The influence of assistive technologies on experiences of risk among older adults with age-related vision loss (ARVL)

Abstract

Purpose

Living with risk is a salient part of everyday living and although risk affects everyone, older adults are often regarded as a high-risk group, particularly older adults who are aging with a disability, such as vision loss. A prominent focus within low vision rehabilitation is the provision, and training, of older adults in the use of low vision assistive devices as a strategy to manage risks in both the home and community environment. This study aimed to unpack the influence of assistive technologies on experiences of risk among eleven older adults (aged 65+) with age-related vision loss.

Materials and methods

This critical ethnographic study used home tours, the go-along method, and a semi-structured in-depth interview.

Results

The study identified five prevailing themes including: 1) Moving away from the individualization of risk; 2) The cost of assistive technologies as a risk contributor; 3) Practicing ‘responsible living’; Technology as an adaptive strategy to risk taking; 4) Resisting the label of ‘at risk’; The influence of technology on self-identity; and 5) Technology as a substitution versus supplement for social connectedness.

Conclusions

The study findings highlight the importance of moving beyond a technico-scientific perspective of risk, in which risk is framed as an objective phenomenon located in older adults’ bodies, and instead framing risk within a broader sociocultural perspective which moves our attention to those contextual or environmental factors that shape experiences of risk for older adults with vision loss.

IMPLICATIONS FOR REHABILITATION

• Risk taking is an inevitable aspect of everyday living.

• An individualized approach to risk management is problematic.

• The cost of assistive technology is a contributing risk factor.

• Technology use may cause risks to social identity, embarrassment, and stigma.

• Technology use can help mitigate risk among older adults.

Keywords:

• Assistive technology
• risk
• older adults
• age-related vision loss
• critical ethnography

Introduction

Living with risk, which is conceptualized as assessing and preventing future harm [1] is a salient part of everyday living [2,3]. The responsibility for risk management, however, has become largely individualized [4], with the argument going so far as to suggest that risk avoidance is the civic duty of responsible citizens [1]. Although risk affects everyone, regardless of age, older adults are regarded as a high-risk group [2] and this is even more true for older adults aging with disability, such as vision loss. For instance, the risk of falls increases with age among older adults, with the global prevalence of falls being 26.5% among the older adult population [5] and an estimate of 48.3% among older adults with vision impairment (Ehrlich et al. 2019). This finding was further supported by Nyman et al. [6] in their exploratory qualitative study with 44 older adults with low vision, where findings indicated that outdoor falls were linked to environmental features such as poorly maintained sidewalks, and occurred more frequently in the winter and when older adults were crossing the street or stepping up/down from a curb. Laliberte Rudman et al. [7] in their critical interpretive synthesis, found that older adults with low vision are typically positioned as either “at risk” (such as at risk of functional decline, dependence, injury and accidents, social isolation, and emotional distress) or as “a risk” to others (particularly focused on economic and social risks, such as the perceived public health care burden of low vision or the social burden on family, friends, and statutory services for assistance), leading to the idea that older adults with low vision embodied risk is associated with the construction of old age as a time of decline, dependency, loss of productivity, and an increasing need for protection [8,9].

Risk has largely been examined from two theoretical perspectives including the technico-scientific and the socio-cultural [9–11]. Much of the existing literature reinforces a limited technico-scientific understanding of risk, which conceptualizes risk as an objective phenomenon which can be predicted and controlled [10]. Here, decision-making about risk behaviors comprises objective and rational evaluation [10]. Typically, risk is considered as being in a state of potential threatening or hazardous event that may lead to harm or loss [12], thus indicating the importance of risk avoidance [13,14]. In alignment with this perspective, older adults are considered responsible to comply or be judged for failure to respond rationally to risky situations [14,15]. Two of the primary limitations of the technico-scientific perspective includes the overwhelming assumption that older adults are inherently ‘at risk’ and the individualization of risk, thereby placing it in older adults’ bodies [7]. Further, by conceptualizing risk as an objective phenomenon, with less attention paid to sociocultural processes that shape and perpetuate risks [7], older adults fall into a medicalized approach to risk management. In contrast to a technico-scientific approach to risk, various sociocultural theories of risk have been developed such as, Beck’s risk society theory, the cultural-symbolic approach proposed by Mary Douglas, and Foucauldian governmentality [11]. Here, the social and cultural context, within which risk-related decisions occur, are considered [17]. This perspective involves the individual’s subjective perception, judgment, and the meaning of risk as opposed to the actual objective risk that influences behavior [4,7]. Given this, for older adults, risk and risk taking is accepted as a constructive part of life [9,18]. In addition, it promotes self-determination among older adults by emphasizing autonomy and the benefits of positive risk taking [9]. It is this sociocultural approach to risk that served as the theoretical underpinning for this paper.

Set within the broader context of a healthcare system in which risk avoidance is increasingly the goal [19,20], the centering of risk, as it relates to vision loss rehabilitation, has become pervasive, often to the detriment of focusing on meaningful participation and quality of life. Vision loss among older adults is steadily increasing [21]. In Canada, it has been estimated that visual impairment increases substantially with age ranging from 2.7% among adults ranging 45–54 years old to 15.6% among older adults between the age of 75–84 years [22]. Age-related vision loss (ARVL), which includes macular degeneration, diabetic retinopathy, and glaucoma, refers to a permanent loss of vision that interferes “with the performance of common age-appropriate seeing tasks” [23] and cannot be corrected by eyeglasses, contact lenses, medication, or surgical intervention. A prominent focus of low vision rehabilitation is the provision and training of older adults to use low vision assistive devices (LVADs). LVADs refer to “any item, piece of equipment, or product system, whether acquired commercially, modified, or customized, that is used to increase, maintain, or improve the functional visual capabilities of an individual with a disability” [24]. LVADs have the potential to help older adults with ARVL stay in their homes longer [25,26], enhance personal safety [27–29], promote social and community involvement [30], and enhance performance of everyday occupation [27]. Despite the benefits of LVADs to support ARVL, many older adults either never acquire such technologies, or abandon them shortly after purchase [29].

Older adults’ technology adoption and use is influenced by economic, practical, and psychosocial factors including: cost [25–27,31–34], limited knowledge of the types of assistive technology available or how to use them [27,31,35], concerns regarding privacy [26,32], and a perceived ‘poor fit’ with the environment [36]. Usability factors including the efficiency, reliability, simplicity, and safety of the technology [25,27,31,32], ease of use, and appearance [26], are also important factors influencing adoption. While much research has looked at how these factors influence the use of technologies by older adults, there are no known studies that look at how assistive technologies shape experiences of risk among older adults with ARVL.

Study purpose

The broader focus of this study answered the research question: “How are the decision-making processes of older adults with ARVL, as it relates to technology adoption, influenced by the negotiation of identity; that is, how are older adults’ decisions shaped in relation to broader societal discourses regarding the ideal aging identity and a personal desire to convey the self in particular ways (i.e. as independent, competent, and self-reliant)?”. As part of this broader study focus, a prevailing theme regarding the influence of assistive technologies on experiences of risk emerged, which informed the basis for this secondary analysis paper.

Materials and methods

The study adopted a critical ethnographic approach. Critical ethnography questions the prevailing status quo and dominant power structures present within society [37–39]. A modified version of Carspecken’s [40] five-stage approach to critical ethnography was adopted which includes: 1) building a primary record; 2) preliminary reconstructive analysis; 3) dialogical data generation; 4) discovering system relations; and 5) using system relations to explain findings. The study received ethics approval through the Research Ethics Board at Western University.

Participant sample

Participants were enrolled in the study if they: 1) were 65+ years of age; 2) had a self-reported diagnosis of ARVL, identified as macular degeneration, glaucoma, and/or diabetic retinopathy (no formal measure of visual acuity was performed to determine degree of vision loss); 3) were able to communicate in English; and 4) had the cognitive capacity to understand the scope and requirements of the study. The age of 65 years and older was chosen based on age categorization in Canada, as specified by Statistic Canada, in which seniors are considered 65 years and beyond. Following informed consent, eleven participants were enrolled and completed three data collection sessions (see Table 1 for participant demographic characteristics). Sessions were completed at a place and time of the participants’ choosing and all sessions were audio recorded and later transcribed for data analysis.

Table 1. Participant demographic characteristics (n = 11).

	N = 11
Age (years)
65-70	2
71-74	1
75-80	4
81-85	4
Sex
Male	4
Female	7
Current marital/partnership status
Married/common law	5
Living with partner	0
Separated/divorced	1
Widowed	5
Single	0
Current financial situation
Excellent	1
Good	10
Fair	0
Poor	0
Highest level of formal education completed
Less than grade/elementary school completed	0
Grade school completed	0
Some high school	1
High school completed	2
Some college/university	2
College/university completed	6
Living situation
Your own house or condominium	7
A rental home/apartment condominium	3
Apartment/condo in retirement/adult lifestyle community	1
An apartment/room/flat/house owned by a family member	0
Boarding with a friend in a house or apartment	0
Other	0
Name of vision loss condition
Age-related Macular degeneration (ARMD)	8
Glaucoma	3
Diabetic retinopathy	0
Cataracts (in addition to either ARMD or glaucoma)	3
Unknown	0
Other	0
Age-related vision loss onset
Gradual	7
Sudden	4
Time since your vision loss condition was diagnosed.
0-2 years	0
3-5 years	2
6-10 years	4
More than 10 years	5
Average age when vision loss began to affect function	70.2
Currently using any low vision assistive device (LVAD)
Yes	9
No	2

Methods of data collection

The first data collection session consisted of a home technology tour [41], in which participants took the researchers on a video-recorded tour of the home to discuss those technologies that supported their vision loss. Hand-drawn room sketches of where technology was placed within the home were used to create digital renderings (see Figure 1 for an example of a digital rendering created using www.floorplanner.com). The second data collection session was a go-along interview [42]), which is a method that combines observation and interview, during which participants acted as the navigational guide of their local community. The purpose of the go-along interview was to understand how participants made decisions regarding technology use in their community environment. The third, and final, session consisted of a semi-structured interview, which was focused on decision-making regarding technology use in the context of both their home and community settings. This session also gave participants the opportunity to expand, clarify, or retract any information shared during previous sessions (see Table 2 for more information on the data collection process).

Figure 1. Home Tour Map for P2.

This image shows the placement of assistive technologies throughout the home of P2 including in their bedroom, living room, laundry room, and kitchen.

Table 2. Description of the three-step data collection process.

Home tour	Go-along method	Semi-structured interview
First in-person data collection session. Video-recorded. Focused on learning how older adults with ARVL make decisions to use technology within the private sphere of the home. Home tour revolved around six key questions including: 1) What technology is present in each room? 2) Where is the technology placed? 3) Who uses the technology? 4) How often is the technology used? 5) What activities does the technology support? 6) How was the technology learned to be used? A comprehensive map of each room, detailing the placement of the technologies discussed, was created using www.floorplanner.com	Second in-person data collection session. Audio-recorded. Focused on which technologies are used in public spaces, how older adults decide to use the technology, which occupations are supported by technology use, and what challenges are encountered in the absence of technology use. Questions asked were open-ended and were crafted ad-hoc. Field notes detailing any observations made by the researcher during the go-along were written.	Third in-person data collection session. Audio-recorded. Focused on allowing participants to reflect on if, and how, their sense of who they are and how they want to be seen by others impacts their decision-making regarding the use of technologies in private (i.e. home) versus public (i.e. community) spheres. Followed a dialogical interview format, whereby open-ended questions were used to lightly structure the interview, but the researcher also followed the lead of the participant.

The home technology tours were video-recorded while the go-along’s and the semi-structured interview were audio recorded and transcribed verbatim. Whether textual or video files, a consistent approach to data analysis was adopted for this study. The analysis process began by reading each transcript or watching each video file individually to develop a rich understanding of the data before drawing comparisons between data sets. Two research assistants individually began with low level, or line-by-line, coding which consisted of underlining, circling, and highlighting important key words and quotes from each individual transcript. Two research assistants (i.e. YG and BC) independently coded each transcript to confirm, challenge, or add keywords. Following low level coding, our research team proceeded to high level, or theoretical coding, whereby we framed our high-level codes around a socio-cultural approach to risk, which is congruent with data analysis approaches used in ethnographic studies. After low- and high-level coding was completed, codes were compared within and across data sets to form categories and themes that emerged from across the participant data. Resulting categories and themes were refined through ongoing team meetings.

Results

The study findings were organized into five prevailing themes including: 1) Moving away from the individualization of risk; 2) The cost of assistive technologies as a risk contributor; 3) Practicing ‘responsible living’: Technology as an adaptive strategy to risk taking; 4) Resisting the label of ‘at risk’: The influence of technology on self-identity; and 5) Technology as a substitution versus supplement for social connectedness. To protect participant anonymity, the names of all people, places, and organizations have been omitted and participant numbers have been used in replace of names.

Moving away from the individualization of risk

In contrast to the technico-scientific approach to risk, which situates risk within the responsibility of older adults to manage, participants in this critical ethnographic study described enlisting various assistive technologies to manage environmental risks within both the home and community.

Within the home environment, participants acknowledged the presence of environmental risks, particularly related to their use of kitchen appliances. Participants ultimately relied on adaptive technologies, such as raised bumps placed on the stove to identify the temperatures as a guide for avoiding burning food, or more dangerously starting a fire. Another strategy to mitigate physical risks in the home environment included having fall detection pendants to call for assistance if participants experienced a fall in the home. For example, P1 stated: “It’s the connection that I have to the hospital. It’s a phone and I wear a button around my neck and all I do is press it and someone will come on the phone from the hospital and ask me what’s wrong.” In addition to assistive technologies, many participants described using compensatory strategies rather than, or in addition to, technology to mitigate physical risks within the home. For example, participants relied on strategies such as wayfinding, use of memory, spatial awareness, and reducing clutter to be able to locate items and avoid bumping into objects. The organization and layout of furniture and objects were described to be important for safe navigation during both the day and nighttime. For example, P9 discussed the challenges of clutter and acknowledged the importance of spatial awareness as her vision loss progressed, such as remembering the number of steps to a certain area of the house or keeping belongings in the same spot in the house. With respect to keeping items in a consistent location, P9 stated: “I put things sort of where I know where they are…I could live in clutter, years ago I could live in clutter, right now I don’t want to live in clutter.”

A more prominent theme was the use of technologies to support community participation. Participants were more inclined to use assistive devices to manage physical risks than rely on compensatory strategies. In particular, the use of a white cane was described by several participants as a tool to help navigate poorly marked curbs, elevations and/or uneven surfaces, and to avoid feelings of embarrassment associated with running into others. For example, P3 discussed her reliance on the white cane to safely navigate the community, stating: “I still don’t like it, but I guess I’m more comfortable with it if I’m out –I know if I’m going shopping or going out where there’s a lot of people I need the cane because I would run into them, and this way they can see that I don’t see them so they get out of my way I think.” Some participants that used the white cane in the community described its importance in managing risks in public spaces, like parking lots, which they perceived to be ‘too risky’ to navigate without the device. The white cane was described to be particularly important at crosswalks, as motorists often recognized the meaning of the white cane and gave the user more allowances for time. For example, P6 stated: “And, the pedestrians and drivers especially, they recognize the white cane. And so, they kind of adjust. Yeah, so that helps. That’s why I have it. Even when I walk here, I know that the traffic can be a little busy. Sometimes especially after work. So, people will see that I have it.”

Despite the benefits of assistive technology use in community spaces, participants also discussed the limitations. For example, participants described how technology use did not eliminate all experiences of physical risk and that ongoing difficulties with navigating steps in community spaces, risk of hitting others with the white cane, or running into other objects remained. Participants also identified that the use of technologies, at times, created new experiences of physical risk, that were not previously present. For example, P8 discussed that the white cane inhibited his arm movements, causing him to feel unbalanced: “It sort of inhibits your arm movement when you’re trying to use the cane. But I guess I’ll have to get using it more…I like to be able to move my arms freely…If you went to two sticks, like, your arms would be equally balanced that way.”

Overall, although participants expressed limitations of assistive technology and the development of new risks, particularly in public spaces, most participants expressed technology to be helpful and thus relied on the use of technology to manage physical environmental risks.

The cost of assistive technologies as a risk contributor

Many factors weighed into participants’ decision-making regarding technology adoption, including the financial risk of covering out-of-pocket expenses. For some participants, financial security and/or good insurance benefits mitigated these risks, such as for P11 who stated: “If something was a few thousand, I could afford that. I wouldn’t necessarily want to, but I would.” For others, however, financial risks weighed more heavily in the decision-making process and various supports were sought to cover the costs of technologies perceived as necessary, including seeking assistance from family members, obtaining funding thorough government or charitable sources, or use of free trials. For example, P7 described options for obtaining technology, if she could not afford to purchase them independently: “I would probably look to see if you could get it somewhere, can you get it, can you borrow it sort of somewhere or can you, you know, is there some kind of a charity.”

Participants appeared to engage in a type of balancing act whereby the cost of technology was balanced against the perceived independence it would provide, with participants often weighing their independence more highly than possible financial risks associated with purchasing technologies. Participants expressed that although independence was more highly valued than the financial risks associated with costs of devices, there were still limits to what participants could afford. These limitations were particularly prevalent in the context of one particular device: the e-Sight glasses. This technology was of interest to several participants; however, others described the cost of the glasses as unobtainable or the benefits of investing in the glasses not outweighing their cost. For example, P2 described e-Sight glasses to be a device exclusively for “people with money.”

Concerns with the cost of low vision assistive devices were further complicated by the progressive nature of ARVL, with many participants commenting on the financial risk being more apparent for older adults with ARVL, due to the rate at which they outgrow their assistive technologies. As a result, participants often made anticipatory decisions about whether to purchase technologies based on their visual acuity and assumed future functional needs. For example, P8 described no longer being able to use his CCTV to its full capabilities given the progression of his vision loss: “I can’t see a whole lot with the CCTV anymore, but I can see a little bit if I need to. And I can sort of read the headlines of the paper and that.” Given that this participant had progressive vision loss, it is likely that the specific type of CCTV being used did not fit their current visual-functional state. That said, there are many CCTV options for different visual-functional capabilities, but this participant experienced financial risk because the CCTV being used did not align with their current visual capabilities anymore.

Practicing ‘responsible living’: Technology as an adaptive strategy to risk taking

Several participants discussed how their use of assistive technology acted as an adaptive strategy for engaging in desired occupations in a way that mitigated personal risk and enabled them to participate ‘responsibly’ in their daily activities.

For some participants, technology was used to adapt how a previously enjoyed occupation was performed. For example, P1 used to be an avid bird watcher but no longer felt safe travelling into his community to engage in bird watching, due to his vision loss. Although not his preferred way to engage in this occupation, he now used his computer to look at pictures of birds: “One of the hobbies I had, before all this happened, of course – I’ve been a birder. And I love looking at pictures from birds around the world…I have them set up so that when it comes on my screen first, and it stays there. And then I’ll swap it for another picture” (P1). Similarly, P10 began using audiobooks to re-engage in the occupation of reading, which they had previously abandoned due to vision loss: “One thing that I have, because of my vision, is the [audio book] player. I can’t read books anymore, at least it’s very, very difficult. So, I listen.” For other participants, however, even with the use of assistive technology, they were no longer able to engage in their desired occupations, such as P5 who previously enjoyed crocheting: “So, like I used to be able to still crochet and never could knit again when the second eye went bad, but I could use a 3-diopter magnification and that is – it’s useless to me at this point.”

Participants often described the adoption of certain assistive technologies to mitigate their risk of physical injury. In fact, some participants were so reliant on certain devices, such as the white cane for P3, that they doubted their ability to travel into the community without it, for fear of getting hurt: “I don’t know whether I could go out walking without that cane” (P3). However, even with the use of adaptive devices, some occupations were perceived by participants as too risky. For example, P4, even with the help of magnifiers, no longer felt comfortable doing detailed wood carvings out of fear he would injure himself.

Participants frequently weighed potential risks associated with participating in occupation against the perceived benefits. In this context, occupation is defined as those “day-to-day activities that enable people to sustain themselves, to contribute to the life of their family, and to participate in the broader society” (Crepeau et al. 2009, p. 28) and are typically classified as self-care, productivity, and leisure (Crepeau et al. 2009). Participants managed these potential risks through adapting the way they participated in the occupation with the use of technologies or finding new ways to engage in these occupations. In addition to devices, several participants described using adaptive strategies such as asking others for help, being more cautious, relying on memory for wayfinding, or completing tasks at a slower pace. For example, P9 preferred to rely on what she referred to as “mental and spatial adaptations” which included using memorization and keeping things in the same spot in her house, as opposed to relying on assistive technology.

Resisting the label of ‘at risk’: The influence of technology on self-identity

Participants discussed juggling many factors related to their self-identity, when considering their use of assistive technologies. Participants frequently discussed making considerations related to how their use of assistive technologies may be perceived by others, however, those decisions on whether to use technology seemed to vary based on the context. Risks to social identity, embarrassment, and stigma were factors that appeared to weigh more heavily into decisions about whether to use assistive technologies in public spaces rather than at home. For example, refusing to be viewed as in need of help dictated P7’s initial refusal to use technology in community settings: “It’s being seen as needing something, needing help or, you know…when they told me I needed to use a white cane, no I’m not using a cane. Because you don’t want to be seen as, you know, needing help, or at least I don’t.” In particular, the use of the white cane in public spaces was discussed by participants as a symbol of vision loss and disability: “See, I don’t like the cane because it signifies you don’t see, and I hate going out with that cane…It signifies you’re different” (P3). P5 described a similar discomfort in using the white cane in the community due to fear of increased attention from strangers: “I hesitated about using the cane. I did use it sometimes, but not as often as I should have…Well I thought that it really did draw attention to me and maybe I don’t like drawing attention to me, I don’t know.” For a select few, technology use in public spaces posed little or no risk to their social identity. For example, P4 described no concern regarding how others perceived their use of technology to support vision loss: “I mean I’m not afraid of looking stupid by using a device out in public…If that will help me…that’s the way it is” (P4).

The appearance of technology appeared to be a factor that weighed heavily into whether a participant was willing to use an assistive device in public spaces, given the associated risks to self-identity. For example, as P4 stated: “Why would I buy ugly things?” Other participants made similar comments describing wanting technology to be reasonably aesthetic or presentable, not wanting to be presented as “geeky” or “grotesque”. However, if a less aesthetic device was their only option, participants would reluctantly accept the technology, particularly if the risk of physical injury or threat to personal safety outweighed the risks the technology use had on their self-identity. Participants discussed considering the danger of not using their devices. Ultimately, if participants had the decision of going into public spaces using their assistive technologies (e.g. magnifiers, spectacles and/or white cane), even those that may be less aesthetically appealing, or staying home, most participants chose their independence: “So, it was a matter of going out in public with a cane or not going out in public, I would go with a cane. I’m not going to stay home. I’ll use whatever is necessary” (P7).

Technology as a substitution versus supplement for social connectedness

Participants relied on both their assistive technologies and social supports for managing risk. When seeking assistance, particularly in public settings, participants had varying views of whether they preferred to rely solely on their assistive technologies, ask their social supports for help, or rely on a combination of technology and social support. These decision-making processes differed based on the context and type of social support available.

Within community settings, the use of assistive technology often invited unwanted attention from strangers. While this was viewed negatively by most participants, others, such as P10, were not bothered by the attention: “The only thing I ever use in public is a magnifying glass…people look at you, you know, but that doesn’t bother me.” Having to rely on others for assistance was a common challenge expressed by participants, however, they were more inclined to rely on their informal social networks, particularly family members and friends, as opposed to using assistive technology in public spaces. For example, P4, described relying on his wife for support and managing risks in the community with tasks such as financial transactions and travel planning: “If I lost my wife for one reason or another, if she decided to throw me out or whatever, I’d be screwed”. When family or friends were not available, participants often needed to rely on strangers. Although there was a general reluctance to seek help from strangers when using assistive devices, out of fear of victimization or due to a desire to be perceived as independent, some participants, such as P9, were comfortable asking strangers for help compared to using technology to mitigate risks in public spaces: “I’m very upfront now and, saying, like, when I had to phone for that address. I said, ‘I’ve got a vision problem. I’m struggling to read numbers.’"

Although most participants viewed technology as a way of mitigating risks to social isolation and loneliness, for others, their devices had the opposite effect and created new experiences of social risk. For example, P6 discussed the white cane as hindering socialization with others as it acted as a barrier to people engaging in conversation: “I used a cane in public and I find a cane is a hindrance to communication. People don’t want to converse except to be occasionally helpful”.

Within the home environment, the spouses of participants often provided a great deal of assistance supporting communication needs, such as telephone or computer use, thereby helping to mitigate the risk of social isolation and loneliness. Assistive technologies such as phones, Google Hangout, social media, and Facetime helped participants maintain meaningful connection with members of their social networks, including friends and family who lived a distance away: “She’s [sister] in Arizona and we sit and have coffee every morning” (P2). P9 described using her computer to stay connected with friends, which was particularly necessary as she lived alone: “When you live alone…this is my communication…I’ve always, being a writer, I guess, I’ve always kept in touch with people more at a distance. I still do and, I still do with my computer. You know, it’s keeping in touch with people” (P9).

Discussion

This study took a critical ethnographic approach to understand the influence of assistive technologies on experiences of risk among older adults with age-related vision loss (ARVL). Results were organized into five prevailing themes including: 1) Moving away from the individualization of risk; 2) The cost of assistive technologies as a risk contributor; 3) Practicing ‘responsible living’; Technology as an adaptive strategy to risk taking; 4) Resisting the label of ‘at risk’; The influence of technology on self-identity; and 5) Technology as a substitution versus supplement for social connectedness.

Across the themes, decision-making processes, related to whether participants chose to use their technologies, were heavily tied to weighing the benefits of use with the associated risks. The benefits of technology use were often framed around increased independence [43], safety [43–44], and enhanced ability to engage in desired occupations [30]. For participants where re-engagement in meaningful occupations was not possible, due to the nature and progression of their vision loss, assistive technologies were used for adapting occupations to enhance participation [45–47]. Risks associated with using certain devices, however, were still present and often were tied to issues of cost [30,48,49], fear of embarrassment [50–51], and/or aesthetically unappealing technologies [50,52]. Such findings are reinforced in the existing literature on low vision. For example, Fraser et al. [53] discusses how the perceived and lived stigma of older adults with vision loss are common barriers to functioning and participation. Ultimately, in this study participants weighed factors such as independence, personal safety, and enhanced ability to engage in desired occupations more heavily than the financial risks associated with purchasing technologies or the fear of embarrassment or social ridicule. Moving forward, low vision rehabilitation clinicians would benefit from communicating possible risks, in addition to the benefits, of assistive technologies to allow for more informed decision-making and an enhanced sense of autonomy.

Another prevailing idea that came up across the study themes was the idea that decisions regarding technology use to manage risks were highly dependent on context; a finding that has been reinforced by Peek et al. [54] who argued that older adults’ perceptions of technology and decisions related to technology use for risk management appeared to be embedded, and shaped, by the older adults’ context. For example, participants were comfortable using assistive technologies to manage risks within their home environment, perhaps due to familiarity with the organization of the home and an absence of risk to social identity. However, within public settings, participants were often hesitant to use certain technologies, particularly those that identified them as blind or partially sighted, such as the white cane [50,51,55]. Research conducted by Hersh [51], indicated that individuals with late onset vision loss lacked self-confidence with regards to using the white cane. This was due to the notion that cane use was a symbol of blindness [51]; a feeling that was largely influenced by fear of public perception, social embarrassment, and stigma. These study findings move the research needle forward by taking into consideration a more holistic approach to contextual factors including physical, cultural, financial, and social that shape experiences of risk [56–59]. Moving forward, however, there needs to be a greater focus, in both research and practice, to push our thinking beyond a narrowed technico-scientific approach to risk and instead move our attention to those contextual or environmental factors that shape experiences of risk for older adults with ARVL.

Technology alone was often seen as inadequate to mitigate experiences of risk for older adults with ARVL. In fact, across the findings, older adults often described using compensatory strategies in addition, but also sometimes instead of, assistive technologies. For example, participants relied on strategies such as wayfinding, use of memory, spatial awareness, and reducing clutter to be able to locate items and avoid bumping into objects [60–62]. Participants also described relying on family and friends, and even strangers at times, rather than relying on technologies to support community engagement [63–66]. Such findings are supported in the existing literature, such as by Worth [66] who found that some individuals with a vision impairment disguise their vision loss to avoid appearing disabled and instead engage with strategies to ‘pass’ as sighted [66]. This is because of the notion that making their vision impairment visible can be a double-edged sword. For instance, making their vision impairment visible may lead to more support from strangers, which marks them as disabled and exposes them to discrimination [66]. This finding will help to support future clinical practice by teaching clinicians that there is not a one-size-fits-all approach, but rather experiences of risk are nuanced, as are the strategies, including technology, used by older adults with ARVL to manage risk.

Although it may often be assumed that technology reduces experiences of risk, the study findings demonstrated that technology can, at times, lead to further experiences of risk. For example, by using the white cane, which is an obvious identifier of vision loss, participants described experiences of hindered socialization with others when the cane acted as a barrier to conversation. Participants also described the risk of physical injury they experienced when using the white cane due to inhibited arm use. For others, the exorbitant cost of assistive technologies that some participants felt were necessary to support their occupational participation, resulted in greater financial risk for those who were already in precarious financial situations. Such a novel finding points to the importance of future research, and practice, unpacking how technologies can both mitigate risk but also shape further, or new, experiences of risk.

The study findings should be understood within the limitations of this study. First, the study participants varied in terms of their degree of vision loss, years since diagnosis, and current use of technologies to support occupational participation. Although participant homogeneity would never be sought in a critical ethnographic study, the findings are shaped by this demographic variability and, as such, may not provide as clear a picture of how technologies shape experiences of risk. Future research would benefit from taking such demographic factors and mapping those to decision making. For example, future research could map ARVL diagnosis to both the type of assistive technology used and experiences faced. A second study limitation is that the findings are from a secondary analysis of the broader study data. As such, the information collected may not be as rich than if risk had been the primary focus of the study. Certainly, future research would benefit from an exclusive focus on technology adoption as shaped by experiences of risk. A final study limitation relates to the recruitment methods for this study which saw most participants being recruited from one low vision service provider in London, Ontario, Canada. Future research would benefit from recruiting participants who are not otherwise receiving low vision rehabilitation services, as their experiences of risk may be quite different as compared to older adults who receive such formal supports. For example, the experience of a person with congenital vision loss (i.e. blind from birth) may be different from those who acquire a vision impairment later in life [67]. Further, the difference in usability of assistive technology between older adults that are well trained in AT use by a vision rehabilitation service provider and those not well trained may further influence their perceptions of risk and so future research should take these differences into consideration when recruiting participants to future studies.

Conclusion

In the process of understanding how assistive technologies influence experiences of risk for older adults with ARVL, the findings of this study highlighted how these assistive technologies have the power to not only mitigate various types of risk, but also create new experiences of risk. Participants described their use of assistive technologies to manage physical environmental risks, and although some noted limitations to these technologies, the majority favoured their use. Furthermore, participants also highlighted financial risks associated with the cost of purchasing their assistive technologies, having to weigh the benefits and financial costs in their decision-making processes. Assistive technologies were described as adaptive strategies by many participants for mitigating the risk of not engaging safely or responsibly in their desired occupations. Participants also discussed considering how their use of assistive technologies, particularly in public spaces may influence others’ perceptions of them as ‘the other’. Finally, these technologies were noted to mitigate risk to social isolation and loneliness, while at other times created new experiences of social risk. Recognizing these views of how low vision assistive devices can mitigate experiences of risk while also creating new experiences of risk is important in supporting older adults with ARVL in their daily use of these technologies in their home environment and public spaces.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the Social Sciences and Humanities Research Council of Canada

Notes on contributors

Colleen McGrath

Dr. Colleen McGrath is an Associate Professor in the School of Occupational Therapy at Western University. Her program of research is focused on the occupational needs of older adults experiencing age-related vision loss, including macular degeneration, glaucoma, and diabetic retinopathy.

Yvonne Galos

Yvonne Galos is a registered occupational therapist in British Columbia. She completed her Bachelor of Health Sciences and Masters of Science in Occupational Therapy at Western University. Her research and practice interests include stroke and neurorehabilitation, assistive technology use in older adults, and implementation of digital health initiatives.

Emmanuel Bassey

Emmanuel Bassey (MD) is a PhD candidate in Health and Rehabilitation Science at Western University. His program of research is focused on the social participation needs of adults living with a vision disability, particularly adults experiencing vision loss later in life.

Bernice Chung

Bernice Chung is a Master’s student in the School of Occupational Therapy at Western University. She completed her Bachelor of Health Sciences at Western University. Her research interests include quality of life and aging, assistive technology, and community mobility.