National Eye Health Education Program (NEHEP)

April 1999

• I. Introduction
• II. Background
• III. Rationale for a Public Education Program
• IV. Overview of the Communication Plan: A Low
Vision Public Education Program
• V. Research and Program Evaluation
• VI. Timeline for Year 1
• Appendix A: Scope and Extent of the Problem
• References

The National Eye Health Education Program (NEHEP) of the National Eye Institute (NEI), one of the National Institutes of Health (NIH), is establishing a Low Vision Public Education Program. This program aims to increase awareness of low vision and its impact on quality of life and is directed toward people with low vision, their families and friends, and the health care and service professionals who care for them.

In August 1996, the NEI formed an ad hoc working group composed of researchers, low vision specialists, educators, and eye care professionals to discuss the development of a low vision public education program. In addition, the NEI undertook qualitative research--focus groups, one-on-one interviews, and telephone interviews--to assess the impact of low vision on individuals in the United States.

Relying on the results of the qualitative research, the working group concluded that the program's two primary audiences should be people over 65 years of age who have low vision and members of high-risk populations, including Hispanics/Latinos and African Americans, who are likely to develop low vision before the age of 65. The secondary audiences identified were health care professionals, including primary care physicians and allied health professionals; other professionals who work with older Americans, including social workers, assisted living workers, and senior center workers; and members of the aging network, including representatives of the National Association of Area Agencies on Aging, the American Association of Retired Persons (AARP), the National Council on Aging (NCOA), and others.

The goals of the program are to raise awareness about low vision and to offer suggestions and sources of information that may improve the quality of life for people with low vision and those who care for them.

The following section of this communication plan provides the background of the NEHEP and the Low Vision Public Education Program. Section III provides a rationale for a public education program based on the research summarized in Section II. Section IV provides an overview of the communication plan, including the program's purpose, overall goal and objectives, target audiences, strategies, and the role of the NEHEP Partnership. Section V discusses research and evaluation issues.

National Eye Institute

Eye disease, visual impairment and disability, and blindness are major public health problems. Convinced that visual disorders constituted a national problem that could be solved only by greater emphasis on vision research, Congress authorized the establishment of the NEI in 1968 as part of the National Institutes of Health (NIH), U.S. Department of Health and Human Services. The Institute's mission is to find new ways to prevent, diagnose, and treat diseases of the eye and visual system, thus preventing, reducing, and possibly even eliminating blindness.

National Eye Health Education Program

Since its inception, the NEI has conducted a public information program that responds to inquiries and disseminates authoritative information on eye disease and the progress of vision research. Educational materials for the public have described the causes, if known, of common eye diseases; their signs and symptoms; methods of prevention and treatment; referrals to sources of help; and current, relevant research. Blindness prevention education became more important during the past decade when the results of several clinical trials provided dramatic evidence that laser treatment could reduce the risk of vision loss from diabetic retinopathy.

Although the NEI has long been committed to communicating research results to appropriate audiences, a sustained, large scale health education program was precluded by lack of a scientific basis, funding, and personnel. In 1988, the Congress appropriated funds that enabled the NEI to increase its commitment to preventing blindness through public and professional education programs and through encouraging regular eye examinations. This appropriation was the first to be designated for eye health education.

In response, the NEI established the NEHEP to implement large scale information, education, and applied research programs. The NEHEP is directed by the Office of Communication, Health Education, and Public Liaison within the Office of the Director. Its goal is to prevent vision loss and blindness by educating the public and health professionals about sight-threatening eye diseases. The NEHEP also seeks to ensure that the results of eye and vision research benefit everyone. The NEHEP emphasizes public, patient, and professional education on the importance of early detection and treatment of diabetic eye disease and glaucoma. The NEI chose these blinding eye diseases as the NEHEP's initial focus for three reasons

:

• The high prevalence of diabetic eye disease and glaucoma;
  
  
• The scientific evidence demonstrating that blindness caused by these diseases can often be prevented by early detection and treatment; and
  
  
• The existence of important health messages that need to be conveyed to a variety of target audiences.

An essential component of the NEHEP's success is its Partnership, which consists of organizations that are interested in eye health education and are capable of furthering the achievement of NEHEP's goal. This group includes professional, voluntary, and civic organizations; government agencies; and private industry. Currently, close to 60 organizations are represented in the NEHEP Partnership.

Literature Review Summary

An extensive review of the literature is attached in Appendix A. Briefly, the classification of what constitutes low vision has changed over time. Today, the classification includes people who suffer visual acuity and field loss. Yet most people with low vision do retain some residual visual ability and, with the aid of rehabilitation and assistive devices, can maximize the use of that vision to maintain independence and productivity.

The impact of low vision is severe:

• According to data collected in 1994 by Louis Harris and Associates for the Lighthouse International, low vision affects 26 percent of adults older than 75 (3.5 million people), 17 percent of adults between 65 and 74 (3.1 million people), and 15 percent of people between 45 and 64 (7.2 million people). Age-related macular degeneration (AMD) accounts for nearly half of all cases of low vision, followed by cataract, glaucoma, diabetic retinopathy, optic nerve disease, and injury to the eye.
  
  
• In terms of quality of life, people with low vision have difficulty with the activities of daily living, leisure pursuits, education, vocation, and social interactions. Older persons with visual impairments may experience grief, confusion, fear, anxiety, depression, loss of control, and loss of self-esteem.
  
  
• Costs include the direct cost of treatment, loss of personal income, associated costs such as Social Security disability benefits, and loss of productivity, among others. The most recent cost figure for care and services provided to people who are blind or have visual impairments is more than $22 billion per year (Alliance for Eye and Vision Research, 1995).
  
  
• Demographically, low vision affects African Americans older than 65 at a rate of 105.9 per thousand, compared with 71.7 per thousand for non-Hispanic whites. Low vision tends to impact the lives of women more than that of men. This may be due to the fact that women tend to live longer. Family income also appears to be related to visual impairment, although the pattern is less clear; within all age categories, people at the lowest income levels tended to have the highest rates of visual impairment.
  
  
• As the U.S. population ages and the racial/ethnic composition continues to diversify, the issues related to low vision will also continue to grow.
  
  

Help exists for people with low vision. Rehabilitative services, environmental modifications, and assistive devices have been shown to be effective in helping people with low vision use their residual vision more effectively, yet these services and devices are not often used, probably for a variety of reasons:

• Lack of perceived need for services and devices;
  
  
• Lack of awareness of the options;
  
  
• Lack of training and education in use of assistive devices and environmental modifications; and
  
  
• Lack of insurance or Medicare coverage for services and devices.
  
  

Qualitative Research

In early 1997, the NEI conducted qualitative research among middle-aged and older people with low vision and those close to and caring for them. The purpose of the research was to explore the following issues:

• The ways low vision affects quality of life;
  
  
• Awareness of services, information, and devices available to help; and
  
  
• Appropriate interventions to increase awareness of available services, information, and devices.
  
  

People with low vision were interviewed in focus groups, personal interviews, and telephone interviews. Focus groups were divided by age, gender, and income. Telephone interviews were conducted with nine respondents. Two additional focus groups were conducted with people who care for friends or family members with low vision. Following is a summary of the major findings of this qualitative research.

• Quality of Life
  
  Participants were asked whether low vision had affected the quality of their lives. Driving was cited as the activity most often affected by low vision. Reading and sewing were other activities frequently mentioned. Men were more likely to say that they did not experience quality-of-life problems because they could receive help from their spouses.
  
  
• Coping
  
  Many older adults with low vision felt that it was a natural part of the aging process and that they must learn to live with it.
  
  
• Services and Devices
  
  Participants had a low level of awareness about low vision services and devices.
  
  Those people with low vision who were aware of services often did not access them because they did not think that their vision was poor enough or because they were not blind. Until significant vision loss occurred, people with low vision were not interested in using devices.
  
  
• Eye Care Professionals
  
  Many participants reported that eye care professionals who diagnosed their low vision gave them little medical information or information on coping with low vision.
  
  Many participants reported being told that there was nothing more the eye care professional could do for them. This made them "feel terrible" and some of the older adults stopped seeing eye care professionals when their glasses no longer helped them.
  
  
• Messages
  
  When asked what messages they would wish to hear, participants identified two: "Information and help are available," and "You are not alone."
  
  
• Friends and Relatives
  
  Respondents reported that they prefer receiving information directly rather than receiving it indirectly through friends and relatives. Information should therefore be provided directly both to people with low vision and to their friends and relatives.
  
  
• Channels
  
  Respondents prefer to receive information through the following channels: eye care professionals; the media, including television programs and talk radio programs; a toll-free number to access information; magazine articles; billboards; and community sites and groups such as senior centers, pharmacies, libraries, low vision organizations, clergy, and state governments.
  
  
• Educational Materials
  
  Respondents would like to have the following educational materials developed: a video that would be provided to them by an eye care professional but watched at home; a large print brochure with medical information and information on services and devices; and a television public service announcement (PSA) promoting a toll-free number for information.

Concept Testing

In May 1998, the NEI conducted focus groups with people from a variety of education and income levels and who have low vision. The purpose was to test three concepts that convey information to people about getting help for their low vision problem (Appendix B). All participants were between the ages of 55 and 85, and all had low vision. Participants answered questions about difficulty with activities such as driving, cooking, sewing, and reading the newspaper and did a self-assessment of vision quality.

The main objectives of the focus groups were as follows:

• Identify a concept that motivates people with low vision to learn more about their condition and take control of it.
  
  
• Identify key words and visuals for audience motivation.
  
  
• Identify barriers and obstacles to seeking help with low vision issues.
  
  
• Probe for understanding of the term "low vision" and identify alternative terms or language.
  
  
• Probe for media habits.
  
  

Key Findings

• Participants felt that "low vision" generally described their vision. Some alternative words and phrases included "poor," "bad," and "limited" vision.
  
  
• Participants identified a number of ways in which having low vision has affected their lives. These include not being able to drive, sew, read, or cook. Low vision also has an emotional impact.
  
  
• Most participants were aware of a number of places where they could get information about low vision and other health conditions. Participants were open to the idea of receiving information about low vision from family members.
  
  
• Concept 1: Your Vision May Be Limited, But Your Options Aren't. Some participants felt that this concept provided a clear and simple message. The word "new" in the tagline Teach Old Eyes New Tricks was seen as important. It suggests that some new innovation is available. Other participants felt that it was uninformative. There was some confusion about the use of the words "low" and "limited" in the same concept.
  
  
• Concept 2: See Low Vision in a New Light. Participants felt that this concept was clear and relevant. Some felt that the definition gives a good description of low vision. Others felt that it was too wordy and told them what they already know.
  
  
• Concept 3: If Your Eyes Are Going, These Products and Services Can Make a Difference. Participants identified with this concept immediately because of the magnifying glass used in the visuals. It is eye catching and straightforward. Participants in each group noted, however, that "night" should be highlighted rather than "day," since that is when they have the most trouble seeing. A number of participants did not like the reference to their eyes "going" in the headline.
  
  
• There was no unanimous favorite among the three concepts. However, more participants preferred the magnifying glass concept to the other two. They felt that it was eye catching and direct, and they did not have to spend a lot of time reading it. Participants suggested that examples of available products and services should be included in the concept. It would also help to note that some of these things may be free. Including the NEI logo would add credibility and give authority to the concept.
  
  
• Participants suggested a number of places where they would like to see the concept and where it is most likely to get their attention, including television, direct mail, newspapers and magazines, senior centers, the library, and insurance companies. Participants indicated that receiving the information from a family member would be acceptable.
  
  

Recommendations

• Include examples of the products and services that are available. Note which products and services are free.
  
  
• Include a toll-free number for seeking further information rather than an address. Participants unanimously indicated that they would rather call than write for information.
  
  
• Display information in magazines such as the AARP magazine and on television.
  
  

Program
Research based on quantitative and qualitative sources indicates that a public education program on low vision is needed to educate people with low vision and the professionals, family, and friends who support them. To determine whether such a program is actually necessary, the current environment must be examined. What information and communication needs should a public education program address? What are the challenges? Finally, what opportunities exist to make the program a success? Answers to these questions can help guide the NEHEP in developing appropriate strategies for a public education program.

Information and Communication Needs

• The vast majority of people age 65 and older with low vision are unaware of services and devices that could help them to improve the quality of their lives.
  
  
• The need for information will increase as the number of Americans who are at greatest risk, those age 65 and older, doubles over the next 30 years.
  
  
• While government agencies and voluntary organizations may have resources to help people with visual impairment, these resources are not known to most of the public. Consumers now have no easy way to access information about resources in their communities.
  
  

For these reasons, it appears that the timing is right to launch a public education program on low vision. Through networks such as the NEHEP Partnership, public and private agencies are ready to work together to educate the public and increase access to information and services.

Challenges

• More research is needed on low vision.
  
  
  • There is a lack of epidemiological data on the prevalence of low vision.
    
    
  • Little research exists on the efficacy of low vision devices and services.
    
    
• Many eye care professionals have not traditionally addressed rehabilitation issues with their patients who have low vision.
  
  
  • NEI focus group participants reported that some eye care professionals told them upon diagnosis that they could do nothing more to help them. As a result, participants said that they gave up searching for help.
    
    
• Older adults with low vision may not be interested in seeking devices or services. NEI focus group participants reported the following:
  
  
  • They were more interested in seeking a cure for the eye disease than in learning how to cope with vision loss.
    
    
  • They did not perceive their vision loss to be serious enough to warrant the use and expense of services and devices.
    
    
  • They did not perceive themselves to be within the constituency of organizations that offer services for "the blind."
    
    
  • They perceive low vision as part of the natural aging process. They assume that there is nothing to be done except adapt to the loss of independence.
    
    
• For an education program to be effective and sustainable, access to low vision devices and services must be available.
  
  
• Some older adults lack access to services and devices because of their cost. Medicare and Medicaid do not currently cover low vision services and devices. Low vision is more prevalent among populations at lower socioeconomic levels and among older Americans who have fewer financial resources to purchase services and devices (NCHS, 1998).
  
  
• Some adults with low vision lack access to services because eye care professionals with expertise in low vision are not available in their communities. While there may be an adequate number of eye care professionals across the country, they may not be evenly distributed geographically.
  
  
• Many older adults lack access to information about low vision devices and existing services in their communities because it is difficult to obtain. A few universal access points for information must be established.
  
  
• Multiple channels of communication will need to be used in a public education program. People with visual impairment cannot always take full advantage of the kinds of media typically used in education programs, such as television, newspapers, and magazines. Targeting social networks to reach the intended audience may not be effective. Focus group participants reported that as they lost their vision, their involvement in social networks decreased.
  
  
• Communication about low vision is a challenge. The term "low vision" is not understood by people who have it.
  
  

Opportunities

• People with low vision are looking for hope. Although products, services, and some treatment information exist, many people with low vision are unaware of them. Information about ways to cope with low vision should be well received.
  
  
• Focus group participants who saw their eye care professionals regularly said that they would like to receive information from them on services and devices. Eye care professionals are important channels for reaching people with low vision.
  
  
• The aging network, including the National Association of Area Agencies on Aging, the AARP, the NCOA, and senior centers, provides another effective channel to reach older adults with low vision. Aging network professionals have regular contact with many older adults and do not usually provide information on low vision.
  
  
• Staff working in assisted living facilities, adult day care centers, and home health agencies have daily contact with older people and could also provide them with information. All of the professionals working with older adults need to learn more about the issue of low vision and, specifically, how they might help their clients.
  
  
• As the Health Care Financing Administration (HCFA) requires more older adults to receive their medical care through managed care organizations (MCOs), establishing links with MCOs will be important. It is to the advantage of MCOs to provide their patients with information that can help them remain independent. Managed care staff can disseminate information and educate patients about low vision devices and services. Managed care physicians can refer their patients to low vision services.
  
  

Opportunities for the NEHEP Partnership

Members of the NEHEP Partnership will also benefit from participating in a low vision public education program. Benefits include the following:

• Greater visibility for the issue of low vision may help create an environment in which people better understand low vision issues and needs.
  
  
• A national public education program may provide a more effective promotional platform for Partnership members that have already been offering low vision public education programs in local communities.
  
  
• A national public education program will help Partnership organizations keep their members abreast of the ways to best meet the needs of their patients and the population at risk.
  
  
• Educational materials developed as part of the program will help Partnership organizations reach their audiences more effectively.
  
  

Because the issue of low vision is so complex, a multiphase plan is needed. Following is the proposed plan for the Low Vision Public Education Program.

The following plan is based on qualitative research conducted by the NEI in 1997 and 1998, direction from the Ad Hoc Working Group on Low Vision, and on a roundtable discussion on low vision that took place at the Fourth National Eye Health Education Conference in March 1997, as well as the preliminary plan review held in November 1997 with the NEHEP Partnership. The plan also incorporates suggestions from a panel of experts in health education, social marketing, and health information technology who met in November 1998.

The plan calls for an education program that begins with an awareness-building consumer campaign. Because creating awareness takes time, the plan focuses on Year 1 activities but refers to activities that can be added in subsequent years.

Purpose
The purpose of the Low Vision Public Education Program is to address the impact of low vision on those who have it and to bring the message to them, their families, and the health and service professionals who care for them that information and help are available.

Low vision can result in profound lifestyle, physical, economic, social, and psychological consequences. People who have low vision often have a restricted field of vision, have trouble reading standard size print, cannot distinguish colors or adjust to changes in light or glare, and/or have trouble with depth perception. Yet historically, people with low vision have had a difficult time learning about services available to them or about adaptive equipment that could enhance their functioning and quality of life and return to them a measure of independence. Until recently, they had to seek out for themselves most of the rehabilitation services and information they obtained. Part of the reason is that many eye care professionals view low vision as untreatable and therefore offer few resources to their patients.

Overall Goal
To improve the quality of life for people age 65 and older who have decreased visual function that interferes with their activities of daily living.

Objectives

• To increase awareness among people 65 and older, their families and friends, and the general public about low vision and to assure them that services, assistive devices, and environmental modifications are available to help people with low vision and improve their daily functioning.

• To increase awareness among those affected by low vision that they are not alone and that help is available.

• To increase action taken by family members, friends, and partners to support those with low vision.

• To increase action taken by people with low vision, including increased use of appropriate services, devices, and environmental modifications that might help improve their daily functioning.

• To increase referrals to services that assist people with low vision by increasing awareness among professionals who work with older people of the potential benefits of low vision services.

• To enlist the support of the public health and health policy communities and of private sector organizations for low vision problems and solutions.

Target Audiences
The two primary audiences are (1) people age 65 and older who have decreased visual function that interferes with their activities of daily living and (2) people under age 65 who are particularly at risk for low vision--i.e., Hispanic/Latino and African American populations. Besides focusing on these populations in general, certain segments of the primary audience may be targeted:

• People with undiagnosed low vision, who may think that their vision problem is untreatable.

• People who are diagnosed (understand that they have low vision) but are unaware of services and devices available to assist them.

Other segments include those who are aware that they have low vision but who are not using available services, and those already using services who would benefit from additional information and continued support. The program is not seeking to raise awareness among people who are already receiving some type of low vision care, but to provide information that will help individuals identify themselves as having low vision and seek help. The need to target other segments will be considered later in the program.

The secondary audiences include family members and friends of the target audiences, health professionals, eye care professionals, members of the aging network, professionals who interact with aging adults, social workers, and assisted living providers.

In reaching the secondary audiences, the program seeks to reach health care and service providers who are not specialists in low vision. The program should raise awareness of the next step that a health care or service professional should take with patients or clients to help them receive the assistance they need.

Messages

The focus group research demonstrates that positive and encouraging messages designed to address the psychosocial issues of independence and the ability to enjoy everyday activities are critical to the program. Overall messages to be included in all materials include the following:

• Hope (but not promises) and help are available for people with low vision.

• Visual rehabilitation and training can be beneficial and may help restore some measure of independence.

• Minor, low cost home modifications can make a significant difference in functioning and safety and may also help restore some independence in daily living.

• You are not alone. You can get help for the vision problems that keep you from doing things you used to enjoy.

Strategies
To respond to these information and education needs, the program will employ these strategies:

1. A broad-based consumer media campaign to raise awareness of low vision issues and rehabilitative services and devices among all target audiences.
   
   
2. Educational materials that will be distributed to consumers and through health care professionals, social services organizations, and other groups that serve older adults.
   
   
3. An outreachprogramto increase awareness of low vision issues and opportunities among health care professionals, social services organizations, and other groups that work with older adults.
   
   
4. A traveling exhibiton low vision to be displayed in shopping malls nationwide.
   
   
5. A limited toll-free number for consumers to order educational materials.
   
   
6. The use of new technology such as a special section within the NEI web site to increase accessibility.
   
   

Strategy 1: Consumer Media Campaign

The consumer media campaign will be launched in the fall of 1999. It will include PSAs, a drop-in news or feature story (MATT), and ongoing media relations, including pitching the story to selected health writers and broadcasters.

• PSAs The campaign will include PSAs for print, radio, and television that disseminate the message of hope and help to the target audiences. Print PSAs will be produced in large type for easier readability. Suggested lengths for PSAs may include 30-second television PSAs and 30- and 60-second radio PSAs. Actual lengths will be determined during the design and development process.
  
  
• Preprinted Newspaper Story To reach smaller weekly and community newspapers, a preprinted newspaper story of eight to ten column inches will be produced and distributed with an accompanying illustration. Actual size will be determined during the design and development process.
  
  
• Ongoing Media Relations To maintain media coverage of the low vision program throughout Year 1 and beyond, continuing to find ways to keep the issue current with the media will be critical. As part of an ongoing media relations strategy, the NEI will undertake the following steps:
  
  
  1. Publicize Low Vision News
     
     
     • Future changes in Medicare and Medicaid reimbursement of low vision services and devices would provide an excellent news angle.
       
       
     • Human interest stories featuring either notable people who have low vision or eye care professionals and low vision specialists who help people with low vision provide opportunities for feature articles in both print and broadcast media.
       
       
     • Other strategies for making news might include linking low vision stories to events such as Grandparents Day and Older Americans Month.
       
       
     • Low vision could be linked to existing eye care programs by listing it as a consequence of not treating certain conditions and producing accompanying stories.
  2. Television and Radio Features and News Series on Low Vision
     
     Many evening news and feature programs offer specials and series on various health topics. The NEI might develop a news/feature package and target it to specific shows and their producers to encourage them to feature low vision as an issue. The package would be pitched to producers highlighting the available information and materials such as story ideas, VNR and/or b-roll, and experts to contact for interviews. The package would be made available to national and local broadcast outlets as well as to cable channels. Shows that should be targeted include late night radio, prime time magazine-format shows on the networks, and educational programs on cable. The NEI could help promote viewership of the shows through the NEI home page, newsletters, and media releases.
     
     Older adults with low vision may need to view television and video programs more than once in order to absorb all of the content. Producers of television shows on low vision should be encouraged to produce videotapes of their programs in quantity for distribution to libraries, video stores, senior centers, and other community locations that provide free video lending services. In addition, producers of television shows may be encouraged to integrate low vision into the storylines of existing shows.

Strategy 2: Educational Materials

The NEI will develop a number of low vision education materials carefully tailored to appeal to the target audiences and produced in both English and Spanish. In addition to materials for the primary audience, the NEI will produce educational materials aimed at the families and friends of people with low vision. These materials are also intended for health care professionals and other service providers to use in educating older adults with low vision and their friends and families about the condition and about the rehabilitative services and devices.

• Consumer Pieces
  
  A variety of formats will be used to convey information on low vision, such as a large print publication, an audiotape, and a videotape. These materials will include general information about low vision, its causes, and its treatment; recommend an eye examination to evaluate low vision; outline in general terms the steps people with low vision can take to improve their quality of life and maintain their independence; and list additional sources of information.
  
  
• Professional Pieces
  
  In addition to the consumer education materials, health professionals (e.g., primary care physicians, nurse practitioners, physician assistants) and other professionals and service providers working with older adults (e.g., social workers, assisted living workers, staff at senior centers) will receive an information kit containing the consumer pieces, plus the following:
  
  
  • Screening tool: Identifying Low Vision in Your Older Patients.
    
    
  • Poster for the examining room: If you answer "yes" to two of these questions, talk with your doctor about what you can do.
    
    

  The screening tool will provide health professionals who may not be familiar with the problem with tips on identifying visual impairment in their patients. The examining room poster will prompt discussion between patients and their health professionals.

  To encourage professionals who work in the low vision field to share their expertise, the NEI could also create a speech or series of speech modules with slides or overheads. These materials would be tailored for use with communities and/or colleagues in terms of content and literacy level, and they would be prepared in such a way that speakers could tailor them to their local needs or organizational goals. The local speakers kit could be developed in Year 1 and distributed starting in Year 2.

• Materials for Family and Friends Materials for this audience will include the general booklet on low vision, along with one or both of the following topics:
  
  
  • How To Get Help for People With Low Vision
    
    
  • Vision and Care: Helping Your Loved One Live With Low Vision
    
    
  This information will provide families and friends with information and resources to assist people with low vision. It will also address the psychosocial issues of isolation, grief, sadness, and depression and how to deal with them.

Strategy 3: Outreach Program To Increase Professional Awareness
Eye care professionals have addressed the low vision issue in a number of ways, including the establishment of low vision practice pattern guidelines and low vision sections within their professional associations. Nevertheless, research suggests that many general health care professionals, similar to their patients with low vision, have limited awareness of rehabilitation resources, services, and devices available at the national and local levels. Research has also provided insights into what patients with low vision want in terms of information and assistance; these insights could be useful to health care professionals, including general eye care professionals, in counseling their patients. In addition, information on the scope of the growing low vision issue, the NEHEP education program, results of NEI research in this area, and updates on access issues such as reimbursement would be valuable for eye care professionals whose low vision practices will undoubtedly grow as the American population ages.

To increase awareness of low vision and provide insights into the needs of patients with low vision, the following professional education activities are recommended:

• Exhibit of low vision materials at professional meetings and conferences;
  
  
• PSA print advertisements for professional journals;
  
  
• Professional journal articles and editorials; and
  
  
• Presentations at professional meetings.
  
  

• Exhibit of Low Vision Materials at Professional Meetings and Conferences
  
  The NEI exhibit will be displayed at professional meetings and conferences to promote and distribute the low vision educational materials. The exhibit should be used at annual meetings of the NEHEP Partnership members in Year 1 to introduce the new Low Vision Public Education Program, as well as in subsequent years to continue to maintain high visibility with these critical audiences.
  
  One or two other meetings could also be selected for exhibiting low vision educational materials starting in Year 2 of the campaign. For example, the exhibit could be used to reach MCOs, an increasingly critical source of health services for older Americans. Key national managed care meetings include the annual meeting of the American Association of Health Plans. Additional professional meetings might include those of the American Society on Aging and associations of physical and occupational therapists.
  
  
• PSA Print Advertisements for Professional Journals
  
  To increase awareness of low vision and promote the public awareness campaign to MCOs, other health and aging professionals, and eye care professionals, a public service print ad specifically designed for these professional audiences will be developed and distributed to their journals and other special publications. Information on how to order the kits will be included in the ads.
  
  
• Professional Journal Articles and Editorials
  
  Increasing the attention that professional journals give to low vision through peer-reviewed articles, editorials, and letters to the editor would be an excellent way to increase awareness of the issue. Through a coordinated effort, the NEI and the NEHEP Partnership members could identify a list of topic areas for articles and seek out and encourage authors to submit papers to a list of target publications. Since peer-reviewed articles require significant lead time, planning this effort should begin as early as possible to ensure that some articles begin appearing in journals during the first year of the program. This strategy can be employed throughout the program to promote new research findings, developments in devices, and updates on access issues (reimbursement), among other developments. NEI could respond to issues raised in professional journals with editorials and letters to the editor from Dr. Kupfer. Reprints of articles and editorials could be incorporated into the Low Vision Public Education Program and the NEI exhibit on low vision displayed at professional meetings.
  
  
• Presentations at Professional Meetings
  
  Similarly, presentations at professional meetings would increase awareness of low vision issues among professional audiences. The NEI and NEHEP Partnership members could identify key meetings of eye care professionals, other health professionals, and the aging network to target and develop several speech topics and speakers to place on these meeting programs. Because major professional meetings are planned at least a year in advance, this activity should begin early to develop some speaking platforms in Year 1 of the program. This activity should be ongoing throughout the program.
  
  

Strategy 4: Traveling Exhibit on Low Vision
The NEI is developing a traveling exhibit on low vision that will launch in 2000. The exhibit will increase public awareness about low vision and the resources available to help people who have it. The exhibit will be designed to provide information about low vision and eye diseases, contain an interactive multimedia touchscreen program, highlight local resources, and display low vision assistive devices. The exhibit will be displayed in shopping malls throughout the country and may be staffed by volunteers from local organizations.

Local media can be provided with the media kit and encouraged to run news stories about low vision that will coincide with the exhibit in area shopping malls. The exhibit will reference the low vision materials available from NEI.

Strategy 5: Toll-free Number
To assist in handling the anticipated increase in requests from the general public for low vision materials, a special toll-free number can be set up. This number would be answered by a recording that would prompt callers through the ordering process via a series of menu choices. Such a system would avoid sudden increases in calls to the NEI Office of Communication, Health Education, and Public Liaison (at 301-496-5248) and provide for rapid, efficient processing of orders. Professionals would continue to order materials through the existing toll-free number.

Strategy 6: New Technology
The World Wide Web has become an increasingly important resource for people looking for health information. However, the large volume of information results in a need to evaluate the sources for reliability. NEI can capitalize on its web site as the Federal source of information about eye health information by adding a special section about low vision.

In addition to posting the materials for viewing and providing an online order form, the interactive program developed for the traveling exhibit could be adapted for the NEI web site. Other interactive or animated programs may be developed to help viewers experience low vision and the result of using assistive devices.

Program Launch
A press conference will launch the program and the media campaign in the fall of 1999. Dr. Kupfer will provide an overview of the scope and importance of the issue, outline the NEHEP plans to educate Americans about low vision, and unveil the new materials. Experts on low vision or other dignitaries from within and outside the Federal government may be present at the press conference to answer reporters' questions.

Invitations will be sent to national print and broadcast media, wire services, specialty publications and journals, and NEI's media list; NEHEP Partnership members; members of the aging network; and representatives of organizations working in the low vision field.

Additional materials will be developed to support the program launch:

• Media Kit
  
  The media kit will be distributed at the press conference announcing the launch. It will include copies of the PSAs and of the educational materials developed for the target audiences, a press release about the Low Vision Public Education Program, a fact sheet on low vision, background information to help reporters prepare their stories, and contact information for potential interviews with NEI staff or others involved in the campaign.
  
  
• VNR and B-Roll
  
  The VNR, which is the television equivalent of a printed press release, will run one and a half to two minutes, followed by three to five minutes of b-roll that individual stations can use to develop a story on their own. This format allows stations to choose whether to run the VNR as is or to edit the b-roll to fit their news format. The VNR will commemorate the program launch and will be distributed via satellite uplink and mail to television stations in the top 25 markets nationwide. Before the choice of these markets is finalized, they will be examined to ensure that they have the greatest reach to the target audiences.
  
  
• Audio News Release
  
  This radio script, the equivalent of the press release and VNR, will be based on the VNR and will run not more than 60 seconds. It will be distributed to radio stations nationwide via syndication.
  
  
• Media Placements
  
  Major media, including national television and radio news and talk shows and national health columnists, will also be approached individually to encourage them to write stories about low vision. Where possible, interviews with Dr. Kupfer, director of NEI, will be scheduled.
  
  

A detailed plan will be developed to detail the sequence of events for the program launch.
Role of the NEHEP Partnership

The NEHEP Partnership has traditionally advised the NEI on the roles that intermediary organizations can play in eye health education efforts. These traditional roles will be important in raising awareness and educating the public, patients, and health care professionals about low vision. The NEHEP Partnership may be instrumental in the following ways:

• Distribute campaign materials directly to the target audience.
  
  
• Form a speakers bureau to give presentations to the general public, patients, and health care professionals.
  
  
• Collaborate on joint ventures within the community to disseminate campaign materials.
  
  
• Promote the campaign through organization publications.
  
  
• Support ongoing research by including NEI questions on organizational surveys.
  
  
• Implement education programs targeted to high risk groups.
  
  
• Provide resources to conduct specific activities or produce materials.
  
  
• Collaborate in joint ventures with private industry to promote messages or distribute educational materials.
  
  
• Assist with continuing medical education courses for health care providers or education programs for allied health care professionals.
  
  

An additional role for intermediaries will be to provide continuing medical education, an effort that is crucial to the communication effort. Primary care providers are likely to have direct contact with older adults experiencing low vision and are considered a key intermediary group. Further, the reality of the managed care referral process supports a focus on health care professionals. Therefore, the NEI will work with relevant NEHEP Partners to support their development of continuing medical education programs that will facilitate clinical identification of persons with low vision and their referral to appropriate medical and rehabilitative services.

Given the new reliance on technology and the Internet in public education efforts, another role for the NEHEP Partnership members will be to promote low vision messages and materials via their web sites. They can promote specific aspects of the public education program or provide an active link to the low vision area on the NEI web site. They may provide assistance in the development and testing of the interactive section of the NEI web site. Their membership may represent the target audiences and as such, their feedback would be invaluable. An online evaluation can be developed to facilitate testing and gather comments.

Further research will be conducted to support development efforts and to allow evaluation of the campaign.

A proposed strategy that could play a key role in both campaign development and program evaluation is a baseline knowledge, attitudes, and practices (KAP) survey. Because of the time needed to develop and clear such a survey through the Office of Management and Budget, this strategy cannot be implemented before the campaign launch. However, other research methods may be more feasible and efficient:

• Conducting a secondary analysis of an existing data set (1995 National Health Interview Survey (NHIS) and Disability Supplement or the most recent version of the Medicare Current Beneficiary Survey) to determine the prevalence of low vision, the use of assistive devices, and economic data. Some of these data are available, but they are not compiled in such a way to be as useful as they could be for program development and evaluation.
  
  
• Adding questions to an omnibus survey.
  
  

Campaign Development

• Conduct secondary analyses of the 1995 NHIS and the most recent version of the Medicare Current Beneficiary Survey.
  
  
• Pretest the educational materials for comprehension and usability with consumers, caregivers/family members, and professionals.
  
  
• Explore how the low vision education materials could best be created for use in community outreach.
  
  
• Research the specific media (programs, times, types) most popular with older adults with low vision.
  
  

Program Evaluation

• Compile and analyze media coverage.
  
  
• Conduct customer satisfaction surveys to determine satisfaction with and usage of low vision educational materials.
  
  
• Support the NEHEP Partnership organizations in their efforts to measure success in developing local programs and resources.
  
  
• Monitor grantees in their efforts to measure success in research related to visual impairment and rehabilitation.
  
  

To accomplish the objectives for Year 1 outlined above, the initial stage of the Low Vision Communication Plan will be completed in three phases. Phase I will be devoted to final approval of the Plan by NEI and the NEHEP Partnership. Phase II will consist of materials development. Phase III will consist of evaluation, feedback, and plan correction.

Phase I: Final approval of the Low Vision Plan

February 18, 1999	Provide draft plan to the NEI
February 24, 1999	Receive comments from the NEI
March 26, 1999	Final revisions and approval

Phase II: materials development

March 1-June 15, 1999	Develop professional and consumer educational materials as described in Section III
July 12-16	International Low Vision Conference
Week of July 19	Meet with NEI staff to discuss recommendations arising from the International Low Vision Conference
July 23-30	Complete revisions and prepare for pretesting
August 1999	Pretest materials with target audiences
September 1999	Revise educational materials and print; convert print materials to HTML and PDF for uploading to NEI's web site
June 1-September 30, 1999	Develop press materials as described in Section III
October 1999	Launch the Low Vision Public Education Program

Phase III: Evaluation

November-December 1999	Compile and analyze media coverage of launch and campaign (continue quarterly)
January and April 2000	Compile and analyze information received from bounceback cards used with educational materials
November 2000	Conduct post-campaign KAP survey with the public and people with low vision

Low vision is broadly defined as any chronic visual condition that is not correctable by glasses or contact lenses and that impairs everyday activities. This definition of low vision usually excludes people who are totally blind. In 1978, the World Health Organization recognized the vast gray area between normal vision and blindness. This area came to be known as low vision (Colenbrander and Fletcher, 1995).

The classification of conditions that constitute low vision has changed over time. Today, the classification includes people who suffer loss of visual acuity and those who suffer loss of visual field. Most people with one of these conditions have residual vision and, with the aid of devices and rehabilitation, can maintain an independent, productive way of life (Rubin, 1996).

For the purpose of the Low Vision Public Education Program Communication Plan, the NEI and the Ad Hoc Working Group on Low Vision define low vision as visual impairment that interferes with a person's ability to perform daily tasks such as reading and driving and that cannot be corrected by conventional glasses or contact lenses.

Causes of Low Vision
Most people with low vision in the United States are 65 years of age and older and have AMD, cataract, glaucoma, diabetic retinopathy, or optic nerve disease. AMD accounts for almost 45 percent of all cases of low vision.

Consequences of Low Vision
For the individual, low vision often results in a restricted field of vision or in diminished ability to see sharpness of detail, read conventional size print, determine color or depth perception, see contrasts, adjust to changes in light or glare, or locate objects (Marmor, 1992; Beaver and Mann, 1995). This disability results in profound lifestyle, physical, economic, and psychological consequences. It ranks behind only arthritis and heart disease as the etiology for impaired function in people older than 70 (Swagerty, 1995).

Visual impairment has been found to be strongly associated with greater difficulty in performing the activities of daily living, leisure pursuits, education, vocation, and social interactions. Affected daily activities include walking, getting outside, and transferring to and from a bed or chair (Branch et al., 1989). Daily life becomes complicated when people are unable to read their mail, check price tags, read nutritional and food preparation information on food packages, drive, sew, or travel alone. As a result, many people with low vision become socially isolated because they can no longer enjoy simple activities such as playing cards or going to a movie. The health of older people with low vision may be compromised when they cannot recognize medications or read labels, or they lose interest in cooking because the microwave panel or stove dials are indiscernible (Faye, 1998).

Visual impairment affects not only these people's ability to read, but also their ability to move safely in their environment, make decisions, and communicate with others (Warren, 1995). There is strong evidence that among aged persons low vision increases the likelihood of falling. (Bachelder and Harkins, 1995; Swagerty, 1995) The loss of stereoscopic vision and depth perception place them at much higher risk for falling.

Over 60 percent of all people with visual impairments work, and one third of these people report that their vision problems cause them at least some difficulty on the job. In 1994, Louis Harris and Associates conducted a survey for The Lighthouse, Inc. Half of all respondents to that survey reported that loss of income due to low vision was a very or somewhat serious problem.

According to the clinical literature, older persons who confront visual impairment may experience a range of psychological reactions, including grief, confusion, fear, anxiety, depression, loss of control, loss of self-esteem, and diminished social comfort (Bachelder and Harkins, Jr., 1995; Branch et al., 1989). The AARP (1992) reported that older persons with visual impairments were often socially isolated, depressed, and dependent on others.

Economic Impact
Raasch and colleagues (1997) point out that the costs associated with low vision are high for individuals, families, communities, and the Nation. Costs included the direct cost of treatment, impeded progress and increased costs of education, the loss of personal income for those in their employable years, associated costs (such as Social Security disability benefits) (Raasch et al., 1997:288). Low vision also affects the families of people with visual impairment, often placing financial, social, and psychological stresses on family members. The lost productivity of those caring for or assisting persons with visual impairments also adds to the cost of low vision (Raasch et al., 1997:288). Care and services provided for individuals who are blind or who have visual impairments cost the Nation in excess of $22 billion each year (Alliance for Eye and Vision Research, 1995).

Extent of the Low Vision Problem
Minimal epidemiological data have been available on the prevalence of low vision, except in regional or limited studies. The Disability supplement of the NHIS in 1994 and 1995 included a question asking if anyone in the respondent's household had "serious difficulty seeing, even when wearing glasses or contact lenses." The rate estimates from these studies offer the most current and comprehensive view of visual impairment in the United States. For all ages, the rate of visual impairment was 32.5 per 1,000 persons (Benson and Marano, 1998). Table 1 summarizes some of the 1995 NHIS findings.

Category	Under 45 Years	45-64 Years	65 Years and Over
Age	20.3	48.3	76.0
Sex Male Female	27.7 12.8	60.3 37.1	93.7 63.2
Race White Black	21.8 11.9	45.6 67.9	71.7 105.9
Family Income Less than $10,000 $10,000—$19,999 $20,000—$34,999 $35,000 or More	29.0 29.8 23.1 15.6	62.6* 89.9 68.1 36.4	132.8 63.3 72.1 74.8

* Figure does not meet standard of reliability or precision.

The prevalence of visual impairment increased among older populations in the 1995 NHIS (Benson and Marano, 1998). The 1995 NHIS findings also showed that males in the United States had higher rates of visual impairment than did females at all ages. Projections from the Baltimore Eye Study also demonstrated that visual impairment increased dramatically with age. While less than 1 percent of people in their 50s were projected to have visual impairment, 13 percent of people over age 80 had visual impairment (Tielsch et al., 1990). In the 1994 Lighthouse survey noted above, 26 percent of people over 75 reported having a vision impairment.

In the 1995 NHIS, African Americans under 45 years of age had lower rates of visual impairment than non-Hispanic whites, but those older than 45 demonstrated rates of impairment that outpaced those of non-Hispanic whites by more than 20 percent (Benson and Marano, 1998). These findings confirmed the Salisbury Eye Evaluation Study's results that showed higher rates for African Americans than for non-Hispanic whites.

The 1995 NHIS findings also demonstrate that family income appears to be related to visual impairment, although there is not as clear a pattern (Benson and Marano, 1998). Within age categories, those at the lowest income levels tended to have the highest rates of visual impairment. These results confirm data from the 1980s demonstrating that lower socioeconomic groups have a higher prevalence of visual loss at all ages (Kirchener and Peterson, 1988).

Demographics of People at Risk for Low Vision

Because visual impairment is largely related to aging, an understanding of the experience of older people in the United States is important. A 1996 report (Siegel) of the Administration on Aging of the U.S. Department of Health and Human Services, Aging into the 21st Century, profiled older Americans and expected trends and challenges. The number of older people and the rate of aging are soon expected to increase steeply with the aging of the baby boom cohort. This expansion implies a vast increase in the number of persons requiring special services, including vision rehabilitation services. A shift in racial/ethnic composition of the elderly is also expected. As compared with 15 percent today, in 2050, about one third of the elderly will be other than non-Hispanic white.

Large increases are also expected in some very vulnerable groups such as the oldest old living alone, older women, older racial minorities living alone and with no living children, and older unmarried persons with no living children and no siblings. While the elderly, on average, experience less poverty than the rest of the population, these groups also have high percentages living in poverty or with low incomes. Those with a combination of these characteristics are subject to living in poverty to a disproportionate degree.

Households maintained by older persons consist primarily of married couples or a woman alone. While nearly three quarters of older men are married and live with spouses, only one third of older women are married and live with spouses. Not including spouses, one in eight older people live with other relatives. A significant shift toward solitary living occurred in recent decades as many older persons desired independence and chose to live alone if their health and finances permitted. Solitary living increases with advancing age as older women and men are widowed. Many of those living alone have children living nearby or who regularly keep in touch with them. While roughly 31 percent of all older people lived alone in 1990, only about 8 percent lived alone and had no living children.

In 1995, 64 percent of older people were at least high school graduates (Bureau of the Census, 1996c), and the proportion is expected to increase. Despite the overall increases in education levels, older people remain the least educated age group in our society. This problem is compounded by those older people who have limited facility in the English language.

Recent projections on life expectancy predict considerable increases over current figures, implying that a larger proportion of the population is likely to survive to very advanced ages. Whether people live well during these added years of life is another issue. According to projections of self-reported health status, which is a health measure associated with longevity, the proportion of older people reporting fair or poor health tends to increase with advancing age. The number of older people with poor health is projected to increase sharply from 1990 to 2030, paralleling the population increase. On the basis of expected population increases, the number of persons at all levels of disability would be expected to grow, even if reductions in the proportions of those with disabilities were assumed.

Help for People with Low Vision

Services

Historically, people with low vision have had a difficult time learning about services available to them or about adaptive equipment that could enhance their functioning and quality of life (Rosenthal, 1995). Until recently, most of the rehabilitation services and information that individuals with low vision obtained were self-initiated. Lack of direction from eye care providers has been attributed to their training in the medical model and the view that low vision is untreatable (Rosenthal, 1995). This issue was also raised by many of the participants with low vision in the NEI focus groups, who reported receiving little medical information or information on coping with low vision from their eye care professional upon diagnosis. Many participants reported being told that there was nothing more that the eye care professional could do for them. This made them "feel terrible," and some of the older adults stopped going to their eye care professionals when their glasses no longer helped them.

In 1990, when the HCFA broadened its definition of physical impairment to include low vision as a condition that merited rehabilitation, physicians could refer clients for occupational therapy services with the single condition of visual impairment (Code of Federal Regulations, 1994). Some clinicians endorse having primary care physicians identify patients with low vision during history taking at office visits (Faye, 1998). Physicians can use this opportunity to refer patients with low vision to a rehabilitation source where the outcome of the disease can be evaluated, daily living needs can be analyzed, and assistance to enhance the diminished function can be provided (Faye, 1998). Patients are referred to:

• Ophthalmologists who provide low vision services;
  
  
• Optometrists who are trained to offer low vision remediation;
  
  
• Occupational therapists who specialize in assisting with mobility, work, activities of daily living, and leisure;
  
  
• Rehabilitation counselors who provide vocational counseling, service referral, and case management to help persons with low vision adjust to their vision loss; and
  
  
• Other agencies or institutions that work with and support persons with low vision.
  
  

HCFA gathers data regularly on Medicare through the Current Beneficiary Survey. These data include demographics on respondents with specific disabilities such as low vision. Data on the use of Medicare services by people with low vision are not readily available (S. Maloney, personal communication, January 4, 1999).

Devices

Ophthalmologists and optometrists typically prescribe optical devices for persons with low vision. These devices may include reading glasses with high-powered lenses and reading prisms; absorptive lenses; telescopes and telescopic spectacles for tasks requiring vision at near, middle, and far distances (Porter et al., 1992); and reversed telescopes or mirrors for treatment of visual field defects (Bailey and Hall, 1990).

The appropriate selection of a low vision device or technology and the subsequent training of the user in its application are crucial for ensuring its proper use. The 1993 Consensus Validation Conference held by the National Institute on Disability and Rehabilitation Research recommended that individuals selecting low vision devices consider the following:

• Comprehensive clinical evaluation by a low vision specialist;
  
  
• Evaluation of their functional abilities;
  
  
• Determination of financial resources and funding options;
  
  
• Discussion of feelings related to using low vision devices;
  
  
• Referral, when appropriate, to an electronic aids specialist;
  
  
• Instruction in the use of the device and a trial use period;
  
  
• Final selection of the low vision devices; and
  
  
• Ongoing followup service to monitor the continued effectiveness of the devices.
  
  

After home safety, the two most pressing needs of many people with low vision are reading and writing (Beaver and Mann, 1995). Reading devices and strategies include adjustable lighting, prescription reading glasses, large print publications, nonelectronic magnifying devices, closed-circuit televisions (CCTVs), cassette recordings, electronic reading machines, and computers with large print and speech output systems. The use of bold black felt tip markers is strongly suggested when writing. Writing tablets with bold lines help people with low vision write in a straight line.

Many people with low vision use nonelectronic magnifiers, which come in a variety of sizes and styles. Most are used to read short items such as a telephone number, dictionary definition, and menus (Jahoda, 1993). Some have found CCTVs, which enlarge printed, handwritten, and graphic material electronically onto a monitor screen, beneficial for tasks that require more reading. Although CCTVs provide more efficient character enlargement access to materials than nonelectronic magnifiers, they have some disadvantages for reading written text (Beaver and Mann, 1995). The movement of the text on the CCTV causes some people to experience eye fatigue and motion sickness when they read for long periods. To avoid this, some people read from large print books, listen to audiocassette versions of books, or use an electronic reading system.

Today, computers are increasingly used to assist those who have low vision with activities such as reading and writing. Large computer monitors, e.g., 21 inches and larger, coupled with larger font text work well for some who do not require excessive magnification. Others benefit from electronic reading systems. Printed material is scanned into the computer's memory, and the words that have been scanned are spoken aloud through the speech synthesizer. Others use a screen enlargement system that displays information on a computer screen in a variety of magnification levels up to 16 times the standard size. For some, combining screen enlargement with audio feedback through a speech output system reduces the need to continually view the screen when typing and thus reduces eye fatigue (Beaver and Mann, 1995).

Environmental Modifications--Home Safety
Simple modifications and in-home adaptations may be all that is needed for a person with low vision to improve mobility and acquire a greater degree of independence. Contrasting colors are often helpful. Tape (in a contrasting color) applied to the top edge of each step is useful in preventing falls. Younger and Sardegea (1991) found that darker colors on furniture, light switches and plugs, and electrical outlets made them easier to see when contrasted with white or beige walls, ceilings, and carpets. Motion lights that automatically turn on when someone enters a hallway, room, or closet may prevent falls. Telephones with large numbers and clocks and watches that have larger print and speech output are useful. Placing large print labels on the stove and microwave also helps.

Effectiveness of Low Vision Interventions
A recent article by Raasch and colleagues (1997) reviewed the research literature on the efficacy of low vision interventions to determine the value of low vision services and devices. The studies used different measures to determine how well a low vision intervention worked--patient satisfaction, frequency and type of use, degree of use, or the ability to read print of a certain size. These studies reported "success" with low vision aids ranging from 23 percent to 100 percent. This wide range results from the different types of interventions and definitions of success used.

In general, the research supports the value of low vision examinations, rehabilitation, and assistive devices. Some of the specific results are as follows:

• Goodrich and Mehr (1986) found that training in the use of magnification was effective in promoting continued use of low vision devices (LVDs). The authors reported that 85.4 percent of the devices were still being used 12 to 24 months after they were prescribed. Continued use of devices was highly related to the presence of a supportive significant other. Training in the use of LVDs also contributed to their continued use. Those veterans who discontinued the use of devices offered several reasons: use of other devices, dislike of the way the device performed, or further vision loss.
  
  
• Raasch and colleagues (1997) advocate that any assessment of low vision interventions use two approaches to determine effectiveness: (1) the evaluation of performance of specified tasks of value to the patient and (2) an assessment of quality of life (i.e., the individual's capabilities, attitudes, and psychological state). None of the studies reviewed included quality of life measures, and many did not include any performance measures. Besides establishing the type and magnitude of the change in functioning and the quality of life of the individual, the study should compare the outcome of the low vision intervention with the outcome of the treatment of other disorders.
  
  

Awareness and Utilization of Services
While low vision rehabilitation services and devices are available, many people with low vision do not appear to be aware of their availability or to use them. More than 40 percent of Americans age 65 and older are not aware of public or private agencies in their communities that provide services for people with vision impairments (Arditi, 1996). In the Lighthouse survey noted earlier, only 1 percent of the people who described themselves as having visual impairment reported using vision rehabilitation services, 2 percent reported using job training and placement services, and 2 percent said they received counseling to help with emotional support.

Among Lighthouse survey respondents who reported not having used clinical services, 21 percent said they had not used these services because they were not familiar with them. Lack of awareness was cited as a reason respondents did not use other services: recreational services (12 percent), rehabilitation training in daily skills (16 percent), counseling services (12 percent), and job training or placement services (10 percent).

Abyad, A. (1997). In-office screening for age-related hearing and vision loss. Geriatrics, 52, 45-54.

Alliance for Eye and Vision Research. (1995). A vision of hope for older Americans' progress and opportunities in eye and vision research. An official report to the White House Conference on Aging.

American Association of Retired Persons. (1992). Fact sheet. American Association of Retired Persons. Washington, DC.

Arditi, A. (1996, April 26). Low vision services available nationally and barriers to people help. Proceedings of the National Eye Institute Low Vision for the Lay Person Symposium at the Festschrift for Jay Enoch.

Bachelder, J. and Harkins, D. Jr. (1995). Do occupational therapists have a primary role in low vision rehabilitation? American Journal of Occupational Therapy, 49, 927-930.

Bailey, I. L. and Hall, A. (1990). Visual impairment: an overview. New York: American Foundation for the Blind.

Beaver, K. A. and Mann, W. C. (1995). Overview of technology for low vision. American Journal of OccupationalTherapy, 49, 913-921.

Benson, V. and Marano, M. A. (1998). Current estimates from the National Health Interview Survey, 1995. National Center for Health Statistics. Vital Health Statistics, 10(199).

Branch, L., Horowitz, A. and Carr, C. (1989). The implications for everyday life of incidents of self-reported visual decline among people over age 65 living in the community. Gerontologist, 29, 359-365.

Code of Federal Regulations: Public Health, part 42. (1994). Office of Federal Register National Archives and Records Administration. Washington, DC: U.S. Government Printing Office.

Colenbrander, A., and Fletcher, D. C. (1995). Basic concepts and terms for low vision. American Journal of Occupational Therapy, 49(9), 886.

Crews, J. E. (1994). The demographic, social, and conceptual contexts of aging and vision loss. Journal of the American Optometric Association, 65(1), 63-68.

DeSylvia, D. (1990). Low vision and aging. Optometry and Vision Science, 76, 319-322.

DiStefano, A. and Aston, S. (1986). Rehabilitation for the blind and visually impaired elderly. In S. Brody and G. Ruff (Eds.), Aging and Rehabilitation. New York: Springer, 203-216.

Fagerstrom, R. (1994). Correlation between depression and vision in aged patients before and after cataract operations. Psychological Reports, (75), 115-125.

Faye, E. Living with low vision. (1998). Postgraduate Medicine, 103, 167-178.

Fletcher, C., Shindell, S., Hindman, T., and Schaffrath, M. (1991). Low vision rehabilitation finding capable people behind damaged eyeballs. Western Journal of Occupational Therapy, 45, 563-565.

Foxhall, M. J., Barron, C. R., Von Dollen, K., Shull, K. A., and Jones, P. A. (1994, August). Low-vision elders: Living arrangements, loneliness, and social support. Journal of Gerontological Nursing, 6-14.

Gieser, D. K. (1992). Visual rehabilitation: The challenge, responsibility, and reward. Ophthalmology, 99(10), 1622-1625.

Goodrich, G. (1994). Visual rehabilitation: How to better meet public needs. Proceedings of the National Eye Care Forum II: Vision for the Future, March 20-21. San Francisco.

Goodrich, G. and Mehr. E. (1986). Eccentric viewing training and low vision aids: current practice and implications of peripheral retinal research. Journal of Optometry and Physiological Optics, 63, 119-126.

Jahoda, G. (1993). How do I do this when I can't see what I'm doing? Information processing for the visually disabled. Washington, DC: U.S. Government Printing Office.

Jose, R. T. (ed). (1983). Understanding low vision. American Foundation for the Blind.

Kirchner, C. and Peterson, P. (1988). Estimates of race-ethnic groups in the US visually impaired and blind population. Data on blindness and visual impairment in the US: A resource manual on characteristics, education, employment, and service delivery, pp. 93-101.

The Lighthouse. (1994). The Lighthouse national survey on vision loss: The experience, attitudes and knowledge of middle-aged and older Americans. New York: The Lighthouse, Inc., Louis Harris and Associates, Inc.

Massof, R. W. (1998). A systems model for low vision rehabilitation. II. Measurement of vision disabilities. Optometry and Vision Science, 75, 239-373.

National Institute on Disability and Rehabilitation Research. Consensus Statement. (1993). Meeting held January 25-29, 1993.

Nilsson, U. and Nilsson S. (1986). Rehabilitation of the visually handicapped with advanced macular degeneration. Documenta Ophthalmologica, 62, 345-367.

Porter, E., White, J., Goldbert, J., Demer, J., and Koval, A. (1992). Predicting successful low vision rehabilitation with telescopic spectacles. Journal of Visual Impairment and Blindness, 86, 29-32.

Prevent Blindness America. (1995). 1994 report on sports and recreational eye injuries. Prevent Blindness America.

Raasch, T. W., Leat, S. J., Kleinstein, R. N., Bullimore, M. A., and Cutter, G.R. (1997). Evaluating the value of low-vision services. Journal of the American Optometric Association, 68, 287-295.

Rahmani, B., Tielsch, J. M., et al. (1996). The cause-specific prevalence of visual impairment in an urban population. The Baltimore Eye Study. Ophthalmology, 103(11),1721-1726.

Rosenthal, S. B. (1995). Living with low vision: A personal and professional perspective. American Journal of Occupational Therapy, 49, 861-864.

Rubin, G. (1996, April). The demography of low vision and age-related visual disability on quality of life. Proceedings of the University of California Berkeley Symposium on Low Vision for the Lay Person. Baltimore, MD.

Rubin, G. S., West, S. K., et al. (1997). A comprehensive assessment of visual impairment in a population of older Americans. Investigative Ophthalmology and Visual Science, (38), 557-568.

Sommer, A., Tielsch, J. M., Katz, J., et al. (1991). Racial differences in the cause-specific prevalence of blindness in East Baltimore. New England Journal of Medicine, 325, 1412-1417.

Swagerty, D. Jr. (1995). The impact of age-related visual impairment on functional independence in the elderly. Kansas Medicine, 96, 24-26.

Tielsch, J. M., Sommer, A., Witt, K., Katz, J., and Royall, R. M. (1990, February 1). The Baltimore eye survey research group. Blindness and visual impairment in an American urban population. Archives of Ophthalmology, 108, 286-290.

Tinetti, M. E., Speechley, M., and Ginter, S. F. (1998). Risk factors for falls among elderly persons living in the community. New England Journal of Medicine, 319(26), 1701-1707.

Warren, M. Including occupational therapy in low vision rehabilitation. (1995). American Journal of Occupational Therapy, 49, 857-860.

Watson, G., De L'Aune, W., Stelmack, J., Maino, J., and Long, S. (1997). National survey of the impact of low vision device use among veterans. Optometry and Vision Science, 74, 249-259.

Weinrab, R., Freeman, W., and Selezinka, W. (1990). Vision impairment in geriatrics. In B. Kemp, K. Brumel-Smith, and J. Ramsdell (Eds.). Geriatric Rehabilitation. Boston: Little, Brown, 223-234.

Younger, V. and Sardegna, J. (1991). One way or another: A guide to independence for the visually impaired and their families. San Jose, CA: Sardegna Productions.