Perspectives on Home Safety: Do Home Safety Assessments Address the Concerns of Clients With Vision Loss?

Abstract

PURPOSE. We explored the occupational performance and home safety perspectives of older adults with vision loss. Our study focused on the person–environment interaction to ascertain whether participants’ concerns are addressed by three commonly used home safety assessments.

METHOD. Twenty-two older adults with vision loss participated in face-to-face interviews regarding their perspectives on home safety. We compared categories generated from a content analysis of the data with the contents of three standardized home safety assessments.

RESULTS. Five categories of home safety emerged from the analysis: (1) lighting, (2) contrast, (3) visual distractions, (4) glare, and (5) compensation strategies. Comparisons of content in the three home safety assessments with emerged categories revealed that study participants had specific concerns about home safety that were not thoroughly addressed in the selected assessments.

CONCLUSION. The findings provide preliminary content areas that should be included in the development of a home assessment specific to the low vision population.

Keywords

activities of daily living environment home care services safety vision,low

Low vision is defined as permanent vision loss that cannot be corrected by surgery, medication, or corrective lenses; this vision loss interferes with a person’s ability to perform everyday activities (National Eye Institute [NEI], n.d.). According to the NEI (2004), vision loss affects about 3.3 million adults in the United States. Most conditions that cause low vision are age related. Because the U.S. population of older adults is increasing, the prevalence of low vision conditions is also expected to increase (NEI, n.d.). Studies have indicated that vision loss diminishes personal safety, interferes with engagement in activities of daily living (ADLs), and increases risk of falls and fractures (Cox et al., 2005; Dahlin Ivanhoff, Sonn, Lundgren-Lindquist, Sjörstrand, & Steen, 2000; Dhital, Pey, & Stanford, 2010; National Organization on Disability, 2000; Raina, Wong, & Massfeller, 2004). Despite such concerns, many older adults with low vision have a strong desire to live independently in their own homes (Girdler, Packer, & Boldy, 2008).

Occupational therapy practitioners play a pivotal role in enabling people who have vision loss to age safely and independently in their homes. To fulfill this role, practitioners conduct home assessments and provide recommendations and intervention. A review of the literature, however, revealed that to date no standardized English-language home assessment has been developed for adults with low vision. Although several home safety assessments are available, none are designed to evaluate specific issues related to sensory features, including environmental visibility and how the person interacts with his or her personal space. Carignan, Rousseau, Gresset, and Couturier (2008), a research team that developed a French version of a home assessment for people with low vision, emphasized that the issue is not whether people with vision loss can prepare a meal but whether they can prepare the meal in their home with specific environmental support such as lighting, contrast, and organization.

Moreover, many existing standardized home assessments were developed on the basis of the researchers’ experience and knowledge, with little input from people with vision loss. A substantial difference may exist between professional assessment of environmental risk and the perceptions of older adults with vision loss (Trimble, Clemson, & Cusick, 1995). The study described in this article examined the perspectives of older adults with vision loss on their occupational performance and home safety and focused on person–environment interaction.

Method

Design

To better understand how older adults with low vision perceive home safety, we used qualitative methodology. This approach provides detailed individual perspectives about the phenomena of experiences within home environments. Additionally, this methodology reveals categories that can be compared with the contents of selected home safety assessments. We obtained approval from the University of Alabama at Birmingham Institutional Review Board and informed consent from participants.

Participants

We used purposive sampling to recruit adults with visual impairment from various sources and locations, including a retirement community, a low-income housing neighborhood, a low vision rehabilitation center, and three low vision support groups, all located in central Alabama. Inclusion criteria included ≥ age 50 yr, noncorrectable vision loss with visual acuity between 20/30 (near normal) and 20/1000 (profound loss) using the LEA Numbers (Good-Lite Co., Elgin, IL) or Colenbrander intermediate chart (Precision Vision, LaSalle, IL), and score of 16 or greater on the Mini-Mental State Examination–Blind (MMSE–Blind; Busse, Sonntag, Bischkopf, Matschinger, & Angermeyer, 2002) to indicate intact cognition. The MMSE–Blind, a modified version of the MMSE (Folstein, Folstein, & McHugh, 1975), does not include items that require a person to read or write (Busse et al., 2002). To ensure balanced perspectives from people with different degrees of visual impairment, we used the World Health Organization (WHO) categories of visual impairment (Colenbrander & Fletcher, 1995) to categorize potential participants. We chose the WHO coding categories because they are the most recognized classification system for rating visual impairment. Specific categories used in this study were near normal (20/30–20/70), moderate (20/80–20/160), severe (20/160–20/400), and profound (20/400–20/1000; Table 1). Adults who had received low vision services within the past year, had any neurological insult, or did not meet the screening criteria were excluded. Twenty-two adults with vision loss (16 women, 6 men) were enrolled in the study; their mean age was 71 yr (range = 50–88). All participants were White except 1, who was of American Indian descent. Diagnoses related to the participants’ vision loss included macular degeneration, diabetic retinopathy, and glaucoma (Table 1).

Table 1.

Characteristics of the Study Sample

Variable	Mean	Range
Age, yr	71	50–88
MMSE–Blind scores	19.7	16–22

	n	%
Gender
Male	6	27
Female	16	73
Race
White	21	95
American Indian	1	5
Location of home
Urban	16	73
Rural	6	27
Levels of visual impairment
Near normal (20/30–20/70)	7	32
Moderate (20/80–20/160)	7	32
Severe (20/160–20/400)	2	9
Profound (20/400–20/1000)	6	27
Diagnosis
Age-related macular degeneration	11	50
Diabetic retinopathy	1	5
Temporal arteritis	1	5
Corneal transplant (both eyes)	1	5
Optic neuritis	1	5
Optic nerve hypoplasia or nystagmus	1	5
Central areolar choroidal dystrophy	1	5
Coloboma or glaucoma	1	5
Myopic macular degeneration	1	5
Unknown	3	14

Note. The diagnosis category adds to >100% because several participants had multiple vision diagnoses. MMSE–Blind = Mini-Mental State Examination–Blind.

Procedures

Five trained interviewers interviewed the participants in their homes using a semistructured questionnaire. Three interviewers were graduate students from a local university’s entry-level occupational therapy program, and two were practicing occupational therapists enrolled in a postprofessional low vision rehabilitation graduate certificate program. We trained the interviewers through a series of hands-on sessions addressing the qualitative methodology and interviewing technique, the study protocol, and procedures for administration of screening tools.

Deborah K. Bennett developed the semistructured questions for the interview on the basis of research identifying difficulties that people with low vision encounter during occupational performance (Cox et al., 2005; Dahlin Ivanhoff et al., 2000; Dhital et al., 2010; National Organization on Disability, 2000). Because visual regulatory conditions such as illumination and contrast affect performance by influencing the visibility of environments, these conditions were specifically addressed in the questions. Two university faculty members with American Occupational Therapy Association (AOTA) specialty certification in low vision rehabilitation reviewed and approved the questions (see Figure 1 for a sample of semistructured questions).

Figure 1.

Sample semistructured interview questions.

Each interview began with general questions such as “Describe in general things in your home that cause you difficulty” and progressed to more specific areas such as “Describe to me your experience with using kitchen appliances.” When necessary, additional probes and questions were posed to encourage reflection and further elaboration on the topic. The interviews were audiotaped and transcribed verbatim. Each interview lasted about an hour. The interviewers took detailed field notes to supplement the transcription.

Data Analysis

To analyze the interview data, we applied Dahlgren and Fallsberg’s (1991) seven-step procedure for qualitative data analysis to reveal categories. These procedures prompt coders to move from becoming familiarized with the content to labeling and contrasting categories. Two of the authors (Bennett and Vogtle) independently analyzed the data line by line to identify statements that were relevant to the purpose of the study. These two coders constantly compared the data they generated for similarities and differences, resulting in the identification of categories that were modified as data emerged. Additionally, both coders met throughout the analysis process to establish consent for the coding. Differences of coding opinion were resolved by consulting with the first author (Barstow), who has extensive experience in low vision rehabilitation. Strategies to ensure trustworthiness of the data included peer debriefing; journaling; collecting information with thick, rich description; and comparing field notes (Lincoln & Guba, 1985).

We then compared the emerged categories with the contents of three standardized home safety assessments that occupational therapists commonly use:

The Safety Assessment of Function and the Environment for Rehabilitation (SAFER; Oliver, Blathwayt, Brackely, & Tamaki, 1993), which evaluates older adults’ abilities to manage safely within their home environment (Oliver et al., 1993). The assessment contains 97 items divided into two broad areas—home environment (e.g., bathroom) and specific functions (e.g., personal care).

The Westmead Home Safety Assessment (WeHSA; Clemson, Roland, & Cumming, 1992), which was designed to assess home environmental hazards. It includes 72 hazard categories listed in 13 sections pertaining to specific areas of the home (Clemson et al., 1992).

The Housing Enabler (Iwarsson & Isacsson, 1996), a home safety assessment developed from an original ideogram for assessing architectural barriers in official buildings in the United States. The tool contains 188 items assessing accessibility in home environments and the immediate outside surroundings for people with functional limitations.

We selected these three assessments because of their clear documentation of the approaches used for instrument development and their adequate psychometric properties. We sought to determine whether the content of the assessments reflects the perspectives of people with low vision on home safety and occupational performance.

Findings

Lighting.

All participants reported lighting to be a determinant of occupational performance and home safety. They discussed both room lighting and task lighting required for occupational performance such as dialing a telephone, determining clothing color, and reading. One participant with moderate visual impairment reported, “Anywhere in the house where I do anything at all, I have to have extra light.” Light bulbs and lighting types were also discussed as important factors facilitating occupational performance. One participant reported, “I have two of the task lights with the special bulbs [full spectrum lighting]”; another stated, “Sometimes I mix purple and black [clothes]. I have to take it to the door to see what color it is or go outside,” both locations with increased illumination. Several participants mentioned the use of flashlights for tasks that required good near vision, such as setting a thermostat or finding the keyhole to unlock the door of their home.

Participants emphasized the need for lighting in storage areas such as closets and kitchen cabinets to enhance visibility for identification of items such as clothing and food products. One participant stated, “My problem is my shoes… . I can’t tell the difference. I have to take them outside to tell if they’re black or brown.” Another stated, “I use the blue LED lights in my closet to help me get my clothes.” A third noted, “I have some difficulties as far as the cabinets, because the light don’t really go into the cabinets good enough.”

All participants reported a need for optimum light levels in areas of task completion. Under-cabinet, task, and overhead lighting were reported as equally important for occupational performance. One participant stated, “I would like to have light under my kitchen cabinets. I get it [a kitchen item] out and put it under the light and see enough to see.” In reference to the laundry room, a participant noted, “I have fluorescent. It’s well lit.”

Participants adjusted window coverings to allow more light into the house during activities such as leisure tasks, reading, and eating. One participant stated, “I sit by the window when playing games”; a second stated, “I open blinds and doors for light”; and a third reported, “I don’t have window dressing, as you can see, because I need the light.”

Several participants reported difficulty with occupational performance when moving between light levels, especially from indoor to outdoor environments. One participant stated, “When walking inside a restaurant with dim light on a bright day, I don’t recognize their faces until I am in there 15 or 20 minutes, and then I can tell.”

Most participants described outdoor lighting on steps and in garages as crucial for safety during mobility. Some used motion lights and lighting with a timer to aid them when leaving or coming home. One participant reported the importance of “lights that come on automatically at dusk and go off at dawn.” In reference to motion lights, another stated, “I have motion lights out there, and they come on just as I start down the steps, and also with pulling in from the street, just when I start turning in … and also I have a motion light on this side of the house.”

Contrast.

Contrast consists of the visible qualities of objects against backgrounds. All participants, even those with minimal visual impairment, reported contrast to be a primary area of concern affecting activities related to home safety. Many participants discussed contrast specifically in the context of functional mobility; examples included compromised safety from lack of contrast in indoor and outdoor stairwells, curbs, driveways leading to mailboxes, tree roots in yards, and door facings. One participant reported difficulty judging curb height because of the lack of contrast; referring to his outdoor street curb, he said, “Here your step up to the curb was big, and it threw me, and I broke this wrist.” Another reported, in discussing stairs, “I’m going to have to make me a line or something on that [stair edge]. A lot of times I miss one of the steps.” A third participant reported the benefit of contrast in the outdoor environment: “I can see the different coloration in the concrete and the blacktop out there, so I know that directly across … is the mailbox.”

Another frequently mentioned activity for which participants reported benefits from contrast was meal preparation. Participants reported that contrast enhanced safety for tasks such as pouring liquids, measuring, and cooking on smooth-top stoves.

Visual Distractions.

Visual distractions are elements in the environment that obscure visibility, such as pattern and clutter. Although many home safety assessments include observation of environmental clutter and its influence on safe mobility, clutter creates an additional hazard in the home of a person with vision loss. Lack of clutter not only is important for functional mobility and fall prevention but also enhances the ability to perform ADLs safely and efficiently. Participants consistently reported the implementation of organizational strategies to reduce clutter. Each participant stressed how his or her life was either enhanced by organizational strategies or plagued by the lack of them during occupational performance. One participant who lived among clutter stated, “We spend lots of time looking for things we have lost… . It’s our greatest time consumer.” Participants had many safety concerns because of unexpected disorganization or clutter. One participant reported, “I fell down face first into the garbage can lid, which was on top of the curb at that point [it usually was on the can], and I broke my nose in three places.”

Although not as often, participants described difficulties resulting from both overlaid and inlaid patterns. Examples included difficulty locating items for eating, cooking utensils, or playing cards when placed on a patterned tablecloth or countertop. One participant noted, “I sometimes lose things on my countertops.” When the interviewer asked whether the speckled countertop affected visibility, the participant responded, “Yes, it does.” Another example was difficulty finding things in a crowded cupboard or drawer partly or solely because of difficulty in distinguishing pattern and low contrast between items.

Glare.

Participants reported concerns with glare in outdoor and indoor environments. Some reported that they avoided going outdoors because of diminished safety secondary to glare. Additionally, they reported avoiding activities such as taking out the mail during daytime hours when the sun was brightest. One participant stated, “I very seldom go out there… . Like today [a sunny day] is worse on my eyes than a cloudy day.”

For indoor environments, participants often reported the benefit of adjustable window coverings. Most participants reported that vertical or horizontal blinds were their preferred window covering, allowing them to control light and glare levels. One participant reported, “We have vertical blinds and windows on each side. When the sun is shining, you do have to close those blinds; it is too light in there.” Another stated, “There’s no curtains on the top part of the windows—too much glare.” Two participants took into consideration the types of window coverings when they built their houses. One participant reported situating her house to avoid the sun coming directly in the windows but allowing adequate illumination in the house: “My living room, when the sun is shining, is very bright. My home is facing north, so I don’t get the huge glare… . We did that for a purpose.” Incandescent light bulbs were also mentioned as a source of glare: “I don’t like the regular light bulbs.”

Compensation Strategies.

Compensation strategies involve the use of other sensory systems, devices, or methods to simplify or eliminate tasks or steps in activities that typically require vision. Participants reported a variety of strategies they applied during occupational performance to enhance independence and safety. For example, several participants reported using hearing to compensate for vision loss. One participant reported, “I use talking prescription ID on my bottles.” Another stated, “If I drop something, I can hear it on the floor… . If it’s on a rug, I couldn’t hear it and I couldn’t see it, so I chose the bare floor.” One participant reported replacing carpets with hardwood floors to alert her when a small item was dropped.

Participants often reported compensation through touch when discussing functional mobility. Many participants relied on assistive devices such as walkers, standard canes, white canes, and handrails for physical support as well as for information about the nature of support surfaces. Additionally, participants used touch to aid in appliance use; they marked dials with tactile adaptations to ensure accurate settings without reliance on vision.

Some participants reported using cognitive compensation strategies such as counting steps throughout the home and on stairs. One participant reported, “I can count my way all the way to the edge [of the driveway].” Participants also reported using organization as a cognitive compensation strategy, especially in medication management and meal preparation. Several participants mentioned using pillboxes, organizing pill bottles in separate locations for medications to be taken at different times of the day, and storing dangerous items such as knives properly so they would not mistakenly injure themselves. One participant stated, “I have meds placed right where I know which is which, and I know when I’m supposed to take it.” Another said, “I’ve bought knives with sheaths… . I always have my knives turned backwards and down. I bought a plastic knife thing, so I keep them all in there with the sharp edges and points in the slot.”

Other participants reported that they had stopped performing activities that require good near vision or coordination between vision and movement of body parts simply because they did not feel safe. One participant stated, “I do have quite a lot of problems doing that. Usually … I will get my daughter to set the thermostat for me.” Another reported, “I’ve stopped mowing, cutting shrubbery … which I used to do, but I cut through the extension cord and knocked myself out.”

Task omission was also noted when discussing meal preparation. Some participants stated that they omitted certain tasks, such as cutting, when preparing meals. Others did not cook certain types of meals because they were unable to determine when food was cooked. One participant stated, “I just couldn’t tell if it [meat] was done.”

Comparison With Home Safety Assessments

The qualitative data collected in this study indicated that people with vision loss have specific concerns regarding occupational performance and home safety that are unique to this population. When we compared participants’ concerns with the content of the three selected home safety assessments, we found that many concerns were not included or were not covered in sufficient detail to thoroughly assess the home and safety of people with vision loss. Table 2 compares the content of the three home safety assessments with the emerged categories.

Table 2.

Comparison of Emerged Categories With Contents of Three Home Safety Assessments

Category	WeHSA	SAFER	Housing Enabler
Lighting
General indoor	Present	Present	Present but limited
General outdoor	Present	Present	Present
Type	Absent	Absent	Absent
Wattage	Absent	Absent	Absent
Placement	Absent	Absent	Present but limited
Switch access	Present	Absent	Absent
Night lighting	Present	Present	Absent
Storage areas	Absent	Present but limited	Present but limited
Garage	Present	Absent	Absent
Window coverings	Present but limited	Absent	Absent
Task lighting	Absent	Absent	Absent
Contrast
General indoor	Present but limited	Absent	Absent
Kitchen	Absent	Absent	Absent
Bedroom	Absent	Absent	Absent
Living room	Absent	Absent	Absent
Bathroom	Absent	Present but limited	Absent
Stairs	Present	Present	Absent
Indoor pathways	Present	Absent	Absent
Thresholds	Present	Present	Absent
Indoor floor coverings	Present	Present but limited	Absent
Curbs	Absent	Absent	Absent
Sidewalks	Present	Absent	Absent
General outdoor	Present but limited	Present but limited	Absent
Outdoor surfaces	Present but limited	Present but limited	Absent
Visual distraction
Clutter	Present	Present	Absent
Obstacles	Present	Absent	Present
Pattern	Present but limited	Absent	Present but limited
Glare	Present but limited	Absent	Absent
Compensation strategies	Present but limited	Present but limited	Present but limited

Note. WeHSA = Westmead Home Safety Assessment; SAFER = Safety Assessment of Function and the Environment for Rehabilitation.

Lighting.

Participants consistently reported the importance of lighting and described in detail where it should be placed and qualities of the source (wattage, type). All three home safety assessments include assessment of lighting in general indoor and outdoor spaces. None of the assessments, however, mentions task lighting used for near vision activities such as reading. Additionally, only the Housing Enabler includes storage or cabinet lighting, which participants reported to be of vital importance when identifying and locating objects, and content is limited to kitchen storage areas. None of the three assessments addresses lighting quality. Participants reported the significance of adjustable window coverings, such as blinds, to allow for additional light during occupational performance. Only the WeHSA addresses window coverings; however, the assessment prompts the therapist to determine the client’s ability to physically open and close the covering. All three assessments disregard evaluation of the window coverings to control room illumination.

Contrast.

Participants discussed in detail the need for contrast enhancement for key objects and support surfaces to enable safe occupational performance. The WeHSA recommends assessment of contrast on steps and pathways only; none of the assessments address contrast in other environmental spaces and its effect on task completion.

Visual Distractions.

Visual distractions, specifically clutter and pattern, are additional elements participants reported that jeopardized their safety and contributed to prolonged task completion. Both the WeHSA and SAFER include assessment of general environmental clutter, but none of the assessments examines clutter as it relates to task performance and environmental visibility. Both the WeHSA and the Housing Enabler address obstacle identification in main traffic pathways and seating areas, but neither assesses the visibility of these obstacles. The WeHSA and the Housing Enabler both assess pattern on floor and stair surfaces but ignore pattern in other areas.

Glare.

Participants reported difficulty with task completion and avoidance of environments because of glare. The WeHSA directs the therapist to assess general room glare secondary to light sources, but the other two assessments disregard this environmental feature. All three assessments largely ignored glare from other sources, such as shiny surfaces and sunlight, and the presence of window coverings to eliminate indoor glare from sunlight.

Compensation Strategies.

All three assessments include some aspect of task performance; however, none specifically prompts the therapist to assess strategies that people with vision loss commonly use. Participants reported using a variety of adaptive equipment and techniques to accomplish their ADLs, as well as avoiding some activities, and delegating some tasks. Although these are not features of the environment, they provide the practitioner with important information about the client’s insight, problem solving, and adaptability. All three assessments largely ignore these features of person–environment interaction specific to tasks affected by vision loss.

Discussion

This qualitative study explored the perspectives of older adults with vision loss regarding their occupational performance and home safety. Five categories of home safety issues emerged from the interview data, four of which—lighting, contrast, visual distractions, and glare—describe crucial features of the home environment for older adults with vision loss. The absence or presence of these features can create barriers or facilitators to occupational performance and home safety. The fifth category, compensation strategies, describes how participants adapt to their diminished vision to improve person–environment interaction. The three selected home assessments, WeHSA, SAFER, and Housing Enabler, include many of the described environmental features participants identified (Table 2). However, the assessments were designed for the general population and were developed without input from people with vision loss. As a result, they lack the detail necessary for occupational therapy practitioners to thoroughly assess this population and make accurate recommendations regarding safety.

Although general home safety assessments are useful, this study indicates that people with vision loss experience specific issues related to home environments that, when not addressed, often lead to preventable home accidents such as falls and injuries (Cox et al., 2005; Dhital et al., 2010). Although the three assessments do address person–environment interaction in the home, their failure to address environmental features and details specific to people with vision loss may compromise the completeness and validity of their results. For example, all three assessments address general indoor and outdoor lighting; however, none evaluates light source type, wattage, placement, switch access, or window coverings. For people with vision loss, not only the absence or presence of features but also the qualities of the features contribute to environmental safety. Additionally, because these assessments do not describe these environmental features in detail, practitioners who lack knowledge regarding occupational performance and vision loss may miss valuable information about environments and safety.

Study Strengths and Limitations

We investigated the perspectives of older adults with a range of visual impairment from rural and urban areas on a wide variety of ADLs and instrumental ADLs. Therefore, the results reflect a broad, thorough perspective of the safety concerns encountered by this population and provide occupational therapy practitioners with a unique client-centered point of view. In addition, the two authors who independently coded the data achieved perfect agreement for the five categories, supporting the credibility of the data analysis.

This study relied on participants’ verbal descriptions of occupational performance and elements of home safety. The interviewers did not observe participants’ performance on any specific ADLs; however, they did observe and verify the physical and sensory elements of the home that participants described during interviews. The study was performed in one geographic area of the country, and therefore results may not be transferable to the entire population of older adults with low vision because of geographic differences in climate, culture, or architectural style.

Future Research

For occupational therapists to thoroughly assess the person–environment interaction of people with vision loss, development of a population-specific home assessment is needed. This assessment should reflect the safety concerns and sensory conditions identified by participants in this study. Further research should focus on the development of a client-centered home assessment for people with vision loss.

Conclusion

As the number of people with visual impairment grows, occupational therapists will increasingly be called on to assess safety, specifically in the home environment. Results of this study indicate that existing home safety assessments rely heavily on assessment of the physical features of environments but fail to thoroughly address sensory elements. Sensory elements must be assessed in sufficient detail to effectively intervene in the home environment of people with vision loss.

Footnotes

Acknowledgments

We thank the study participants and assistants Laura Ashley, Emily Guarino, Kathryn McCormick, and Magen Renta for contributing to data collection.

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