Running Head: PED WITH LOW-VISION DIAGNOSES 1

Use of Personal Electronic Devices (PEDs) for Older Adults with Low-Vision Diagnoses

Shayne Barker

Jennifer Messer

Stephanie Rogers

University of Utah
PED WITH LOW-VISION DIAGNOSES 2

Use of Personal Electronic Devices (PEDs) for Older Adults with Low-Vision Diagnoses

By the year 2020 it is estimated there will be 3.9 million people with low vision, due to the

aging population of the baby boomer generation (Smallfield, Clem, & Myers, 2013). Low vision

is a condition that cannot be medically corrected, nor is it a reversible medical condition. Low

vision can have various causes as well as impacts on areas of visual performance, and disability

that can result in an impact on functioning (Smallfield et al., 2013).

Findings across the literature (Kim, Han, Park, & Park, 2016; Jutai, Strong, & Russell-

Minda, 2009) suggest that there is a lack of understanding of what technology is available to assist

adults with low vision, as technology keeps growing and changing. Due to the increase in the

number of people in the aging generation, technology, and advancements in technology need to

continue to be addressed. Low vision can have an impact across many areas of individual’s lives

and significantly impacts occupational engagement. It is estimated that 94% of people with a low

vision diagnosis can no longer participate in at least one preferred occupation (Mohler, Neufeld,

& Perlmutter, 2015). In addition, “many assistive technologies are being developed to help visually

impaired people, because they still have difficulty accessing assistive technologies” (Kim et al.,

2016, p. 3). Due to the lack of literature supporting assistive technology use by older adults with

low vision, our research aims to look at two types of assistive devices, including hand held

magnifiers and PEDs. This will result in an analysis of devices that support and are beneficial to

those with a low vision diagnosis.

Background

Findings across the literature have looked at the many factors that can affect reading

ability. These factors include what font type and size are most readable (Russell-Minda et al.,

2007), lighting (Eperjesi, Maiz-Fernandez, & Bartlett, 2007), and the use of line guides (Cheong,
PED WITH LOW-VISION DIAGNOSES 3

Bowers, & Lovie-Kitchin, 2009). However, the most common prescription for adults with low

vision are low vision devices (LVDs) (Copolillo & Teitelman, 2005). Current research on

reading rehabilitation in older adults with low vision can be broken into two categories,

electronic and nonelectronic. Prior to the 1980’s, LVDs were restricted to non-electronic items

such as magnifying glasses and optical corrections such as glasses (Dagnelie, 2013). In the

1990’s electronic devices were introduced when closed circuit televisions were first employed to

create high contrast magnification for reading items that could be placed underneath. Today

technology on smartphones and other PEDs provide more mobile options for older adults with

low vision.

Non-electronic Devices

Current research, including systematic reviews, on non-electronic devices has shown the

effectiveness of implementing vision aids such as magnifying glasses. Proper magnification and

training with these vision aids has shown significant increases in reading ability and speed for

older adults (Gothwal & Bharani, 2015; Jutai, Strong, & Russell-Minda, 2009; Nguyen,

Weismann, & Trauzettel-Klosinski, 2009). These devices have also been shown to increase

reading accuracy in adults ages 49-95 (Markowitz, Kent, Schuchard, & Fletcher, 2008).

Electronic Devices

Current research on electronic devices, not including PEDs, include research on closed-

circuit televisions (CCTVs). A systematic review looking at the effectiveness of assistive

technologies for low vision rehabilitation found moderate evidence for the use of CCTVs to

increase reading speed and duration of reading (Jutai et al., 2009). Most studies did not address

other electronic devices besides CCTVs, such as smartphones or tablets.

PED WITH LOW-VISION DIAGNOSES 4

Personal Electronic Devices

Current research on PEDs is very limited, and due to the constantly changing environment

of technology it is difficult to generalize across PED use. Crossland, Silva, and Macedo (2014)

looked at how adults used PEDs like smartphones, tablets, and e-book readers. Their results

showed that 81% of the respondents utilized a smartphone. This study also suggests we need

more focus on the older population and low vision, as they stated that only 9 of the 132

participants had age-related macular degeneration. This suggests that more research needs to be

done on older adults and use of technology with vision impairments. In their research, it was

found that the older the adults were, the less likely they were to utilize a smartphone device and

the more likely they were to use an e-reader device. Two major limitations of this study are that

this was a self-report, and that the people that completed the survey needed internet and

technology access.

Objective

Overall, electronic devices like CCTVs are expensive and not portable. Non-electronic

devices such as magnifying glasses are more widely utilized due to their low cost and portability,

but typically cannot be used in poor lighting, or adjusted based on personal preferences such as

text size. With the advancement in technology of smartphones and other PEDs there are now

more options for older adults with low-vision diagnoses. With proper training and

implementation are PEDs more effective than hand-held magnifiers for older adults with low

vision diagnoses?

The purpose of our research is to compare PEDs and hand-held magnifiers to analyze

whether they increase reading speed, accuracy, and perceived performance in adults 60 and

older. Our hypothesis is that reading speed, perceived performance, and accuracy will increase in
PED WITH LOW-VISION DIAGNOSES 5

adults with low vision diagnoses through use of a PED, compared to hand-held magnifiers. This

study will advance the field by providing research to either justify training and using PEDs with

older adults, or maintain that we should use more traditional approaches such as hand-held

magnifiers with this population.

Methods

Design

This study will be designed as a prospective quasi-experimental single group pretest

(hand-held magnifier)/posttest (PED magnifier).

Participants

Participants will be recruited through referral from local ophthalmologist and optometrist

offices. Clients of these offices that have been previously prescribed a hand-held magnifier will

be contacted and asked to participate in the study. Participants, upon completion of the study,

will have the opportunity to keep the PED that they used during the study. Criteria for inclusion

in this study will be an official diagnosis of low-vision made by an ophthalmologist or

optometrist, adults older than 60, no history of cognitive impairment or neurological disease,

previously given a hand-held magnifier, and English reading/speaking. Criteria for exclusion in

this study will include being completely blind, or having previous experience with a PED as a

low-vision device.

Upon initial recruitment, participants will be screened for cognitive impairment using the

Montreal Cognitive Assessment (MOCA) (Storton & Larner, 2011). Screening for neurological

disorders will be done by asking participants family history, and whether they currently have a

neurological disorder. Participants that qualify will be randomly assigned to perform the
PED WITH LOW-VISION DIAGNOSES 6

Veterans Affairs Low Vision Visual Function Questionnaire 48 (LV VFQ-48) first or reading

speed/accuracy assessment to protect against order effect.

Measurements

Veterans Affairs Low Vision Visual Function Questionnaire-48

The LV VFQ-48 (Stelmack et al., 2004) is an assessment that measures perceived reading

ability. The assessment includes 48 items that covers four functional domains: reading, mobility,

visual information processing, and visual-guided motor behavior. As part of this study only the

reading section will be utilized. Items are rated on a four item Likert scale ranging from Not

difficult to Impossible to do. Higher scores indicate less difficulty with visual tasks. An example

of an item on the LV VFQ-48 would be: Is it difficult to read restaurant menu items?: not

difficult, slightly/ moderately difficult, extremely difficult, impossible and do not do it for

nonvisual reasons (which is scored as missing data). According to Stelmack et al. (2004) only

19% of the items on the LV VFQ-48 can be explained by confounding factors. The assessment

has a 98% item reliability, and an 84% person test-retest reliability.

Reading Speed/Accuracy

This is not a standardized assessment, but has been used by Markowitz et al. (2008) and

shown to be effective in assessing reading speed/accuracy. The item labels will be standardized

so that all clients will receive the same items to protect against measurement bias. Participants

will be asked specific questions about the items they read: Medication (name of medication,

frequency, and how many to take), can of food (name of food, brand name, calories, and serving

size), Milk (expiration date and type of milk (1% etc.)), electricity bill (due date, how much, and

where to send check) microwave (asked to reheat item with 1 min 37 sec duration). Participants
PED WITH LOW-VISION DIAGNOSES 7

will be measured on speed of reading (duration to read) items and correct answers to follow-up

questions.

Procedures

Participants will be recruited through referral from local ophthalmologist and optometrist

offices. After participants are screened to ensure they fit inclusion criteria participants will be

randomly assigned to take the LV VFQ-48 first or the reading speed/accuracy assessment to

avoid order effect. Participants will be assessed with LV VFQ-48 to assess current levels of daily

function with low vision (Gothwal & Bhanrani, 2015). The reading speed and accuracy

assessment will be measured utilizing a hand-held magnifier (medication bottle, can of food,

gallon of milk, electricity bill, and microwave) (Markowitz et al., 2008). This will provide a

baseline of reading function with a previously used LVD. Participants will be assessed in our

clinic under 3,000 lux lighting with glare reducing fabric on the assessment table (Smallfield et

al., 2013). This is to ensure all participants are reading under similar environmental conditions to

avoid confounding factors. If participants require correctional lenses they need to be utilized

during initial and final assessments.

After assessment, participants will receive five one-hour trainings with PEDs. During

these trainings participants will be shown how to utilize accessibility options and manipulate

them to use the camera as a magnifier with automatic focus, and asked to replicate procedures.

The last two sessions will be going into the community with the participants to use the PEDs at

the grocery store and a restaurant to observe and assist participants in a natural context.

Post-assessments will follow the same protocol, but will include different versions of

items included in the reading speed/accuracy assessment. Participants will use their PED instead

of hand-held magnifier to assess targeted outcomes. As during pre-assessment, participants will

PED WITH LOW-VISION DIAGNOSES 8

be randomly assigned to take the LV VFQ-48 first or the reading speed/accuracy assessment to

avoid order effect.

Human Participant Protection

University of Utah institutional review board (IRB) approval will be obtained prior to

starting this study.

Data Analysis Plan

Data cleaning, manipulation and analysis will be conducted using IBM SPSS Statistics

(v.25). Individual participant data will be paired between pretest (handheld magnifier) and

posttest (PED) and a paired sample T-test will be run to assess direction and amount of change

within individual participants.

PED WITH LOW-VISION DIAGNOSES 9

References

Alotaibi, S. J. (2015). Session 4: Assistive technologies to support independent mobility of

visually impaired and blind people. WCSNE 2015 Proceedings, 58(6). doi:

10.20533/wcsne.2015.0020

Cheong, A. M., Bowers, A. R., & Lovie-Kitchin, J. E. (2009). Does a line guide improve reading

performance with stand magnifiers? Optometry and Vision Science, 86, E1078–E1085.

http://dx.doi.org/10.1097/OPX.0b013e3181b4c4d9

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(3), 305-313.

Crossland, M.D., Silva, R.S., & Macedo, A. F. (2014). Smartphone, tablet computer and e-reader

use by people with vision impairment. Ophthalmic and Physiological Optics, 34(5), 552-

557. doi: 10.1111/opo.12136

Dagnelie, G. (2013). Age-related psychophysical changes and low vision. Investigative

Ophthalmology & Visual Science,54(14), 88-93. doi:10.1167/iovs.13-12934

Díaz-Bossini, J. M., & Moreno, L. (2014). Accessibility to mobile interfaces for older people.

Procedia Computer Science, 27, 57-66.

Draper, E. M., Feng, R., Appel, S. D., Graboyes, M., Engle, E., Ciner, E. B., & Stambolian, D.

(2016). Low vision rehabilitation for adult African Americans in two settings. Optometry

and Vision Science, 93(7), 673-682. doi:10.1097/opx.0000000000000870

Eperjesi, F., Maiz-Fernandez, C., & Bartlett, H. E. (2007). Reading performance with various

lamps in age-related macular degeneration. Ophthalmic and Physiological Optics, 27,

93–99.
PED WITH LOW-VISION DIAGNOSES 10

Gothwal, V. K., & Bharani, S. (2015). Outcomes of multidisciplinary low vision rehabilitation in

adults. Investigative Ophthalmology & Visual Science,56(12), 7451. doi:10.1167/iovs.15-

16892

Jutai, J. W., Strong, J. G., & Russell-Minda, E. (2009). Effectiveness of assistive technologies

for low vision rehabilitation: A systematic review. Journal of Visual Impairment &

Blindness, 103(4), 210-222.

Kim, H. K., Han, S. H., Park, J., & Park, J. (2016). The interaction experiences of visually

impaired people with assistive technology: A case study of smartphones. International

Journal of Industrial Ergonomics, 55, 22-33. doi: 10.1016/j.ergon.2016.07.002

Markowitz, S. N., Kent, C. K., Schuchard, R. A., & Fletcher, D. C. (2008). Ability to read

medication labels improved by participation in a low vision rehabilitation program.

Journal of Visual Impairment and Blindness, 102, 774–777.

Mohler, A. J., Neufeld, P., & Perlmutter, M. S. (2015). Factors affecting readiness for low vision

interventions in older adults. American Journal of Occupational Therapy, 69(4).

Nguyen, N. X., Weismann, M., & Trauzettel-Klosinski, S. (2009). Improvement of reading speed

after providing of low vision aids in patients with age-related macular degeneration. Acta

Ophthalmologica,87(8), 849-853. doi:10.1111/j.1755-3768.2008.01423.x

Rodriguez-Sanchez, M. C., Moreno-Alvarez, M. A., Martin, E., Borromeo, S., & Hernandez-

Tamames, J. A. (2014). Accessible smartphones for blind users: A case study for a

wayfinding system. Expert Systems with Applications, 41(16), 7210-7222.

Russell-Minda, E., Jutai, J. W., Strong, G., Campbell, K. A., Gold, D., Pretty, L., & Wilmot, L.

(2007). The legibility of typefaces for readers with low vision: A research review.

Journal of Visual Impairment and Blindness, 101, 402–415.

PED WITH LOW-VISION DIAGNOSES 11

Smallfield, S., Clem, K., & Myers, A. (2013). Occupational therapy interventions to improve the

reading ability of older adults with low vision: A systematic review. American Journal of

Occupational Therapy, 67, 288–295. http://dx.doi.org/10.5014/ajot.2013.004929

Southall K., & Wittich, W. (2011). Barriers to low vision rehabilitation: The Montreal barriers

study. Investigative Ophthalmology & Visual Science, 52(12), 8933. doi:10.1167/iovs.11-

8116

Stelmack, J. A., Szlyk, J. P., Stelmack, T. R., Demers-Turco, P., Williams, R. T., & Massof, R.

W. (2004). Psychometric properties of the veterans affairs low-vision visual functioning

questionnaire. Investigative Ophthalmology & Visual Science, 45(11), 3919-3928.

Storton, K., & Larner, A. (2011). Montreal Cognitive Assessment (MoCA): Diagnostic utility in

a cognitive clinic population. Alzheimers & Dementia,7(4).

doi:10.1016/j.jalz.2011.05.451

Walter, C., Althouse, R., Humble, H., Smith, W., & Odom, J. V. (2007). Vision rehabilitation:

Recipients' perceived efficacy of rehabilitation. Ophthalmic Epidemiology, 14(3), 103-

111.