Mobility Tool Use Relates to Disability Affirmation among Adults with Visual Impairments

Disability characteristics and disability identity

Few studies have examined impairment-related characteristics as potential predictors of disability identity. In a correlational study using a sample of 710 adults with various disabilities, Bogart et al. (2017) found that stigma and severity were predictors of disability identification and that stigma partially mediated the relationship between severity and identification as disabled. Bogart and colleagues did not find significant associations between identification and the following disability characteristics: pain, noticeability (i.e., visibility), and number of impairments. Bogart and colleagues measured disability identification as a single item (“I identify as a person with a disability”) with a five-point, Likert-type response. Previous studies reported similar findings regarding the association between severity and disability identity or identification (Bogart, 2014; Rhodes et al., 2008). Bogart and colleagues operationalized severity as a Likert-style response to the statement “my disability significantly affects my daily life.” Bogart (2014), who measured disability identity using Hahn and Belt’s (2004) PDI instrument, operationalized severity as congenital versus acquired onset. In their qualitative study, Rhodes and colleagues (2008) found that disability severity was associated with identification as disabled. Rhodes and colleagues conceptualized severity as stability, permanence, and visibility of disability.

Studies have also found that mobility difficulties, including limited mobility due to visual impairment, can constrain opportunities for social interaction, with resultant feelings of exclusion or isolation (Lane, McNicholas, & Collis, 1998; McAlpine & Moore, 1995). The National Federation of the Blind, a leading American blindness organization, described the white cane as giving blind people “the ability to achieve a full and independent life, allowing us to travel freely and safely” (National Federation of the Blind, n.d.). However, qualitative research has found that not all people with visual impairments who would benefit from the use of a white cane or dog guide reported using a mobility tool or receiving orientation and mobility (O&M) training. Perception of stigma, embarrassment, or self-consciousness, and concerns related to identification as being disabled have emerged in research as causes of mobility tool non-acceptance (Hayeems et al., 2005; Hogan, 2012). Additionally, Thume and Murphree (1961) found that hope for eventual restoration of sight was associated with resistance to mobility tool use. Wainapel (1989) found that fear of stigmatization was among the key explanations for the delay between the onset of severe visual impairment and the initiation of O&M training; and Seybold (2005) found that fear, anxiety, and stress were the main causes of resistance to O&M training. More recently, in a correlational study using Hahn and Belt’s (2004) PDI subscales in a sample of 206 adults with retinitis pigmentosa, Zapata (2018) found that use of mobility tool positively predicted both disability affirmation (vs. shame) and disability acceptance (vs. denial) in a sample of adults with retinitis pigmentosa. Mobility tool use was intended as a proxy for visibility of disability. Zapata postulated that results indicated an association between “coming out” as having a disability, through the use of a mobility tool, and coming to accept and affirm one’s disability status. However, the interpretability of this finding was limited by the absence of any severity indicators. Such variables as congenital onset, stability of vision, and extent of functional vision may provide insight into the association between mobility tool use and disability identity through their potential relationship with mobility tool use.

The present study

In the present study, the author conducted three multiple linear regressions to explore the potential value of impairment-related factors (i.e., mobility tool use, secondary disability, visibility of disability, stability of disability, congenital vs. acquired onset, family member with same condition, visual status) in predicting participant-reported disability identity, including PDI and GDI (Hahn & Belt, 2004). Based on findings from previous studies on the association between disability severity and disability identification (Bogart 2014; Bogart, Rottenstein, Lund, & Bouchard, 2017; Rhodes, Small, Ismail, & Wright, 2008), the author hypothesized that use of mobility tool, visibility of disability, stability of disability, and congenital onset of visual impairment would be significant predictors of both PDI (disability affirmation and disability acceptance) and GDI. Finally, the author hypothesized that being blind versus having low vision, as a visual impairment-specific indicator of severity, would have a positive association with both PDI and GDI. The remaining impairment-related independent variables were included for exploratory purposes based on available data (i.e., secondary disability, presence of family member with same visual impairment).

Method

All analyses were conducted using secondary, cross-sectional data that were collected by the author—for a separate investigation—via online questionnaire in the spring of 2019. Participants were recruited worldwide through private Facebook groups related to visual impairment and through mailing lists of the National Federation of the Blind. Search terms used to select Facebook groups included “blind,” “blindness,” and “visual impairment,” as well as medical terms for leading causes of vision loss. Participants were invited to complete an online questionnaire related to “attitudes towards blindness” that included questions regarding disability identity as well as demographic and impairment factors. Prior to consenting to participate, participants were informed about study rationale, the voluntary nature of the study, potential risks or discomforts of participation, and anticipated benefits of participation. The author, who has retinitis pigmentosa and related visual impairment, disclosed disability status in the study invitation.

In the present study, participants included in analyses were 212 U.S. residents (66% female; n = 140) between the ages of 18 and 78 years. Participants reported residency in 44 states and Puerto Rico (n = 1). States that were not represented were Hawaii, Alaska, Vermont, West Virginia, Wyoming, and Rhode Island. Participants reported using a dog guide (2%, n = 4), cane (50%, n = 107), both dog guide and cane (7%, n = 14), or neither (42%, n = 89). Additional demographic and impairment characteristics are displayed in Table 1.

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Table 1.

Participant characteristics.

Characteristic	Statistic
Age (SD)	46 (15)
Male	34% (72)
Race/Ethnicity
White	80% (170)
Black or African American	6% (12)
American Indian or Alaska Native	<1% (0)
Asian	3% (6)
Native Hawaiian or Pacific Islander	<1% (0)
Hispanic/Latino (may have endorsed others)	10% (18)
Mixed race/multiple ethnicities	5% (9)
Other race/ethnicity	9% (18)
Cause(s) of VI
Stargardt disease	6% (12)
Retinitis pigmentosa	34% (73)
Macular degeneration	1% (2)
Glaucoma	8% (18)
Cataracts	1% (3)
Diabetic retinopathy	2% (5)
Multiple causes (including other causes)	47% (101)
Age at diagnosis (SD)	21 (18)
Totally blind or light perception (vs. low vision)	24% (52)
Congenital condition (vs. acquired)	21% (45)
More than one impairment	23% (50)
Family member with same condition	40% (86)
Stable condition (vs. progressive)	22% (46)
Uses mobility tool (vs. does not use)	58% (125)
Disability visible to others at least most of the time	39% (84)

The Office for the Protection of Human Subjects at the University of California, Berkeley, approved this study (Protocol # 2019-10-12649). This study was supported in part by an award from Division 22 of the American Psychological Association’s Foundation for Rehabilitation Psychology.

Results

Descriptive statistics

Multiple linear regression analyses were conducted using Stata (v.16). The Bonferroni correction was calculated based on a significance level of .05, yielding a critical alpha of .006. Participant scores on disability affirmation, disability acceptance, and GDI subscales were overall normally distributed (see Table 2). Mean scores, standard deviations, and correlations between the subscales are also displayed in Table 2.

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Table 2.

Descriptive statistics for key variables.

Variables	M	SD	α	Skewness	Kurtosis	Disability affirmation	Disability acceptance
Disability affirmation	3.09	1.07	.82	.16	2.53	–	.69
Disability acceptance	2.94	0.94	.83	.18	2.10	.69	–
Group disability identity	3.76	0.61	.72	–.05	2.67	.57	.53

Regression analyses

Disability affirmation

In the first regression model (see Table 3), disability affirmation was regressed on age, gender, and impairment-related factors: congenital onset (vs. acquired), being blind (vs. having low vision), secondary disability, stable (vs. progressive) condition, use of mobility tool (cane, dog guide, or both), and presence of family member with the same visual impairment. Disability affirmation was positively associated with use of mobility tool (i.e., cane, dog guide, or both; p = .001). The remaining independent variables were not found to be statistically significant predictors of disability affirmation. The regression model explained 13% of variance in disability affirmation scores. Cohen’s f ² was calculated for the model, yielding a value of 0.15, a medium effect (Cohen, 1988).

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Table 3.

Multiple linear regression model predicting disability acceptance.

Predictor variable	b	SE b	t	β	p
	Disability acceptance
Age	–.001	.005	–0.31	–.02	.76
Male	.040	.150	0.26	.02	.79
Congenital onset	.397	.189	2.10	.15	.04
Blind (vs. partial sight)	.392	.219	1.79	.16	.07
Multiple disabilities	–.091	.160	–0.56	–.04	.57
Stable condition	.106	.213	0.50	.04	.62
Visible condition	.095	.178	0.55	.05	.58
Uses mobility tool	.266	.167	1.59	.13	.11
Family member has visual impairment	–.052	.140	–0.37	–.02	.71
Constant	2.82	.237	11.90
Observations	214
R 2	.15
Adj. R 2	.12

Note: B indicates unstandardized coefficient; Adj. R ² = adjusted R ²

*p < .006.

Disability acceptance

In the second regression model (see Table 4), disability acceptance was regressed on age, gender, and the same impairment-related factors included in the first regression model. Disability acceptance was not found to be significantly associated with any independent variables. The regression model explained 12% of variance in disability acceptance scores. Cohen’s f ² was calculated for the model, yielding a value of 0.13, a small effect (Cohen, 1988).

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Table 4.

Multiple linear regression model predicting disability affirmation.

Predictor variable	b	SE b	t	β	P
	Disability affirmation
Age	–.002	.004	–0.52	–.03	.61
Male	.054	.132	0.41	.03	.67
Congenital onset	.217	.166	1.31	.10	.19
Blind (vs. partial sight)	.130	.192	0.68	.06	.50
Multiple disabilities	–.047	.140	–0.34	–.02	.74
Stable condition	.148	.188	0.79	.07	.43
Visible condition	.067	.156	0.43	.04	.67
Uses mobility tool	.515	.147	3.50	.27 a	<.01
Family member has visual impairment	.100	.123	0.81	.05	.42
Constant	2.58	.209	12.36
Observations	215
R 2	.16
Adj. R 2	.13

Note: B indicates unstandardized coefficient; Adj. R ² = adjusted R ²

^ap < .006.

GDI

In the third regression model (see Table 5), GDI was regressed on age, gender, and the same impairment-related factors included in the previous regression models. GDI was not found to be significantly associated with any impairment-related characteristics or gender. Age was significantly and positively associated with GDI (p = .001). The regression model explained 12% of variance in GDI scores. Cohen’s f ² was calculated for the model, yielding a value of 0.13, a small effect (Cohen, 1988).

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Table 5.

Multiple linear regression model predicting group disability identity.

Predictor variable	b	SE b	T	β	p
	Group disability identity
Age	–.01	.00	–3.50	–.24 a	<.01
Male	–.06	.09	–0.73	–.05	.47
Congenital onset	.00	.11	–0.00	.00	.99
Blind (vs. partial sight)	.17	.13	1.31	.12	.19
Multiple disabilities	–.01	.09	–0.06	–.00	.95
Stable condition	.13	.12	1.04	.09	.30
Visible condition	.22	.11	2.10	.18	.04
Uses mobility tool	.11	.10	1.09	.09	.28
Family member has visual impairment	.03	.08	0.32	.02	.75
Constant	1.99	.14	14.25
Observations	212
R 2	.16
Adj. R 2	.12

Note: B indicates unstandardized coefficient; Adj. R ² = adjusted R ²

^ap < .006.

Discussion

The present study contributes to emerging empirical literature indicating a positive association between disability identity (e.g., disability affirmation) and life outcomes among people with disabilities (Bogart, 2014, 2015; Bogart, Lund, & Rottenstein, 2018; Nario-Redmond et al., 2013), including adults with visual impairments (Zapata, 2018, 2020). Consistent with earlier findings (Zapata, 2018), participants with visual impairments who reported use of a mobility tool (cane, dog guide, or both) were, in general, estimated to have higher self-reported disability affirmation, after controlling for age, gender, and severity indicators (i.e., visual status, secondary disability, visibility of disability, stability of disability, congenital vs. acquired onset, and family member with same condition). In contrast to earlier findings (Zapata, 2018), use of a mobility tool was not significantly predictive of disability acceptance, after controlling for age, gender, and severity indicators. These findings lend support to the postulated relationship between “coming out” as a person with a disability, as manifested by use of a mobility tool, and possessing disability-affirming attitudes. Rehabilitation psychology, vocational psychology, and related fields may benefit from a clinical and scholarly consideration of the relationship between disability-affirming attitudes and such consumer decision-making processes as (a) the pursuit of O&M training, (b) commitment to O&M practice and skill development, (c) frequency, duration, and context-specificity of mobility tool use, and (c) choice of cane type.

Assertiveness training (see Hogan, 2012) and disability-affirmative case conceptualization (see Olkin, 2017) may have the potential to benefit consumers who are facing the decision of whether to pursue O&M training or use a mobility tool in their daily lives. Discussing the application of assertiveness training to mobility tool use, Hogan (2012) suggested “working through” fears of stigma and embarrassment related to mobility tool use by asking individuals with visual impairments the following questions: (a) What is your biggest challenge or what frightens you the most?; (b) Would you be embarrassed using the white cane at home by yourself?; and (c) What is the worst thing that could happen when using the white cane in public? Suggesting that confidence-building could relieve feelings of self-consciousness and shame related to mobility tool use and training, Hogan further recommended training in such assertiveness skills as saying “no” to undesired help as well as asking for assistance in an empowered manner. Describing disability-affirmative therapeutic practices, Olkin (2017) proposed that professionals can help support clients in understanding and integrating disability-related attitudes by exploring such themes as (a) how they engage with disability culture and community, (b) how disability affects current social interactions, (c) how disability intersects other identities as well as other cultural and demographic variables, (d) how they experience and respond to “microaggressions,” and (e) how they manage disability-related emotions. Given the current finding that disability affirmation was associated with mobility tool use, and given previous findings that negative disability attitudes (e.g., shame) were associated with resistance to mobility tool use and training (Hayeems et al., 2005; Hogan, 2012; Seybold, 2005; Thume & Murphree, 1961; Wainapel, 1989), both assertiveness training and disability-affirmative practices may have potential to support individuals with visual impairments in overcoming psychological barriers to O&M training and mobility tool use.

A second key finding is that younger participants were estimated to have, on average, higher self-reported GDI, but not higher disability acceptance or disability affirmation. Bogart, Rottenstein, Lund, and Bouchard (2017) found that age predicted disability identification: older participants were more likely to identify as disabled. However, the present study did not examine disability identification, which was measured as a single-item variable by Bogart and colleagues. Instead, the current study examined disability identity as comprised of distinct but not mutually exclusive (see Table 2) personal and group-related attitudes towards disability. This distinction may account for some inconsistency between the respective studies. Younger age, in the current study, was found to predict higher participant-reported feelings of connection to and affiliation with the disability community. Age was not similarly predictive of disability acceptance or disability affirmation. Explanatory research is needed to draw conclusions from this finding, but it is possible that the association between age and GDI reflects a paradigm shift with respect to the dominant model of disability, such as from the medical model to the social model to the disability-affirmative model. For example, the medical model emphasizes within-group differences and promotes impairment-specific remediation, whereas the more recent social model emphasizes commonalities across all disability subgroups and places the onus of change on society rather than the individual (Olkin, 2002). Two decades ago, Swain and French (2000) described the emergence of a new disability-affirmative model of disability identity within the disability literature and disability culture, as reflected, for example, in the Disability Arts Movement (Swain & French, 2000). A sociocultural shift over the past decades (see Cameron, 2011; Darling & Heckert, 2010; Magasi et al., 2015; McCormack & Collins, 2010) could explain higher endorsement among younger participants, on average, of the statement, “People with disabilities have a great deal in common.” A postulation for future investigation, a generational shift towards a disability-affirmative model could explain higher endorsement among younger participants, on average, of the statement, “I want to learn more about the history of people with disabilities.”