tend to vary between 7% - 44% (Schonlau et al, 2002), therefore 25% lies within a normal range. - The technical problem with question 14 may have prevented some potential participants from taking part, reducing the response rate. This issue could perhaps have been detected prior to data collection, had it been possible to pilot an online version of the survey. Unfortunately, time constraints prevented this. - This study was not intended to be generalisable, its main aim necessitating a particular focus on specialist groups with an interest in older adults., which were deliberately chosen. Therefore, their responses may not represent the views of the wider UK occupational therapy population. Nevertheless, should the study be repeated with similar groups of OTs, it is anticipated that comparable responses would be obtained. - As participation was voluntary, those with pre-existing knowledge of or interest in visual impairment were perhaps more likely to respond than those without. This may reduce the study’s representativeness. - The survey was created solely by the researcher. Therefore, its validity and reliability have not been tested or proven, although the pilot study intended to enhance these as far as possible.

20 Future Research? Further high quality research to evaluate and establish an evidence-base for the effectiveness of occupational therapy-led low vision interventions There is the need to establish an evidence-base for the effectiveness of OT-led low vision interventions through further high quality research, as I found during my literature review that most previous research in this area does not tend to be OT specific. Much of the current research also appears to originate from the USA, so more UK-based research around this topic would be useful. To conclude: The survey findings suggest that more must be done to increase knowledge before OTs in the UK can reach their potential in terms of both confidence and competence when working with sight impaired older adults. However, they are in a promising position to make significant future contributions to an important emerging field of practice, and to further improve the quality of life of their older, visually impaired clients.

21 Thank You… I want to sincerely thank you all again for taking the time to participate in my study and for making it possible! In due course, I hope to try to have it published in the BJOT with my supervisor, Dr Dawn Skelton. If you would like to contact me with any comments or queries, my address is Thank you again to everyone who participated!

22 References Access Economics. 2009, Future sight loss UK 1: the economic impact of partial sight and blindness in the UK adult population, [internet], London, RNIB. Available at: [Accessed 22 January 2011]. Adams, O.F. 2007a, “Rehabilitation services.” in: Low vision manual, eds. A.J. Jackson & J.S. Wolffsohn, Butterworth Heinemann, Edinburgh, pp Campion, C., Awang, D. & Ward, G. 2010, “Broadening the vision: the education and training needs of occupational therapists working with people with sight loss”, British Journal of Occupational Therapy, Vol. 73, no. 9, pp City and County of San Francisco: SFGOV. 2009, Common causes of low vision [online]. City and County of San Francisco: SFGOV, San Francisco. Available at: [Accessed 6 June 2011]. Copolillo, A., Warren, M. & Teitelman, J.L. 2007, “Results from a survey of occupational therapy practitioners in low vision rehabilitation”, Occupational Therapy in Health Care, Vol. 21, no. 4, pp Diabetes UK. 2011, Diabetes in the UK : key statistics on diabetes, [internet], London, Diabetes UK. Available at: [Accessed 2nd March 2012]. Evans, J.R. & Mathur, A. 2005, “The value of online surveys”, Internet Research, Vol. 15, no. 2, pp Lamoureux, E.L., Pallant, J.F., Pesudovs, K., Rees, G., Hassell, J.B. & Keeffe, J.E. 2007, “The effectiveness of low-vision rehabilitation on participation in daily living and quality of life”, Investigative Ophthalmology and Visual Science, Vol. 48, no. 4, pp Lord, S., Sherrington, C., Menz, H. & Close, J. 2007, Falls in Older People, 2nd edn, Cambridge University Press, Cambridge.

23 References (cont…) Macular Disease Society. 2011, Registering as severely sight impaired/blind or sight impaired/partially sighted [online]. The Macular Disease Society, Andover. Available at: [Accessed 14 June 2011]. * Rosenfeld, S. 2011, “Vision and occupational therapy: terminology, tips, and trends”, OT Practice, Vol. 16, no. 15, pp Royal National Institute of Blind People. 2010a, The benefits of registering as blind or partially sighted, RNIB and Royal College of Ophthalmologists, London. Royal National Institute of Blind People. 2010b, Community care: support for people with sight problems, RNIB and Royal College of Ophthalmologists, London. Royal National Institute of Blind People. 2009, Sight problems, RNIB, London. Scheiman, M., Scheiman, M. & Whittaker, S.G. 2007, Low vision rehabilitation: a practical guide for occupational therapists, SLACK Incorporated, Thorofare. Schonlau, M., Fricker, R.D. & Elliott, M.N. 2002, Conducting research surveys via and the web, Rand, Santa Monica. Stuen, C. & Offner, R. 1999, “A key to aging in place: vision rehabilitation for older adults”, Physical & Occupational Therapy in Geriatrics, Vol. 16, no. 3/4, pp Warren, M. 2011, “Extending occupational therapy boundaries to assist people with low vision”, British Journal of Occupational Therapy, Vol. 74, no. 1, pp. 1. Withers, C. & Shann, S. 2008, “Embracing opportunities: stepping out of the box”, British Journal of Occupational Therapy, Vol. 71, no. 3, pp World Health Organisation. 1996, Low vision care for the elderly, [internet], Geneva, World Health Organisation. Available at: [Acccessed 26 February 2011].


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