Adaptation of LiFE for older people with vision impairment (v-LiFE)
Initial adaptations
The participant manual, activity planner and activity counter all needed to be made accessible to people with vision impairment.12 The participant manual was modified into large print, electronic (PDF) and audio (CD) versions to suit a variety of vision conditions and preferences. The LiFE manual was also updated to shorten text, and case studies were replaced with examples of people with vision impairment, to ensure participants could identify with the program. The activity planner and activity counter were modified into large print, extra-large print, and electronic (PDF) versions. Participants were encouraged to use whatever device or method of recording they were already familiar with in order to increase compliance. Examples of recording methods included tally counters, voice recorders, counters in a box, marking calendars or electronically recording activities using spreadsheets or word processing software.
Previous pilot testing11 revealed that the standard number of sessions for LiFE was insufficient to adequately train some of the participants in all program activities. Consequently, Instructors were given the option to include an additional two sessions, if required. This was negotiated between Instructors and their individual recipients, which is in line with usual individually-tailored orientation and mobility service delivery. Instructors were encouraged to facilitate participants’ learning by using tactile modelling, verbal instructions, and introduce cues to prompt action (behavioural, situational and environmental) and encourage practice, repetition and reinforcement of activities.
Ongoing adaptations
In the interviews, Instructors reported using a person-centred approach to adapting and delivering the program. Overall, the program was tailored to participants’ preferences (such as where or how often they like to exercise), home environment and health status. Table 1 shows specific adaptations reported by Instructors.
Table 1. Adaptations to the v-LiFE program as reported by Orientation and Mobility Specialists (Instructors)
Adaptations
|
Specific adaptations
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Physical
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Adapted program activities for comorbidities and injuries using performance in the v-LiFE Assessment Tool, professional judgement and advice from the physiotherapist LiFE trainer
|
Program materials
|
Participant manual: Large text, audio, pdf
Recording devices: Large text activity planner and activity counter, word processing software document, spreadsheets, voice recorder, beads
v-LiFE Assessment Tool: Used at the start to guide level of activities, but also used at the end to reinforce progress
|
Activity frequency
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Routine-based (as per LiFE) or allowed LiFE activities to be completed as a block if the participant is not able to complete activities throughout the day
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Number of sessions
|
Additional sessions for older participants, those with health issues, or those having trouble remembering activities
Fewer sessions (which still enabling habit formation of program activities) for younger participants, those without health issues, or those who implemented activities quickly
|
Prompts to perform activities
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Home item prompts (such as a tissue box out of place, or a tooth brush placed in a lower drawer)
Prompts specific to those with low vision: Coloured/big markers/stickers
Prompts specific to those who are blind: Tactile markers (such as embossed stickers)
|
Family
|
Family assisted in recording and monitoring completion of activities
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Training and support required for Orientation and Mobility Specialists (Instructors) to deliver v-LiFE
Seventy-three Instructors received two days of training (approximately 9 hours) in the v-LiFE program. Of these, 51 (69.9%) delivered at least one session to participants between March 2017 and April 2019 (Table 2). Of these 51 Instructors, the abovementioned physiotherapist who was available for technical advice and support, provided phone or email support to seven (13.7%) and two (3.9%) Instructors, respectively. On Instructor request, the experienced colleague attended sessions with two (3.9%) Instructors, and provided phone or email support to 14 (27.5%) and 12 (23.5%) Instructors, respectively.
Table 2. Support provided to Orientation and Mobility Specialists (Instructors) by the physiotherapist and experienced colleague
Trained Instructors (N = 73)
|
Instructors delivered v-LiFE: n (%)
|
51 (69.9)
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Physiotherapist support
|
|
Observed session: n (%)
|
0 (0)
|
Phone: n (%)
|
7 (13.7)
|
Email: n (%)
|
2 (3.9)
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Colleague support
|
|
Observed session: n (%)
|
2 (3.9)
|
Phone: n (%)
|
14 (27.5)
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Email: n (%)
|
12 (23.5)
|
n = number, v-LiFE = Lifestyle-integrated Functional Exercise program for people with vision impairment
Participants
Older adults with vision impairment
Of the 294 RCT participants randomised to receive v-LiFE, the 172 participants who had finished the program at the time of this investigation, and were therefore eligible for a post-intervention interview,and were contacted for by phone interview between March 2017 and April 2019. Of these, three3 were unreachable or declined interview and 15 had withdrawn from the study. Interviews were ceased at 154 interviews, and no more participants were invited after this point. This large sample ensured due to thematic saturation of this diverse population, and no more participants invited after this point. Table 3 shows the demographic characteristics of the 154 v-LiFE recipients who completed the post-intervention interview.
Table 3. Older adults with vision impairment demographic characteristics (N=154)
Demographic characteristics
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N = 154
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Age in years (range: 52 to 92): mean (SD)
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73.2 (10.2)
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Female: n (%)
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92 (59.7)
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Living status
|
|
Live alone: n (%)
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66 (42.9)
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Spouse only: n (%)
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60 (39.0)
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Spouse and children: n (%)
|
15 (9.7)
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Relatives/children: n (%)
|
11 (7.1)
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Other: n (%)
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2 (0.0)
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Education
|
|
Beyond high school: n (%)
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79 (51.6)
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High school: n (%)
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68 (44.4)
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Primary school: n (%)
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6 (3.9)
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Body mass index (Kg/m2): mean (SD)
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28.4 (6.0)
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Comorbidities, n: mean (SD)
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6.6 (3.5)
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Legally blind: n (%)
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134 (87.0)
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Visual acuity (LogMAR): mean (SD)
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1.3 (1.0)
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Contrast sensitivity: mean (SD)
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0.9 (0.7)
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Visual field defect: n (%)
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85 (55.2)
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Vision conditions
|
|
Age-related macular degeneration: n (%)
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48 (31.2)
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Glaucoma: n (%)
|
31 (20.1)
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Retinitis pigmentosa: n (%)
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27 (17.5)
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Cataract: n (%)
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22 (14.3)
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Stroke / head injury: n (%)
|
17 (11.0)
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Diabetic retinopathy: n (%)
|
5 (3.3)
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Don't know/other: n (%)
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75 (48.7)
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Number of vision conditions
|
|
1: n (%)
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103 (66.9)
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2: n (%)
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35 (22.7)
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3: n (%)
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13 (8.4)
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4: n (%)
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2 (1.3)
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5: n (%)
|
1 (0.6)
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n = number, SD = standard deviation
Most recipients were overweight or obese (105/154, 68%; mean body mass index 28.4 kg/m2, standard deviation (SD) 6.0 kg/m2), were older (mean age 73.2 years, SD 10.2 years), female (92/154, 60%), and with high school or above education (147/154, 96%). Recipients were on average 73.2 years of age (SD 10.2 years). The most common vision conditions were age-related macular degeneration (458/154, 31%), glaucoma (31/154, 20%) and retinitis pigmentosa (27/154, 18%). The majority of recipients had only one vision condition (1034/154, 705%).
Orientation and Mobility Specialists (Instructors)
Twenty Instructors were invited to participate in an interview between June and August 2018; of these, eight were unreachable and one declined following initial interest. Interviews were ceased at 11 interviews due to thematic saturation, and no more Instructors invited after this point. Table 4 shows characteristics of the 11 Instructors who completed the interview.
Table 4. Characteristics of the sample of Orientation and Mobility Specialists (Instructors) interviewed (n=11)
Instructor
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Gender
|
Years in role
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Metropolitan/regional
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Older adults with vision impairment trained in v-LiFE, n
|
1
|
F
|
17
|
Metro
|
10
|
2
|
F
|
4
|
Metro
|
3
|
3
|
F
|
2
|
Regional
|
16
|
4
|
M
|
10
|
Metro
|
8
|
5
|
F
|
9
|
Metro
|
6
|
6
|
F
|
8
|
Metro
|
4
|
7
|
M
|
8
|
Metro
|
2
|
8
|
F
|
9
|
Regional
|
6
|
9
|
F
|
2
|
Regional
|
8
|
10
|
F
|
11
|
Metro
|
1
|
11
|
F
|
20
|
Metro
|
1
|
F = female, M = male
The majority of Instructors were female (9/11, 82%) and delivered services in a metropolitan area (8/11, 73%). On average, Instructors had worked in their role for 9.1 years (SD 5.6 years) and delivered the program to between 1–16 participants (mean 5.9, SD 4.5) at the time of interview.
Semi-structured interviews
Themes from interviews with recipients and Instructors were mapped broadly onto the behaviour change wheel intervention functions of enablement, education, persuasion, incentivisation, coercion and environmental restructuring. Themes were also mapped to the COM-B model for the individual participant’s capability, opportunity and motivation16 (summarised in Table 5 with illustrative quotes). Program implementation was also interpreted within habit formation theory21 which was the basis for v-LiFE. Overall, recipients were able to access and engage with the program. However, the program was considered too easy for younger recipients or those already undertaking physical activity or exercise. Instructors generally enjoyed delivering the program and saw it as an extension of their work. Although criticism was scarce, there was some criticism of the high number of activities and difficulty in recording activities for a wide range of participants with different levels of vision or ability to utilise technology.
Table 5. Identified themes from semi-structured interviews with older adults with vision impairment and Orientation and Mobility Specialists (Instructors), and behaviour change wheel components
Themes
|
Quotes
|
Behaviour Change Wheel Component
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Intervention functions
|
Sources of behaviour (subset)
|
Older adults with vision impairment perspectives
|
Delivery aptitude
|
‘Instructors were helpful, making it enjoyable’ (F, 80),
‘…Instructors are very aware of the vision impairments we have’ (M, 70)
‘I found it enjoyable, especially speaking to the … instructor and how I can improve’ (F, 72).
|
Enablement
|
Opportunity (Physical)
|
Social norms
|
‘Yes, [I would recommend it] to anyone with vision problems and balance issues. Particularly those with a cane’ (M, 72).
‘I would recommend it to anyone in fact. There's great value in that. Everyone could benefit from increasing their balance and strength, and those with vision impairment’ (F, 66).
‘I think it would be better suited to more elderly people and less active people’ (F, 59)
‘Not really but this is mostly likely because I am young and still active. These exercises seem more suitable for older adults and those who are not as active or have really bad vision or other disabilities’ (F, 61)
|
Education, persuasion, incentivisation & coercion
|
Motivation (Reflective)
|
Education, training & enablement
|
Capability (Psychological)
|
Habit formation
|
‘(I) have modified the way I (do) daily activities: hanging clothes on line with a sideways steps, tandem walk while waiting for toast’ (M, 68).
‘I didn't like the daily activity ones and didn't have time for them so instead [the Instructor] and I set them up to do them all in sets together’ (M, 68).
|
Environmental restructuring & enablement
|
Opportunity (Physical)
|
Motivation (Automatic)
|
Instructor perspectives
|
Individualised adaptations
|
‘I guess it’s like what we do in O&M… it’s second nature…I modify everything for every person. Because the technique is still the same but the instructions have to change or the environment has to change’ (F, 17 years, 10 older adults with vision impairment).
‘I’d go through that first assessment to see what they could do and then if I felt that they could do a little less of that level, but with some kind of considerable modification I would try that with them, but I’d let them tend to guide me’ (F, 2 years, 16 older adults with vision impairment).
|
Environmental restructuring & enablement
|
Opportunity (Physical)
|
Complimentary to scope of practice
|
‘I just enjoyed the program as a whole; teaching them [older adults with vision impairment] the activities that helped improve their strength and balance and just seeing how much of an improvement it makes to them over the course of time.’ (F, 8 years, 5 older adults with vision impairment).
‘I thought the booklets and how it was all done there for you; you didn’t really have to think about it, you just did it. You just followed the step-by-step and followed the structure and you can change and you can modify as you go’ (F, 17 years, 10 older adults with vision impairment).
|
Incentivisation
|
Motivation (Automatic)
|
Challenges to delivery
|
‘I found it difficult embedding the number of activities into some of everyday routines, especially with older clients. It can be difficult for them to remember even a few activities. Yes, there are ways to document or record the activities or the routines that it was embedded into, but again, because there’s so many it just can be difficult to keep track for clients’ (F, 4 years, 3 older adults with vision impairment)
‘I’ve had a couple that were not computer savvy either or didn’t have any text to speech so it’s just been [challenging] how they record it and how they remember to do the activities’ (F, 8 years, 4 older adults with vision impairment)
|
Enablement & environmental restructuring
|
Opportunity (Physical)
|
O&M = Orientation and Mobility, v-LiFE = Lifestyle-integrated Functional Exercise program for people with vision impairment
Older adults with vision impairment perspectives
Delivery aptitude. Although not explicitly asked, delivery by Instructors was well-regarded based on a perceived good understanding of how vision influences mobility, and the need to adapt activities accordingly. Recipients also appreciated the regular one-on-one sessions in their home and found the program pace well-suited to them.
Social norms. Recipients reported that they would recommend the program to someone like themselves, including those with or without vision impairment, particularly because the program is individualised and aims to improve strength and balance. Recipients who said they would not recommend the program to someone like themselves were usually younger (≤ 65 years) and stated the program would be more appropriate for someone older or less mobile.
Habit formation. Either embedding v-LiFE activities into daily routines or doing the activities in sets was reported. For most, embedding was the preferred method. This aligns with habit formation theory, whereby behaviours are repeated in response to contextual cues, until which point they become automatic.21 However, some recipients preferred to modify the program so that activities were done together rather than throughout the day, often because of time constraints, or preference for a more traditional set-based exercise program.
Orientation and Mobility Specialist (Instructor) perspectives
Individualised adaptations.
Number of sessions. Views were divided among Instructors about whether they should modify program length for each participant or not. For those who didn’t, it was usually because of concern about deviating from the research protocol. All Instructors reported that if the program was rolled out as part of usual service delivery in the future, they would vary session number based on recipients’ preferences, home environment and health statuscircumstances.
Program materials. Typically, recipients’ level of vision had the most impact on whether materials were used and/or modified. For those with functional vision, the activity planner and activity counter were used to record activity completion. For those with low vison, the planner and counter were modified with less text/increased font size. For those with low or no vision, tactile markers were used to aid or replace the activity planner or counter. Other technologies, such as voice recorders or electronic documents were used for some. For those who lived with others, a family member often assisted with completing the activity planner and counter.
Complimentary to scope of practice. All Instructors interviewed reported feeling comfortable and supportive delivering the v-LiFE program to older adults with vision impairment. The benefits experienced by recipients during the program were particularly motivating, and the clear structure of the program was appreciated by the Instructors. Conversely, Instructors reported that other work priorities, such as travel and data collection for the RCT, were external barriers to delivering the program.
Challenges to delivery. Although reported challenges were scarce, Instructors noted two main challenges when delivering the v-LiFE program to older adults with vision impairment. First, Instructors considered it challenging to teach and embed all of the program activities into recipients’The first related to the large number of activities recipients were required to embed into their daily routine, particularly with those who were older or with cognitive issues. The second related to recording activities; although there were many options to record activities, there were instances where Instructors had difficulty finding a method appropriate to the recipient’s vision, memory or technological ability.