Discussion
What This Study Shows
This qualitative study provides a complex model to explain why the experience of vision loss is not always acted on by older people. The model includes psychological attributes, costs to the individual and judgments about normal ageing. The three dimensions of the model could be used by practitioners to identify factors that keep individuals from seeking help and hence a group of higher–risk individuals, for case-finding for vision loss.
Strengths and Limitations of the Study
The strengths of this study are that its theoretical framework and methods have been made explicit, and the sampling strategy was comprehensive to ensure generalisability of the conceptual analysis, and the number of participants was large. We have offered a detailed description of the fieldwork, and described the trustworthiness of our analysis through independent inspection of our data. The data analysis is clearly described and theoretically justified, and its reliability was ensured by having more than one researcher undertaking the analysis. We have described our search for contradictory perspectives. The limitations are that the sample was drawn from a single practice in suburban north London, which chose to continue their participation in a lengthy study of health risk appraisal, and that no different themes emerged from the individual interviews, compared with the focus groups.
Comparison With the Literature
A survey by the RNIB of 5,000 people aged 60 and over exploring the barriers to eye-testing, found that almost half (47%) do not have annual eye tests. Sixty percent of respondents who had not had their eyes tested in the past two years said the main reason for not going was that they had not had a problem with their eyes, which is consistent with the difficulty with judgements about changing eyesight noted in this study. Eighteen percent said the cost of glasses was the main deterrent, rising to 21–26% in low income groups, which supports the views of participants in this study. Of those aged 80 and over, difficulties with access due to transport accounted for 25% of the respondents' reports that they had not had their eyes checked. The importance given to psychological factors is consistent with the importance of self-efficacy in determining uptake of preventive health care in this study population.
Implications for Practice and Research
Education and awareness of the medical and care community, in particular the role of general practitioners in promoting eye health, is a key area of action identified by the Eye Health Alliance. Currently, visual assessment is only required under the Quality and Outcomes Framework (QOF), the annual incentive programme for disease management in general practice, for patients with diabetes. The characteristics of the high-risk group for undetected vision loss could be incorporated into a heuristic (rule of thumb) to help practitioners to identify older patients whose vision could usefully be assessed. This potential heuristic needs development and testing in routine practice.
Another way in which this model can be used is to consider which axis is the most easily modified, so that early efforts to change the situation are more likely to be fruitful. For example, one way to reduce avoidant behaviour may be to reduce the perceived commercial interests of optometrists, by making their relationship with the NHS more visible.