An Enhanced Video for Adults With Low Vision: Impact on Knowledge, Attitudes and the Use of Assistive Devices Beth Dugan, Ph.D. The Institute for Studies on Aging New England Research Institutes 9 Galen Street Watertown, MA USA (617) ext 210

Acknowledgement Research supported by the National Eye Institute (EY012443).

Project Team Sharon Tennstedt, PhD, Investigator Eli Peli, OD, Co-Investigator Robert Goldstein, PhD, Co-Investigator Felicia Trachtenberg, PhD, Biostatistician Steve Braun, BA, Producer Nancy Gee, BA, Data Manager Kristina Richards, BA, Field Supervisor

Outline Low Vision Patient education Content of the video Evaluation study Implications

Low Vision Definition A visual impairment, not correctable by standard glasses, contact lenses, medicine, or surgery, that interferes with a person's ability to perform everyday activities. Age-related macular degeneration (AMD) accounts for approximately one-half of all cases of low vision. There are two types of AMD, wet and dry type accounting for 10% and 90% of cases respectively.

Low Vision In the US approximately 3-5 million adults have low vision. Annual total costs exceed $22 billion on care and services for people who are blind or have visual impairments. (National Alliance for Eye and Vision Research, 1995.)

Living With Central Vision Loss NormalW/ Low Vision

Why Patient Education? During the often rushed clinical encounter when a person first gets the diagnosis – they may be so overwhelmed that they only hear “legally blind” or “no known cure”… ….which may lead the person to stop visiting an eye care professional altogether.

Why Patient Education? believe it is a natural part of aging not aware of treatment options or how to access help believe services are only for the blind, not those with central vision loss cost

?? A video for the visually impaired ??

Low vision is a loss of central vision, not total blindness. Most Americans have access to a television and many have access to a VCR. The video is informative for family members as well. Peli and colleagues have pioneered the use of computerized image enhancement to improve the visibility of the video images for low vision patients.

This figure shows the difference between the enhanced (on the right) and original unenhanced version (on the left). The actual video only presented the enhanced images.

The anatomy and basic pathology of AMD were illustrated – and showed the location and nature of changes that occur with macular degeneration.

The virtual home animation included environmental adaptations and use of visual aids. Changes were depicted for the kitchen, bathroom, bedroom, and living room.

Hope in Sight Video Winner, 24 th Annual Telly Award; 2003 Finalist, International Health & Medical Media Awards, Health Education; (Freddie Award)

Research Questions 1.Will the video intervention increase patient knowledge and improve attitudes? 2.Will the video intervention have a positive impact on adaptive behavior?

Evaluation Plan Proximal Outcomes: Knowledge (eye anatomy and physiology; types of rehab devices; resources). Self-efficacy, emotional responses. Willingness to use low vision aids. Distal Outcomes Behavior change (use assistive devices; environmental changes; rehab svc).

Eligibility:  Speak and understand English.  Be diagnosed with low vision in both eyes.  Not limited by hearing impairment (able to hear a video).  Access to a VCR and telephone.

Sample description (N=151) Gender Male Female % 64% Race White All others % 3% Years ARMD diagnosed (median) (sd) Live Alone 2 person household 3 or more person household % 78% 3%

Subject Pool Informed consent and enrollment T 0 Interview (N=156) T 1 Interview at 2 weeks (n=75) T 1 Interview at 2 weeks (n=79) T 2 Interview at 3 mo. (n=74)T 2 Interview at 3 months (n=77) Randomization Watch the Video Intervention GroupControl Group Video

Measurement A.Demographics. B.Knowledge (eye anatomy, physiology, pathology of macular degeneration). C.Assistive devices (knowledge of, access to, attitude toward). D.Adaptive changes (home, lifestyle) E.Self-efficacy F.Social aspects of low vision G.Emotions re: low vision

Hypotheses Compared to the control group, the intervention group will show greater improvement in: Knowledge Attitudes (emotions; self-efficacy) Behavioral changes (use of assistive devices, adaptive changes in the home).

Statistical Analyses Analysis of covariance (ANCOVA) was used to determine differences by treatment group.

Covariates We controlled for baseline values and covariates:  age  gender  marital status  education  length of vision impairment  # people in household  employment  health

Results Descriptive statistics showed that the intervention and control group were equivalent with respect to all key baseline characteristics.

Knowledge The intervention group improved more in knowledge than the control group; p <.001, Adj R 2 = 0.39 Magnitude of Change? Control group 0.4 pts vs Video group 1.4 pts. (approx one question difference)

Knowledge People who lived alone learned more (~never married, older age); those who had worse health learned less);

Attitudes The intervention group improved more than the control group in their willingness to use assistive devices Books-on-tape (those who lived alone were especially willing to use books on tape); p<.001, Adj R 2 = 0.53; Talking appliances (no significant covariates) p<.001, Adj R 2 = 0.38;

Emotions The intervention group had a decline in reported fear and sadness than the control group. Less afraid (people in better health became less afraid, people in poor health showed no improvement in fear) p<.001, Adj R 2 = 0.34; Less sad (age and gender trends) p<.001, Adj R 2 = 0.28;

Self-efficacy No difference between groups.

Behavior No difference between groups in adaptive changes in the home, or actual use of assistive devices.

Conclusions The video had an impact on our proximal but not the distal outcome measures.

Conclusions The video was effective in: improving knowledge Improving a few attitudes (willingness to use books on tape, and talking appliances) Improving the emotional aspects of low vision (reducing fear, reducing sadness).

Conclusions The video was not effective in: Improving self-efficacy Changing the actual use of assistive devices or rehabilitation services.

Limitations 1.Relied on self-report data. 2.Three-month timeframe. It may take as long as 3 months to make an appointment with a low vision specialist and even longer to obtain devices. 3.The recruitment strategy and inclusion criteria limited the diversity of the sample, which limits the generalizability of the results.

Future Research 1.Will the distal outcomes (e.g., increase the use of assistive devices; increase the use of rehabilitation services) change if allowed more time? 2.If not, what intervention is needed to increase the use of assistive devices and rehabilitative services?