CEU Article

Barriers to Low Vision Rehabilitation:

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

Treatments for numerous diseases and in-
juries require some form of rehabilitation as
part of the healing process. For example,
during recovery from joint or muscle injury,
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physical rehabilitation is an integral part of
the treatment regimen. In the case of
The authors thank Dr. Olga Overbury for her
support in the completion of the study. The
Montreal Barriers Study is funded by the Re-
seau Vision of the Fonds de recherche en
sante du Quebec, the Institut Nazareth et
Louis-Braille, and the MAB-Mackay Reha-
bilitation Centre. Funding for the postdoctoral
fellowship of Walter Wittich is provided by
the Canadian Institutes of Health Research.

2012 AFB, All Rights Reserved Journal of Visual Impairment & Blindness, May 2012 261
 CEU Article
chronic visual impairment, low vision reha-
bilitation services allow patients to adjust
and develop compensatory skills to im-
prove their functional abilities. Vision reha-
bilitation is most commonly known in the
context of blindness, whereby patients ac-
quire skills such as braille reading and cane
or dog guide techniques, or are trained to
perform essential skills for activities of
daily living such as preparing a meal with-
out sight. Nevertheless, the large majority
of individuals who are eligible for vision
rehabilitation are affected by low vision.
These patients have residual vision, but too
little to rely on visual information alone in
their daily lives. Given the changing demo-
graphics within developed countries, the
large majority of these individuals are now
elderly persons who are affected with late-
onset vision loss because of such diseases
or conditions as diabetic retinopathy, mac-
ular degeneration, or glaucoma (Maberley
et al., 2006).
Low vision is generally defined as an
untreatable loss of sight that is not cor-
rectable with standard eyeglasses and that
interferes with the functioning of the in-
dividual, thereby creating a disability
(Faye, 1984). Within the Province of
Quebec, Canada, the legal definition of a
visual handicap is a visual acuity of less
than 20/70 in the better eye with a best
standard correction or a visual field of less
than 70 degrees in diameter (Regie de
lassurance maladie du Quebec/RAMQ,
2006). Individuals who fit these standards
are eligible for low vision rehabilitation
services, which are covered by the RAMQ.
However, not all eligible persons with
visual impairments avail themselves of
this opportunity. The Canadian National
Institute for the Blind (CNIB, 2005) re-
ported that only 28% of the surveyed se-
262 Journal of Visual Impairment & Blindness, May 2012
niors knew how to access vision rehabil-
itation services. Furthermore, 17%
indicated that the distance they had to
travel to the service delivery agency
posed a problem of access. In the Prov-
ince of Quebec, it is estimated that only
20% of eligible clients access vision re-
habilitation services (Gresset & Baum-
garten, 2002). Awareness of these ser-
vices was generally low, and eye care
professionals were not always supportive
of the patients search for additional in-
formation, a finding that has been re-
ported at the national level as well (Gold,
Zuvela, & Hodge, 2006). These numbers
are comparable to a population-based
study conducted in West Virginia, in
which only 19% of individuals with
symptoms of low vision were aware of
vision rehabilitation, and only 12% had
received these services (Walter, Althouse,
Humble, Leys, & Odom, 2004).
These statistics provide the rationale
for the investigation of barriers to low
vision rehabilitation services. Frequently,
studies about barriers to rehabilitation ac-
cess utilize quantitative methodologies,
whereby eye care professionals are sur-
veyed about their referral patterns or cli-
ents at rehabilitation agencies are ques-
tioned about the barriers they experienced
(Adam & Pickering, 2007; Chiang,
OConnor, Le Mesurier, & Keeffe, 2011;
Chiang, Xie, & Keeffe, 2011; Gold et al.,
2006; Keeffe, Lovie-Kitchin, & Taylor,
1996; Koenekoop & Gomolin, 1995;
Overbury, Jackson, & Santangelo, 1987;
Overbury & Wittich, 2011; Sundling et
al., 2007). There is, however, a notable
dearth of research on the barriers to low
vision rehabilitation services from the pa-
tients perspective. In Australia, Pollard,
Simpson, Lamoureux, and Keeffe (2003)
2012 AFB, All Rights Reserved
 CEU Article
conducted focus group interviews with 17
individuals, ranging in age from 25 to 88,
concerning issues related to access barri-
ers. The main topics that emerged were a
general perception of rehabilitation, over-
coming distance and travel barriers to ser-
vices, and interaction with eye care pro-
fessionals as well as service agencies.
Pollard et al. described issues of self-
identity, such that the participants with
low vision did not consider themselves
blind and were thus reluctant to utilize
services that were seemingly geared to-
ward the severely impaired. Another
theme that arose from the analyses was
transportation to the service agencies.
Older individuals reported difficulties
traveling independently because of their
fear of getting lost. Communication prob-
lems with eye care professionals were
also reported. The consensus was that
ophthalmologists did not provide infor-
mation about rehabilitation in the referral
process. At a point at which nothing more
could be done from the medical perspec-
tive, information was finally provided
about low vision rehabilitation services,
but not always.
One particular point of interest in Pol-
lard et al.s (2003) study was the goal of
recruiting persons with low vision who
had not accessed rehabilitation services.
However, only five participants fit this
criterion, even though announcements
had been made over a local radio station.
The study presented here included partic-
ipants who had accessed low vision reha-
bilitation services, participants who were
aware of these services but chose not to
take advantage of them, and individuals
who had never heard of low vision reha-
bilitation services. The aim of the study
was to describe and gain a better under-
2012 AFB, All Rights Reserved
standing of why individuals with low vi-
sion may not (choose to) access vision
rehabilitation services. It was anticipated
that the qualitative data would lead to a
more in-depth understanding of low vi-
sion rehabilitation services, perhaps offer
explanations for some frequently refer-
enced quantitative results, and generate
new hypotheses for subsequent quantita-
tive testing.
Methodology
QUALITATIVE METHODS
To understand the perspectives of patients
of ophthalmology clinics with respect to
the barriers to low vision rehabilitation
services, we used a qualitative description
research paradigm (Sandelowski, 2000).
The objective of qualitative description
studies is to provide a summary of par-
ticipants experiences presented in every-
day language without high-level interpre-
tation. This approach has frequently been
used to investigate topics related to the
delivery of health care services. This
study received ethical approval from the
Institutional Review Board of the SMBD
general hospital, Montreal, Canada.
PARTICIPANTS
The focus group participants were re-
cruited through their involvement in the
Montreal Barriers Study (Mwilambwe,
Wittich, & Freeman, 2009). Six focus
groups were conducted with a total of 21
individuals (F 14, M 7), ranging in
age from 38 to 92. Each focus group was
composed of participants who had not
heard of low vision rehabilitation ser-
vices, had heard of but not accessed these
services, and who knew of and accessed
these services. Heterogeneous groups
Journal of Visual Impairment & Blindness, May 2012 263
 CEU Article
were selected so that differences in per-
spectives on the barriers to low vision
rehabilitation services would be most ap-
parent to the investigators during the fo-
cus group discussions and subsequent
analyses.
DATA COLLECTION
The first author moderated all the audio-
recorded focus groups. The participants
were informed that the investigators were
interested in their perspectives (both pos-
itive and negative) about accessing low
vision rehabilitation services and, in par-
ticular, the barriers to accessing these ser-
vices. The initial interview guide included
three questions: What enabled you to ac-
cess low vision rehabilitation services?
What served as obstacles to you accessing
low vision rehabilitation services? and
What could be done to make it easier to
access low vision rehabilitation services?
These questions were designed to gener-
ate, and allow for the expression of, a
wide range of factors that may serve as
barriers to low vision rehabilitation ser-
vices. Follow-up questions were posed
to generate more in-depth information
on relevant issues. The focus groups
were informal in nature, with an under-
lying goal of stimulating discussions of
experiences among the participants.
During the focus groups, field notes
were taken by the coinvestigator (Wal-
ter Wittich) to identify information that
was unlikely to be picked up by the
audio-recording (Morse & Field, 1995).
This information was used as a second-
ary data source during the analyses.
Proper names were assigned pseud-
onyms, and other identifiers were re-
moved to ensure confidentiality.
264 Journal of Visual Impairment & Blindness, May 2012
CONTENT ANALYSES
The transcripts of the interviews were an-
alyzed using content analysis (Elo &
Kyngas, 2008). Content analysis has three
steps: open coding, creating categories,
and abstraction. During open coding, the
investigators immerse themselves in the
data, reading and rereading the transcripts
in search of text that answers the funda-
mental research question (in this case,
What are the barriers to accessing low
vision rehabilitation services ?) (Polit &
Beck, 2004). Once meaningful text is
identified, the investigators assign labels
in the margin of the interview transcript.
The aim is to assign the requisite number
of labels so as to describe fully the con-
tent of the text (Hsieh & Shannon, 2005).
Next, categories of headings are created
(Burnard, 1991). The final step of content
analysis is abstraction, when the investi-
gators prepare general descriptors of the
data (Polit & Beck, 2004). In the present
study, abstraction involved uploading the
data into ATLAS-ti (2009), a software
program that is designed to aid in the
analysis of large bodies of text. ATLAS-ti
provides an interface whereby researchers
can efficiently move about text-based
documents to examine how the interviews
and assigned categories relate to one an-
other. During this phase of content anal-
ysis, meaningful patterns within and
across the transcripts of interviews (such
as the frequency with which categories
appear in proximity to one another in the
text) were identified. ATLAS-ti was used
primarily as a data management tool. Ac-
cordingly, it was the task of the investi-
gators to decide what interview passages
were relevant and how to categorize se-
lected excerpts. The data analyses contin-
2012 AFB, All Rights Reserved
 CEU Article
ued until it became evident that extending
them would produce no new information
(Morse & Field, 1995).
Qualitative findings
The analyses of the transcripts of the fo-
cus groups generated three themes that
served as barriers to accessing low vision
rehabilitation services, namely, barriers
inherent in the person, the clinic, and so-
ciety at large. Excerpts presented in this
section were judged representative of pat-
terns across the group discussions. In the
presentation of the findings, the partici-
pants who did not know about low vision
rehabilitation services were referred to as
G1s; the participants who knew about low
vision rehabilitation services but did not
access services were referred to as G2s;
and those who knew about low vision
rehabilitation services and accessed the
services were referred to as G3s.
THEME 1: BARRIERS INHERENT
IN THE PERSON
The participants indicated that there is a
connection between the subjective se-
verity of vision loss and the readiness to
seek low vision rehabilitation services.
The more impaired, the more likely it
was that they would access these ser-
vices. It is important to note that the
subjective severity of loss and accessing
low vision rehabilitation services had
important moderating cofactors, such as
compensatory responses (for example,
relying on a partnersubtheme A) and
emotional factors (like denial and ac-
ceptancesubtheme B). Theme 1 was
divided into two subthemes that served
as barriers to low vision rehabilitation
services.
2012 AFB, All Rights Reserved
A: Perceived ability to engage
comfortably in activities of daily living
The participants frequently indicated that
they could manage functional limitations
associated with their impairment; they
had no need to seek rehabilitation ser-
vices. A G2 participant commented, I
dont go because I dont feel that I have to
go. . . . I can do everything by myself.
Thus the ability to engage in everyday
valued activities served as a strong inhib-
itor to seeking help. Similarly, compen-
satory changes made in daily life (such as
relying on a partner for certain tasks) ul-
timately served as a barrier to services. I
was comfortable in my comfort zone at
home. I didnt have to go out. This ex-
cerpt was taken from a G3 participant
who relied heavily on her partner in some
social situations at that time.
B: Participatory losses gradual
in nature
Several G3 participants explained that the
gradual nature of vision loss meant that
early in the onset of the condition, they
denied its existence. One participant com-
mented, Being in denial about what you
are going through is the worst thing in the
world. It was only by recognizing the
consequences of low vision (for example,
on everyday activities) that the partici-
pants facilitated a gradual acceptance of
their visual deficits, which enabled them
to search for low vision solutions, includ-
ing rehabilitation. I wanted my indepen-
dence back. I gave up driving. So when
I started thinking about the car . . . and all
the things that I had to give up, I said No,
I dont have to give up, I have to learn
how to do things. Thus, for some par-
ticipants, the realization that participation
Journal of Visual Impairment & Blindness, May 2012 265
 CEU Article
in valued activities (such as driving) had
been compromised prompted their accep-
tance of their low vision and precipitated
their help-seeking behaviors. Many par-
ticipants indicated that they accessed ser-
vices only after they had accepted their
vision loss. The lack of acceptance is thus
a barrier: It takes a while until you get
used to the vision loss and you are not
threatened to [seek out rehabilitation]. Its
a question of readiness.
THEME 2: BARRIERS INHERENT
IN THE CLINIC
The second theme of barriers to low vi-
sion rehabilitation services arose out of
discussions that centered on health care
service settings. This theme was divided
into the following two subthemes.
A: Inefficiencies in educating clientele
about low vision rehabilitation services
One of the most frequently mentioned
barriers to low vision rehabilitation ser-
vices was the lack of awareness of these
services. For many participants, the chal-
lenge of finding health care solutions was
not obvious: People dont even know
where to turn. Where to do their own
homework. Other participants identified
perceived failings in service delivery, So
if the doctors dont have time to [edu-
cate], they have to get somebody. A liai-
son. A common sentiment was the scar-
city of advertising by rehabilitation
institutes. Some participants expected in-
stitutions to distribute information about
low vision rehabilitation services. Pam-
phlets. There are no pamphlets out here to
give us any information. Another partic-
ipant stated, I find that they dont adver-
tise a lot. Maybe its a lack of funding. I
dont know the reasons. A G3 partici-
266 Journal of Visual Impairment & Blindness, May 2012
pant commented, I mean, to be here for
30 years and not know that there is a low
vision clinic here, I was shocked when I
found out. Where is it exactly? I still
dont know. Is it on this floor, and who is
using it?
One issue that polarized the partici-
pants was the appropriate role of the oph-
thalmologist in disseminating information
on low vision rehabilitation services.
Some participants indicated that informa-
tion about rehabilitation should come di-
rectly from the ophthalmologist. I know
a lot of people who ask me [for informa-
tion about low vision rehabilitation ser-
vices], and Im thinking . . . Why cant the
ophthalmologist help that person? An-
other participant stated, I think that they
[ophthalmologists] should at least point
you in [the] right direction. However,
other participants defended the ophthal-
mologists, claiming that they are very
busy: Every one of the doctors [has] 150
patients to look after. Once they diagnose
you, they figure you are going to do your
homework and to figure out what you are
going to do next. Another participant
added, The doctor has the right not to
know everything. Often, the participants
who defended the ophthalmologists spoke
of a personal responsibility to educate
themselves about low vision rehabilita-
tion services: If I can help myself, I
dont expect to get help from somebody
else.
B: Problems and dissatisfaction
associated with ophthalmic
consultations
The participants described numerous bar-
riers related to low vision rehabilitation
services associated with consultations
with healthcare practitioners. Many par-
2012 AFB, All Rights Reserved
 CEU Article
ticipants indicated that the short duration
of professional-patient consultations was
a barrier to low vision rehabilitation ser-
vices: They cant spend a lot of time
with the patient. I try to leave because I
know that there are 10 15 people waiting
for him. So I dont want to waste his time
with my problems. Another participant
described the impacts of being rushed
through her ophthalmic consultations, I
walk in. He says hello how are you?
I am fine. All of a sudden, I am fine! I
had all these questions. How does that
happen? I think [its the result] of seeing
him rushing. Many participants took ex-
ception to the ophthalmologists bedside
manner: He is a great doctor. But he
walks around. He is not God. I would like
a doctor that I could have a little bit of a
rapport with. Several respondents indi-
cated that health professionals lack of
tact and professionalism compromised
the flow of information about low vision
rehabilitation services: So the resident
leaned forward and whispered in my
ear. You have macular degeneration.
Like cancer 20 years ago! You are not
even allowed to say the words. Finally,
there was general agreement among the
participants that the current procedure
of referral lacks structure and coordina-
tion. The following is a particularly
striking example: I saw an optometrist.
He told me, Oh no, I cannot help you.
You have to see a doctor [at a local
hospital]. I saw Dr. John Doe [altered
for reasons of confidentiality]. He re-
ferred me on here to the low vision
clinic [at the same hospital]. They said,
We are not equipped here. A local re-
habilitation [center] might be better for
you. So I did that.
2012 AFB, All Rights Reserved
THEME 3: BARRIERS INHERENT
IN SOCIETY AT LARGE
The third theme represents barriers that
originate in the participants communi-
ties. This theme is divided into the fol-
lowing two subthemes.
A: Fears associated with having
stereotypes applied
A surprising finding was that the partici-
pants repeatedly described being deval-
ued in their communities. Interactions
with their typically sighted peers served
as a barrier. The participants described
the relationships between these two
groups (individuals with low vision and
those with typical vision) as stressful and
misinformed. Many participants spoke
about prejudicial attitudes associated with
low vision: I function like every other
normal person. Its just my eyes. I always
tell people, there is nothing wrong with
my hearing. There is nothing wrong with
[my] brain. If you touch me, you dont get
a disease. The participants also ex-
plained that the functional manifestations
of low vision are often misunderstood
by people who have typical sight: It
takes you longer to read. You kind of
become a little bit slower, which people
dont understand.
For some participants, the decision not
to enter rehabilitation institutes for the
blind arose out of a fear of being ste-
reotyped. One person who had accessed
low vision rehabilitation services said:
Its a psychological barrier. One of the
doctors talked about [an association for
people who are blind] to me. My back
went up right away. I dont want anything
to do with anything that has . . . the letter
B in it. Another participant added,
Journal of Visual Impairment & Blindness, May 2012 267
 CEU Article
You go there, but you are a little reluc-
tant to identify with them. The partici-
pants explained that such experiences
made them resistant to avail themselves
of low vision rehabilitation services. The
products and services were like a double-
edged sword: beneficial to functioning,
but also a discernible symbol of vision
loss: You have a magnifying glass, or
have someone else read it to you. When
you are with a crowd, it is embarrassing.
B: Transportation: The setting where
clashes occur
Modes of transportation were most often
mentioned as the setting in which this
conflict between groups took place. Al-
though taking a bus or cab to low vision
rehabilitation services may be manage-
able on its own, the participants indicated
that this task becomes much more diffi-
cult if it involves interacting with others
who have typical vision. One G3 partici-
pant said: Transportation is the worst
thing. People bump into you on the
metro, and they are in a hurry . . . they
dont care if you can see or not. . . . It
changes your life; it is a struggle every
single day for me.
Discussion
The purpose of this study was to describe
and gain a better understanding of the
barriers to low vision rehabilitation ser-
vices. The themes that emerged from the
focus group analyses revealed barriers to
low vision rehabilitation services that are
inherent in the individual, in interactions
with vision health professionals, and in
interactions with the sighted community.
With regard to the first theme (the in-
dividual), it is noteworthy how compen-
satory behaviors can serve as a barrier to
268 Journal of Visual Impairment & Blindness, May 2012
low vision rehabilitation services. Some
participants structured their environments
to maximize participation in valued activ-
ities, yet in so doing created an environ-
ment in which there was no reason to seek
help. These responses to decrements of
functional vision gave rise to a catch-22
effect, whereby the participants delayed
their first contact with low vision rehabil-
itation services. Also at the level of the
individual, the participants indicated that
the typical slow progression of their con-
dition delayed their acceptance of vision
loss. Until the participants accepted their
visual difficulties (that is, that they were
ready for rehabilitation), they were not
prepared to seek help for them.
The second theme that arose was bar-
riers inherent in medical and rehabilita-
tion environments. The analyses revealed
dissatisfaction with procedures for ac-
cessing information about rehabilitation
services, including the referrals process,
and with the unavailability of any type of
print material on rehabilitation services.
Moreover, they expressed dissatisfaction
with ophthalmic consultations, including
the length of time devoted to each client,
as well as an aversion to the manners of
some doctors. These factors served as
barriers to continued contact with low
vision rehabilitation services.
The third theme that arose from the
analyses was barriers inherent in society
at large. For this theme, the analyses re-
vealed that interactions with typically
sighted individuals in communities are
sometimes affected by stereotypes about
vision loss. Individuals may be reluctant
to reveal their vision loss to others out of
a fear that these persons may be preju-
diced or that they will be discriminated
against. The one setting in which this
2012 AFB, All Rights Reserved
 CEU Article
clash most often played out was the pub-
lic transportation system. It is not unrea-
sonable to assume that the mistreatment
of individuals with vision loss in the tran-
sit system could lead some individuals to
decide not to visit a clinic.
The barriers to low vision rehabilitation
services remain an underresearched
health care topic. In the section that fol-
lows, a representative model is proposed
that places the themes generated in the
present analysis. This model is proposed
as a first step toward plotting a compre-
hensive representation of barriers to low Figure 1. A representative model that depicts
vision rehabilitation services, in the hopes categories of barriers that influence access to
that it will open a dialogue and inspire low vision rehabilitation services.
future research on this important topic.
The proposed model is inspired by the
vidual category represents barriers that
recognized assistive technology selection
are inherent in the individual, including
and outcomes frameworks (Fuhrer, Jutai,
personality, age, gender, financial re-
Scherer, & DeRuyter, 2003; Scherer,
sources, family and social support, per-
Jutai, Fuhrer, Demers, & Deruyter, 2007).
These authors have proposed assistive sonal knowledge about rehabilitation op-
technology frameworks that have re- tions, expectations, and priorities. The
ceived acceptance within the assistive health care setting category represents
technology community. There are other barriers that are inherent in the clinic set-
conceptual frameworks that depict factors ting, including policies and programs that
that influence rehabilitation help seeking focus on low vision rehabilitation ser-
(for example, Gitlin, 1998; Lenker & Pa- vices, attributes of the ophthalmologist
quet, 2004). The proposed model design and other staff members (that is, knowl-
was selected because, in our opinion, it edge of low vision rehabilitation services
best highlights three crucial elements and motivation to pass along informa-
arising from the analyses presented here: tion), characteristics of the consultations
the time elapsed since the onset of the (that is, the time allocated and receptivity
vision loss; the complex interactions to a question-and-answer period), and
among the individual, the health care set- motivation to refer clients to rehabilita-
ting, and society; and the overall dynamic tion. Finally, the society category repre-
nature of help seeking. sents barriers that are inherent in the sur-
At the heart of the proposed represen- rounding community, including the
tative model (see Figure 1) are three cat- characteristics of the social, demographic,
egories of barriers to low vision rehabil- and cultural community; governmental
itation services: within the individual, the policies on accessing specific rehabilita-
health care setting, and society. The indi- tion services or devices; and the attitudes

2012 AFB, All Rights Reserved Journal of Visual Impairment & Blindness, May 2012 269
 CEU Article
of others with respect to adopting and
using these types of services.
Three key assumptions affect the pro-
gression of individuals through the model
toward the prolonged use of low vision
rehabilitation services. First, the catego-
ries of individual, healthcare setting, and
society are presumed to interact with one
another to create a unique set of barriers
for each individual. On the basis of the
current analyses, it seems apparent that
these categories of factors do not exist as
distinct entities. Rather, there are likely to
be complex interactions among these
three areas.
Second, the proposed model is time
dependent. Similar to other assistive tech-
nology outcome models (Gitlin, 1998;
Lenker & Paquet, 2004), it is assumed in
the proposed framework that accessing
and utilizing rehabilitation are deter-
mined, in part, by the amount of time that
has elapsed since the initial exposure to
low vision rehabilitation services. The left
side of the model represents events that
occur prior to the individual first access-
ing services. During this time, the indi-
vidual becomes aware of functional
changes in vision loss, may acquire some
information about the available programs
and services, and would presumably de-
velop some attitudes toward people with
vision loss (that is, stereotypes). Precon-
sultation awareness of rehabilitation ser-
vices is dependent on societal condi-
tions, such as cultural and legislative
considerations and attitudes of key
other people (Scherer et al., 2007). The
middle section of the model depicts first
accessing of services in the health care
setting, initial outcomes, and relative
satisfaction with these services. The
right-hand portion of the model repre-
270 Journal of Visual Impairment & Blindness, May 2012
sents the longer-term use of low vision
rehabilitation services. This design was
selected to acknowledge the differences
in barriers encountered by new versus
more experienced clientele.
Finally, as a complement to the time-
dependent aspect of the model, it is as-
sumed that individual-level characteris-
tics, including functional vision loss, are
in a state of flux. This instability or un-
predictability is attributable to various
factors and may include the onset and
progression of comorbidity, changes in
marital status, financial considerations,
and living arrangements. These moderat-
ing factors all contribute to the inclination
to seek help and personal resources de-
voted to help seeking.
The proposed model sufficiently inte-
grates the findings arising from the anal-
yses presented here. Prior to initial con-
tact with health care professionals, some
people may demonstrate a reluctance to
access low vision rehabilitation because
they are simply not ready. There is seem-
ingly a coming-to-terms barrier associ-
ated with the onset of a new chronic age-
related health condition (Charmaz, 1983;
Pollard et al., 2003; Whitbourne & Sneed,
2002). Some individuals with low vision
may delay help-seeking (Heine & Brown-
ing, 2002) until such time that valued
activities of daily living (such as driving
an automobile or reading to a grandchild)
are put in jeopardy of being terminated.
The awareness of rehabilitation ser-
vices is an important predictor of the use
of these services (Roelands, Van Oost,
Buysse, & Depoorter, 2002). Although it
is an obvious point, it warrants mention; it
is impossible to avail oneself of low vi-
sion rehabilitation services if one is not
aware of these services. Crucial to the
2012 AFB, All Rights Reserved
 CEU Article
short-term phase are interactions with
health care professionals and gathering
information about low vision rehabilita-
tion services. In the present and other
studies, individuals with low vision indi-
cated that the procedures used to dissem-
inate information about low vision reha-
bilitation services could be improved
(Gold et al., 2006; Gresset & Baumgar-
ten, 2002; Pollard et al., 2003). This bar-
rier may be associated with patient-doctor
consultations that are reportedly short in
duration. After medical procedures have
been completed, little time is left for
questions. More troublesome were the
participants complaints that hospital
staff do not demonstrate basic respect
for patients. It is plausible to suggest
that this could also serve as a barrier to
rehabilitation.
A key assumption of Fuhrer et al.s
(2003) framework is that users make and
remake decisions to continue to use reha-
bilitation services. A critical element of
these ongoing evaluations is the relation-
ship between the user and the profes-
sional. In the assistive technology litera-
ture, some studies have highlighted the
importance of this relationship (Kras-
kowsky & Finlayson, 2001; Wessels, Di-
jcks, Soede, Gelderblom, & De Witte,
2003). Health care professionals are ad-
vised to consider carefully how they com-
municate with clients, because these strat-
egies strongly influence the clients
adherence to interventions (Wessels et al.,
2003).
The final category, society, is linked to
barriers that originate in their communi-
ties response to individuals adaptation
and modifications to their lives after they
have received low vision rehabilitation
services. After individuals have accessed
2012 AFB, All Rights Reserved
low vision rehabilitation services, the bar-
riers to taking up and using prescribed
regimens and adaptive technologies and
strategies persist. Many conventional re-
habilitation interventions (such as the use
of a cane) serve to notify the general
public that an individual is in some ways
different and may incite discrimination.
Yet, an increasing body of literature in the
health sciences has suggested that re-
sponses to marginalization that occur in
social settings vary greatly (Shih, 2004).
Critical here is the ease by which adap-
tations and modifications requisite to the
intervention are made in the individuals
environment. In the assistive technology
literature, this is referred to as fit. Fit
refers to the users subjective evaluation
of how easily and naturally the interven-
tion plan is integrated into the users life.
Several authors (Gitlin, 1998; Kras-
kowsky & Finlayson, 2001; McCreadie &
Tinker, 2005) have emphasized the im-
portance of accessing and incorporating
the users perspective when seeking a
good match among the individual, the
proposed intervention, and the environ-
ment. Kraskowsky and Finlayson (2001)
cautioned that a lack of fit has a strong
negative impact on the adoption of a pre-
scribed intervention plan. The character-
istics and preferences of users, including
the type and design of housing and a felt
need for assistance, interact to influence
the acceptability of an intervention (Mc-
Creadie, Wright, & Tinker, 2006). In the
assistive technology literature, the subjec-
tive evaluation of fit appears to be a good
predictor of the use of rehabilitation ser-
vices and arguably warrants a more prom-
inent mention in the design and imple-
mentation of low vision rehabilitation
services.
Journal of Visual Impairment & Blindness, May 2012 271
 CEU Article
Conclusion
A review of the literature indicated that
barriers to low vision rehabilitation ser-
vices are a complex, multifactor phenom-
enon. Help-seeking behaviors vary dra-
matically, particularly for older adults
whose health status is constantly chang-
ing. One may think that symptoms of
illness or disease would be reliable pre-
dictors of accessing health care. Yet, on
the basis of the analyses presented here,
the factors that influence accessing low
vision rehabilitation services extend be-
yond symptomology. The barriers to low
vision rehabilitation services are rooted in
an interaction of personal, clinical, and
societal factors. It is crucial to acknowl-
edge this interaction when investigating
older populations, for whom these factors
are constantly changing. Thus, a more
comprehensive approach to the consider-
ation of barriers to the use of low vision
rehabilitation services is required. The
number of adults who access these ser-
vices remains low. This situation is
troublesome because individuals who
are unaware of services and programs
are unable to benefit from them. The
present analyses highlight the need for
research on suitable and effective forms
of disseminating information on ser-
vices and programs for this population.
Moreover, these findings underscore the
need for research on barriers to the use
of low vision rehabilitation services that
are intrinsic to the ophthalmologic con-
sultation.
In this article, we proposed that it may
be beneficial to examine other theoretical
conceptualizations to aid in the recogni-
tion and consideration of barriers to low
vision rehabilitation services. In so doing,
272 Journal of Visual Impairment & Blindness, May 2012
it becomes apparent that these barriers
likely change over time and likely exist
prior to the first consultation (Ripat &
Strock, 2004; Roelands et al., 2002). Fac-
tors that may serve as barriers in the short
term may be different from those that
confront people in the long term. In fact,
there are likely numerous decisions to
seek services. The need for effective com-
munication between consumers and pro-
viders is emphasized to encourage and
help clients seek low vision rehabilitation
services. Finally, it is vital to seek the
users perspective and attempt to
achieve a good fit between the clients
needs and the services that are adopted.
This is an area of research that warrants
more emphasis.
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