Introduction
Due to aging of the population and the exponential increase in vision loss with increasing age, the number of older adults with a visual impairment is expected to increase [
1,
2]. Along with the general consequences of aging, these older adults will experience additional restrictions due to vision loss, and as such, they will be doubly burdened [
3]. Vision loss may lead not only to limitations in performing activities [
4‐
12], but also to a loss of these activities [
13,
14], and consequently poses a severe threat to the independence of older adults with a visual impairment.
The concept of participation has become more important since the development of the International Classification of Functioning, Disability, and Health (ICF) by the World Health Organization (WHO) [
15]. According to the ICF, participation is defined as “involvement in life situations”. The ICF offers a comprehensive model of objective disability outcomes but does not address the subjective perceptions of people with disabilities such as quality of life (QoL) [
16]. The WHO, however, does recognize the importance of the QoL concept, as evidenced by their definition of QoL: “the individuals’ perception of their position in life in the context of the culture and the value system in which they live and in relation to their goals, expectations, standards and concerns” [
17]. With respect to the relationship between participation and QoL, and the available options to include the concept of QoL in the ICF, it is recommended to add QoL as a separate domain to the right of participation [
16]. The extent of QoL can be regarded as the ultimate outcome of the disability process [
16].
Studies in older adults with and without disabilities showed that participation contributes to QoL [
18‐
20] and is a means of experiencing one’s social connection with other people and communities [
21]. Participation is also associated with a reduced risk of cognitive [
22] and functional decline [
23,
24]. Therefore, it is important to understand which factors influence the level and the extent of an individual’s participation. According to the ICF framework, there is a dynamic interaction between the health condition, contextual factors, such as personal and environmental factors, and participation [
15].
With aging, the presence of limitations in physical functioning and participation restrictions increases [
25]. Previous research revealed several factors that are associated with participation and participation restrictions. The younger generation of older adults, for example, perceive less restrictions in interpersonal interactions [
25] and are more likely to participate in social and leisure activities [
26,
27]. Other sociodemographic factors, such as income [
28] and educational level [
29], are associated with participation in voluntary work, and cultural and recreational activities. Older adults with a good health status [
30] and those who are physically fit [
31] perceive less restrictions in daily activities and are more likely to participate in social activities. Social support from family and friends is a facilitator of participation in society as well [
32]. Psychological factors such as emotional distress [
33] and reduced self-efficacy [
34,
35] are barriers for participation in outdoor activities, social relationships, and work. In addition to these factors, personal expectancies and personal values concerning participation may determine behavior of older adults [
36]. Based on this literature, it can be concluded that sociodemographic factors, physical health status, social and psychological status, and personal values affect participation.
Although participation has been studied among older adults in general [
25‐
27,
29‐
32], to our knowledge, only a few studies investigated participation of visually impaired older adults. The results of these studies indicate that reduced distance vision restricts participation in social interactions, daily activities (including household activities), leisure activities, and work [
11,
37,
38]. The perceived quality of distance vision as well as the presence of cardiac disease, and the use of special equipment (e.g., cane, pill dispenser) are associated with reduced participation in self-care, household activities, physical activities, and limitations in mobility [
37]. In addition, the physical and mental health of visually impaired older adults affect restrictions in participation [
11]. Apart from these studies, there is little available information about the determinants of participation of visually impaired older adults.
The present study aims to investigate factors that influence the level of participation of visually impaired older adults. For this purpose, the impact of various factors will be examined according to the biopsychosocial model. Based on the literature, we expect that sociodemographic variables, physical health status, social status, and psychological status will affect participation. In addition, the effect of the personal values that visually impaired older adults attach to participation will be examined.
Discussion
The purpose of this study was to assess the determinants of self-reported performance of participation in domestic life, interpersonal interactions and relationships, major life areas, and community, social and civic life among visually impaired older adults. These determinants were investigated according to the biopsychosocial model.
With respect to vision-related variables, we found that the severity, duration, and primary cause of VI had no effect on participation. This is in accordance with the study of Desrosiers et al. [
37] who found that visual acuity was not associated with participation. Other measures of visual functioning (e.g., visual field, contrast sensitivity, acuteness of the onset of vision loss) may have had an impact on participation. However, these measures were not included in our study, because of the unavailability of these data for all study participants. It is beyond question that visually impaired older adults do perceive restrictions in participation [
4,
11,
12]. Our results indicate that, although a visual impairment leads to participation restrictions, the severity of the impairment in itself has no impact on participation of visually impaired older adults.
The finding that perceived physical fitness is a determinant of participation in domestic life is not surprising, given that doing household tasks requires exertion of the physiological system (muscle mass and strength, flexibility, balance and coordination, and cardiovascular function). The association between physical fitness and participation was also found in the study of Anaby et al. [
31] among older adults in general, which showed that balance and mobility affected participation in daily activities and social roles. Lamoureux et al. [
11] found that physical functioning was one of the main predictors of participation restrictions among people with impaired vision. Our finding indicates that physical fitness may be an important prerequisite for participation. This knowledge can be used for the development of rehabilitative interventions.
With respect to the social status variables, only social network size was associated with participation in major life areas (i.e., voluntary work). To our knowledge, this relationship has not been studied before. Unexpectedly, social support appeared not to be related to participation. This is in contrast with the positive effect of support of family and friends on participation, as found in older adults in general [
32]. We used negative interactions as an indicator of social support instead of positive aspects, such as stimulation or encouragement, which may explain the difference in findings regarding social support. Our choice to use negative social interactions as an indicator of social support was based on previous research in visually impaired older adults [
56]. The low prevalence of negative social interactions in our study population, however, may also explain the lack of association between social support and participation.
The psychological status variables (i.e., mental health, helplessness, self-efficacy, and taking initiatives) contributed to the explained variance of participation across the domains. However, a significant association was only found for the domestic life domain; a higher level of helplessness was associated with decreased participation in domestic life. Helplessness refers to an attributional style, explaining negative events and their consequences as uncontrollable, unpredictable, and unchangeable [
52]. Negative outcome expectancies and negative attributions with regard to vision loss may lead to avoidance behavior. To our knowledge, only Lindo and Nordholm [
57] assessed the relationship between helplessness and participation. In a sample of visually impaired adults of working age, they found that helplessness was associated with perceived difficulties in cleaning the home, shopping, leisure activities, and socializing. Despite the modest associations we found in the multivariate models, it seems important to assess psychological functioning in relation to participation [
37].
Perceived importance of participation appeared to be a major determinant in three out of the four participation domains (i.e., interpersonal interactions and relationships, major life areas, and community, social and civic life). Importance refers to the value that an individual attaches to a specific domain and may influence the motivation and choice to engage in a specific domain of participation. In the domestic life domain, however, we found no association for perceived importance. This may be explained by the fact that household activities and shopping are necessities of daily life, irrespective of how one values these activities.
One of the limitations of the present study is the cross-sectional design which limits the inferences of causality. The inclusion of study participants from a low-vision rehabilitation center may imply the selection of relatively motivated visually impaired older adults. Furthermore, the self-report data derived through telephone interviews may imply social desirability bias. With respect to the outcome measure of the study, there is no consensus yet on how participation should be measured [
58]. At the time of data collection, we concluded, based on a review of Perenboom and Chorus [
59] and on our own literature review, that there was no participation questionnaire available that suited the aim of our study, namely to measure self-reported performance of participation. Therefore, we assessed participation by means of items extracted from available population surveys [
41‐
43], and computed participation domain scores by a summation of the frequency of activities. The actual scores, however, are less than the theoretical maximum because of the limits to a person’s time, resources and energy [
60]. We followed one of the options given by the ICF for differentiating “Participation” from “Activities”, and identified four chapters that represent participation. Whether the “Domestic life” chapter is a domain of participation, or whether it is merely connected to activities, is debatable. Whiteneck and Dijkers [
61] recently stated that this chapter is the most difficult to allocate to activity versus participation, and concluded that domestic life focused mainly on individual activities. If so, this may be another explanation that perceived importance was not related to participation in domestic life activities.
Despite the comprehensive biopsychosocial model, the variance in participation could only partially be explained (range 14.5–28.3%). The low explained variance of participation in interpersonal interactions and relationships may be caused by the positively skewed distribution and consequently small variance of this outcome measure. Another reason may be that participation has multiple determinants which makes it difficult to explain participation more accurately [
62]. Factors that were not included in our study may have been a barrier for participation of our study participants, such as the availability of (public) transport and accessibility of (public) buildings.
To our knowledge, this is the first study that applied a biopsychosocial model in order to investigate determinants of self-reported performance of participation in visually impaired older adults. Knowledge of the factors that influence participation is relevant, since participation contributes to quality of life and well-being [
18‐
20]. The results of the present study may guide the development of future low-vision rehabilitation interventions. The relevance of personal values attached to participation in specific domains underlines the need to assess these values before starting rehabilitation in order to facilitate individual goal-setting. Furthermore, interventions should have a multidisciplinary approach, including physical, psychological and social work intervention techniques. Group rehabilitation, instead of an individual approach, is advised because it facilitates sharing experiences and coping strategies between the visually impaired, and may extend the social network. Future studies are needed to study the effectiveness of multidisciplinary group rehabilitation interventions on participation in society.