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(The Effectiveness of Comprehensive Low Vision Services for Older Persons\
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( - November 2004)Tj
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(The Effectiveness of )Tj
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(Comprehensive Low Vision )Tj
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(Services for Older Persons )Tj
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(with Visual Impairments in )Tj
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(Abstract:)Tj
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( This study evaluated the effects of providing )Tj
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(comprehensive low vision services to elderly persons with )Tj
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(visual impairments in New Zealand. The 93 participants )Tj
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(were matched on age, gender, and visual function with 93 )Tj
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(who did not have access to comprehensive low vision )Tj
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(services. No significant differences were found between )Tj
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(the groups at posttest and follow-up on the three primary )Tj
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(dependent variables of visual function, instrumental )Tj
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(activities of daily living, and quality of life.)Tj
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(The author thanks the Royal New Zealand Foundation )Tj
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(of the Blind for its funding of and collaboration in this )Tj
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(study, especially Paula Daye, chief executive officer, )Tj
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(and Trisha Fitzgerald, project manager, for their )Tj
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(dedication to seeing this project to fruition.)Tj
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(The population of New Zealand, as in many other parts )Tj
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(The Effectiveness of Comprehensive Low Vision Services for Older Persons\
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( - November 2004)Tj
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(of the world, is aging, with the most significant growth )Tj
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(in population occurring in the older age groups \(Health )Tj
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(Funding Authority, 1998\). As the population ages, so )Tj
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(does the incidence and prevalence of visual impairment )Tj
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(\(Brennan & Silverstone, 2000; Tielsch, 2000\). In the )Tj
T*
(1996\22697 New Zealand census, 74,000 persons out of a )Tj
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(population of about 4 million indicated that they had )Tj
T*
(difficulty seeing ordinary newsprint or faces from )Tj
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(across the room, even when they wore corrective )Tj
T*
(lenses, to the extent that they required some assistance )Tj
T*
(in functioning \(Health Funding Authority, 1998\). Of )Tj
T*
(these 74,000 persons, about 55% were aged 65 and )Tj
T*
(older. The rate of occurrence of visual impairments )Tj
0 -1.3 TD
(increased from 7 per 1,000 for those younger than age )Tj
0 -1.3 TD
(15 to 98 per 1,000 for those older than age 65 \(Health )Tj
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(Funding Authority, 1998\).)Tj
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(As the population has continued to age, age-related )Tj
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(visual impairments \(visual impairments in persons )Tj
T*
(aged 50 and older\) have become the most common )Tj
T*
(cause of visual impairments in New Zealand and refers )Tj
T*
(to conditions resulting from both normal and )Tj
T*
(pathological changes in the eye related to the aging )Tj
T*
(process \(Brennan & Silverstone, 2000; Rubin, 2000; )Tj
T*
(Schwartz, 2000\). Typical visual changes that are )Tj
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(associated with aging include reductions in visual )Tj
T*
(acuity, response time in adjusting to lowered levels of )Tj
T*
(light, and color discrimination; the most common )Tj
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(pathological conditions related to increasing age are )Tj
T*
(cataracts, diabetic retinopathy, glaucoma, and macular )Tj
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(degeneration \(Brennan & Silverstone, 2000\).)Tj
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(The Effectiveness of Comprehensive Low Vision Services for Older Persons\
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(The onset of age-related visual impairments has been )Tj
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(observed to affect the performance of instrumental )Tj
T*
(activities of daily living \(IADLs\) and to decrease )Tj
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(morale among those who are affected \(Katz & Tielsch, )Tj
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(1996; La Forge, Spector, & Sternberg, 1992; Lindo & )Tj
T*
(Nordholm, 1999; Rudberg, Furner, Dunn, & Cassel, )Tj
T*
(1993\). People who have age-related visual impairments )Tj
T*
(also report more hospital admissions, nursing home )Tj
0 -1.3 TD
(admissions, and contacts with physicians than do )Tj
T*
(persons of the same age who are not visually impaired )Tj
T*
(\(Branch, Horowitz, & Carr, 1989\). They primarily )Tj
T*
(have low vision, and the incidence of total blindness is )Tj
T*
(low. Thus, low vision services are particularly relevant )Tj
0 -1.3 TD
(to them. Comprehensive low vision services, which )Tj
0 -1.3 TD
(consist of a coordinated and integrated approach to the )Tj
T*
(provision of interdisciplinary services, both clinical )Tj
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(low vision services and traditional vision rehabilitation )Tj
T*
(services, are thought to be even more essential )Tj
T*
(\(Goodrich & Bailey, 2000\).)Tj
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(Although comprehensive low vision services are not )Tj
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(generally available in New Zealand, a range of hospital-)Tj
T*
(based, university-based, and private low vision clinics )Tj
T*
(exist, as well as a range of functional low vision )Tj
T*
(interventions and aids that are provided by field staff of )Tj
0 -1.3 TD
(the Royal New Zealand Foundation of the Blind )Tj
T*
(\(RNZFB\) to enrolled members as part of RNZFB\222s )Tj
T*
(overall rehabilitation program. Yet, these services are )Tj
T*
(neither evenly distributed across New Zealand nor )Tj
T*
(coordinated to provide for a cohesive interface among )Tj
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(The Effectiveness of Comprehensive Low Vision Services for Older Persons\
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( - November 2004)Tj
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(them. While there is little doubt that specific optical )Tj
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(and nonoptical interventions are effective in increasing )Tj
T*
(visual function for specific tasks \(Goodrich & Bailey, )Tj
0 -1.3 TD
(2000\), there is only limited evidence of improvement )Tj
0 -1.3 TD
(in independence and mixed results on measures of )Tj
T*
(social interaction and health status for this age group )Tj
T*
(from the provision of either type of service \(Crews, )Tj
T*
(1991; Davis, Lovie-Kitchin, & Thompson, 1995; )Tj
0 -1.3 TD
(Elliott & Kuyk, 1994; Engel, Welsh, & Lewis, 2000; )Tj
T*
(Fagerstrom, 1994; Horowitz, Leonard, & Reinhardt, )Tj
T*
(2000\). However, the recipients of comprehensive low )Tj
T*
(vision services, which integrate these services, have )Tj
T*
(been more consistently credited with a greater ability )Tj
0 -1.3 TD
(to perform a variety of tasks for independent living )Tj
0 -1.3 TD
(with greater independence and self-esteem and fewer )Tj
T*
(physical and mental health problems \(Crews, 2000; )Tj
T*
(Goodrich & Bailey, 2000; Stuen, 2000\). As a result, it )Tj
T*
(may be expected that the provision of a comprehensive )Tj
T*
(low vision service would ameliorate many of the )Tj
T*
(difficulties associated with the onset of significant )Tj
T*
(visual impairments among this population.)Tj
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(A project group was formed by RNZFB to oversee this )Tj
0 -1.3 TD
(study. The group advised on the aims of the study and )Tj
T*
(approved its design and method. A project manager )Tj
0 -1.3 TD
(oversaw all aspects of the study from recruitment of )Tj
T*
(participants to presentation of results. The specific )Tj
T*
(aims of this study, as approved by the advisory group, )Tj
T*
(were to investigate the effectiveness of comprehensive )Tj
T*
(low vision services on visual function, instrumental )Tj
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(activities of daily living \(IADLs\), quality of life )Tj
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(\(QOL\), and the use of health care services in persons )Tj
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(comparisons were made across groups and over time. )Tj
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(The across-group comparisons were made between )Tj
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(comprehensive low vision services and services that )Tj
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(are typically available to this population, since it was )Tj
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(not the purpose of this study to ascertain whether low )Tj
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(vision services are effective compared to no services. )Tj
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(Rather, the purpose was to ascertain whether the )Tj
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(provision of comprehensive low vision services offered )Tj
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(a benefit over and above the mix of services that were )Tj
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(already available to the participants. The currently )Tj
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(available services included both clinical low vision )Tj
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(services and field services available from the RNZFB. )Tj
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(Field services included assessment and instruction in )Tj
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(independent living skills \(ILS\), orientation and )Tj
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(mobility \(O&M\), and communications, as well as )Tj
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(recreational and leisure activities. They are generally )Tj
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(staff and are available to all members of the RNZFB. )Tj
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(Persons are eligible for membership in the RNZFB if )Tj
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(the better eye after the best-possible correction or a )Tj
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(Comprehensive low vision services,)Tj
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( as assessed in this )Tj
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(The services included \(1\) assessment of ocular health, )Tj
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(near and distance acuity, central and peripheral field, )Tj
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(contrast sensitivity, and functional vision; \(2\) )Tj
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(prescription of optical and nonoptical aids; \(3\) loaning )Tj
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(of prescribed aids; \(4\) training in the use of these aids; )Tj
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(and \(5\) follow-up. The RNZFB field staff )Tj
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(supplemented the services of these clinics by providing )Tj
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(preclinical assessments and follow-up instruction in the )Tj
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(participants\222 homes. Instruction included the use of )Tj
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(prescribed optical and nonoptical aids for fulfilling )Tj
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(various IADLs.)Tj
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(The services were standardized across the four sites to )Tj
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(the greatest extent possible. All four sites shared an )Tj
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(operations manual; standard forms for referrals, )Tj
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(making appointments, responding to referral sources, )Tj
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(and establishing clients\222 histories and profiles; an )Tj
T*
(assessment prompt form; a client\222s record sheet; a )Tj
T*
(clinical record; and an equipment order form. The four )Tj
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(sites were monitored throughout the study with the use )Tj
T*
(of these standard forms to assess the degree to which )Tj
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(the services appeared to be standardized across )Tj
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(settings. Although some variation occurred across the )Tj
T*
(sites in the average number of aids prescribed and )Tj
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(hours of instruction provided, this variation seemed to )Tj
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(be appropriate and was accounted for by differences in )Tj
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(Although the services of all the participating clinics )Tj
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(were available to all persons who were referred to )Tj
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(them, regardless of age, only those aged 65 and older )Tj
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(who agreed to participate and were successfully )Tj
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(administered a pretest questionnaire before any of the )Tj
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(components of service were provided were included in )Tj
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(the study. Of 139 persons who received services from )Tj
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(the four clinics during the course of this study, 93 )Tj
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(persons \(64 women and 29 men\) met the criteria for )Tj
T*
(inclusion. These participants ranged in age from 65 to )Tj
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(95, with a mean age of 80.6. They were matched on )Tj
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(age, gender, and visual function with 93 persons from a )Tj
T*
(pool of 192 potential contrast-group participants, who )Tj
0 -1.3 TD
(ranged in age from 65 to 94, with a mean age of 80.3. )Tj
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(Gender and responses to the screening question for )Tj
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(visual function were identical across the groups as a )Tj
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(result of the matching process.)Tj
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(Procedure)Tj
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(One reason for the mixed results of earlier studies on )Tj
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(the effects of clinical services and traditional )Tj
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(rehabilitation services with elderly persons with low )Tj
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(vision \(Crews, 1991; Davis et al., 1995; Elliott & )Tj
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(Kuyk, 1994; Engel et al., 2000; Fagerstrom, 1994; )Tj
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(Horowitz et al., 2000\) may be that these studies have )Tj
T*
(often been limited to a single-group design using pre-)Tj
T*
(and posttest measures. Thus, the analysis of the )Tj
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(findings have not always been able to identify the )Tj
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(relative effect of these services on function over and )Tj
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(above the decline in health and function that has been )Tj
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(observed to occur in this population over time. )Tj
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(Furthermore, the researchers may not have been able to )Tj
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(establish control over time as a confounding variable.)Tj
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(This study sought to address this problem with a )Tj
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(contrast group, since I and the advisory group could )Tj
T*
(not, in good conscience, randomly assign members to )Tj
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(experimental and control groups and therefore )Tj
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(systematically deny access to these services to half the )Tj
T*
(participants. As a result, a contrast group was selected )Tj
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(from a pool of 192 persons who were willing to )Tj
T*
(participate in the study as members of a contrast group )Tj
0 -1.3 TD
(and who were recommended by ophthalmic and )Tj
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(optometric practices and the RNZFB. All potential )Tj
T*
(participants in the contrast group lived in areas of the )Tj
T*
(country where comprehensive low vision services were )Tj
T*
(not available. No existing or commonly available )Tj
T*
(services were kept from them. As a result, the only )Tj
T*
(planned difference between the groups was that one )Tj
T*
(received comprehensive low vision services and the )Tj
T*
(other did not.)Tj
0 -2.399 TD
(To achieve as much equivalence between the groups as )Tj
0 -1.3 TD
(possible, samples were matched on age, sex, visual )Tj
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(function \(rated on a 5-point Likert scale in response to )Tj
T*
(the question, \223How much difficulty do you have )Tj
T*
(reading ordinary print in newspapers?\224\), and ethnicity. )Tj
T*
(Most members of the contrast group were randomly )Tj
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(selected when possible from the pool of potential )Tj
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(the participants in the experimental group. Other )Tj
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(members of the contrast group were not randomly )Tj
T*
(selected, however, because, in some cases, only one )Tj
0 -1.3 TD
(member in the pool was a match for a member of the )Tj
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(experimental group.)Tj
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(All members of the experimental group received, at a )Tj
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(minimum \(1\) a preclinical assessment before their )Tj
T*
(appointment at the low vision clinic, \(2\) an initial low )Tj
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(vision examination, \(3\) training with any aids or )Tj
T*
(devices prescribed in the clinic, \(4\) the loan of these )Tj
T*
(aids for the duration for which they were needed, and )Tj
T*
(\(5\) a follow-up visit in their homes from the RNZFB )Tj
T*
(field staff, with repeated visits for instruction if )Tj
T*
(required.)Tj
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(Measures were taken at intake, before the provision of )Tj
0 -1.3 TD
(any services \(pretest\), and again at a six-month )Tj
T*
(\(posttest\) and one-year interval \(follow-up\) after the )Tj
T*
(provision of services to compare the groups over time, )Tj
T*
(as suggested by Head, Babcock, Goodrich, and )Tj
T*
(Boyless \(2000\). As a result, the design used in this )Tj
T*
(study was classified as a separate-samples )Tj
T*
(\(nonequivalent groups\) pretest\226posttest design with )Tj
T*
(follow-up \(Campbell & Stanley, 1966\).)Tj
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(Three primary and two secondary dependent variables )Tj
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(were assessed. The primary dependent variables were )Tj
T*
(visual function, independence in IADLs, and QOL. )Tj
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(The secondary dependent variables were use of health )Tj
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(The National Eye Institute\222s 25-Item Visual Function )Tj
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(Questionnaire \(VFQ-25\) \(Mangione, 2000\) was used to )Tj
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(measure visual function. The VFQ-25 takes )Tj
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(approximately 10 minutes to administer and consists of )Tj
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(25 vision-targeted questions representing 11 vision-)Tj
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(related constructs, plus an additional single-item )Tj
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(general health rating question. A composite score is )Tj
T*
(available and is determined by averaging the scores on )Tj
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(the 11 vision-related subscales \(general vision, ocular )Tj
T*
(pain, near activities, distance activities, vision-specific )Tj
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(social functioning, vision-specific mental health, )Tj
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(vision-specific role difficulties, vision-specific )Tj
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(dependency, driving, color vision, and peripheral )Tj
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(vision\).)Tj
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(The VFQ-25 is available in the public domain, is )Tj
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(normed, and has demonstrated reliability and validity )Tj
T*
(\(Mangione et al., 2001; Margolis et al., 2002\). It also )Tj
T*
(appears to be robust enough to use across multiple )Tj
T*
(conditions of various degrees of severity \(Mangione et )Tj
T*
(al., 2001\) for epidemiological studies and clinical trials )Tj
T*
(\(Klein, Moss, Klein, Gutierrez, & Mangione, 2001\). )Tj
T*
(The VFQ 25 also has tables of power calculations to )Tj
T*
(determine the required sample sizes for finding )Tj
T*
(significant differences of different magnitudes. For )Tj
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(example, a sample of 40\226161 pairs is needed to detect )Tj
T*
(a point difference of 10 and 5, respectively, between )Tj
T*
(two groups using a repeated-measures design. A mean )Tj
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(moderate but important difference between the groups )Tj
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(\(Mangione, 2000\). As a result, this study had a power )Tj
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(of just over 90% to yield a statistically significant )Tj
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(result if a moderate difference was found between )Tj
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(groups on the VFQ composite score when tested )Tj
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(against a theoretical value of 0.00.)Tj
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(Elliott and Kuyk\222s \(1994\) Measure of Functional and )Tj
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(Psycho-social Outcomes of Blind Rehabilitation was )Tj
T*
(adapted for use in this study as a measure of )Tj
T*
(independence in daily living. This measure may be best )Tj
T*
(characterized as a measure of IADLs. It consists of 13 )Tj
T*
(questions stated in the first person, with respondents )Tj
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(asked to respond on a 4-point scale, from strongly )Tj
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(agree to strongly disagree, to a series of statements )Tj
T*
(starting with \223In my daily life at home, I am.\205\224 A )Tj
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(sample question would be, \223In my daily life at home, I )Tj
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(am )Tj
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(capable of preparing my own meals.\224)Tj
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( Domains )Tj
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(include O&M, ILS, communications, and leisure )Tj
T*
(pursuits. This measure was selected for use in this )Tj
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(study because of its clear relevance to visual )Tj
T*
(impairments; its brevity; and its demonstrated )Tj
T*
(reliability, validity, and sensitivity as a measure with )Tj
T*
(this population \(Elliott & Kuyk, 1994\).)Tj
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(case, it was a measure of life satisfaction and consisted )Tj
T*
(of the statement, \223In the past six months, I would say )Tj
T*
(my overall quality of life has been \(a\) excellent, \(b\) )Tj
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(very good, \(c\) good, \(d\) fair, \(e\) poor.\224 The )Tj
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(Responses from all three primary dependent measures )Tj
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(were transformed so that positive responses had higher )Tj
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(values. The response categories were weighted as 1 = )Tj
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(0, 2 = 25, 3 = 50, 4 = 75, and 5 = 100, as directed in )Tj
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(the instruction manual for the VFQ-25 \(Mangione, )Tj
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(2000\).)Tj
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(health, falls, and the use of medical services \(such as )Tj
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(visits to physicians, visits from nurses, nights spent in )Tj
T*
(a hospital, and nights spent in a residential care )Tj
T*
(facility\). These questions were based, in large part, on )Tj
T*
(the physical health subscale used by Engel et al. )Tj
0 -1.3 TD
(\(2000\), who reported significant improvements on this )Tj
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(measure following the provision of vision )Tj
T*
(rehabilitation services to an aging population. Four of )Tj
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(the questions were used to constitute the secondary )Tj
T*
(dependent measures, outpatient and inpatient care. The )Tj
T*
(variable outpatient care included the number of visits )Tj
T*
(to physicians and the number of visits from nurses over )Tj
T*
(the past two months that the participants remembered. )Tj
T*
(The variable inpatient care included the number of )Tj
T*
(nights spent in a hospital or a residential care facility in )Tj
T*
(the past two months that the participants remembered. )Tj
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(status. The other four questions, about health-related )Tj
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(The Effectiveness of Comprehensive Low Vision Services for Older Persons\
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( - November 2004)Tj
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(covered the following areas: \(1\) visual function \()Tj
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(n)Tj
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( = )Tj
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(25\), \(2\) independence in IADLs \()Tj
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(n )Tj
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(= 13\), \(3\) QOL \()Tj
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(n )Tj
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(= )Tj
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(1\), \(4\) physical health and the use of health care )Tj
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(services \()Tj
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(n)Tj
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( = 9\), and \(5\) demographic information \()Tj
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(n )Tj
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(= )Tj
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(10\).)Tj
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(monitor the equivalence of the programs across )Tj
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(regions, all data used to assess the effectiveness of the )Tj
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(services were collected through self-reports using the )Tj
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(questionnaire described earlier, which was )Tj
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(administered by telephone because of the potential )Tj
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(problems with self-administration that could be )Tj
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(approximately 40 minutes to administer.)Tj
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(the start of data collection to gain feedback on the )Tj
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(wording of the questionnaire, determine the mean time )Tj
T*
(required for its administration, and assess its test\226retest )Tj
T*
(reliability. Because of this trial, six questions were )Tj
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(reworded, and the direction of response categories )Tj
T*
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(subscales to correspond with those in the VFQ-25, )Tj
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(which was the only standardized measure used. Test\226)Tj
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(retest reliability was assessed and found to be )Tj
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(r)Tj
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( = .98. )Tj
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(A measure of internal consistency \(Chronbach\222s alpha\) )Tj
T*
(was also determined and found to be alpha = .94.)Tj
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(All participants were followed up by a third party to )Tj
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(to ensure that the telephone interviews had been )Tj
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(conducted in the expected manner. Some problems )Tj
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(and in one case, data were not included from a )Tj
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(As was mentioned earlier, 139 persons who met the )Tj
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(criteria for selection were seen by the four participating )Tj
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(low vision clinics during the study. Of the 139, 22% )Tj
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(were classified as having mild visual impairment, 50% )Tj
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(as having moderate visual impairment, and 28% as )Tj
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(having severe visual impairment.)Tj
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(electromechanical\) were prescribed for the 139 persons )Tj
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(at the four centers for an average of 2.14 per client. Of )Tj
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T*
(of which were identified as being near-point or near-)Tj
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(point and other aids, 1 as a distance aid only, and 14 as )Tj
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(other. Of the 139 persons, 62% were prescribed at least )Tj
0 -1.3 TD
(1 optical aid, 22% were prescribed 2, and 16% were )Tj
T*
(prescribed 3 or more. In addition, 167 nonoptical aids )Tj
T*
(were prescribed; 95 were classified as lighting or task )Tj
T*
(lighting, 37 as contrast, 10 as reading stands, and 25 as )Tj
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(other. Of the 139 clients, 46% were prescribed )Tj
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( - November 2004)Tj
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(one aid, 7% were prescribed 2, and 33% were )Tj
0 -1.3 TD
(prescribed 3 or more. In addition, 23 electromechanical )Tj
T*
(devices \(closed-circuit televisions [CCTVs] or )Tj
0 -1.3 TD
(computer-enhancement systems\) were prescribed: 21 )Tj
0 -1.3 TD
(CCTVs and 2 computer-enhancement systems. Of the )Tj
T*
(139 clients, 16.5% were prescribed electromechanical )Tj
T*
(devices; no person was prescribed more than 1 )Tj
T*
(electromechanical device. Aids for IADLs were )Tj
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(sometimes provided and instruction given in their use, )Tj
T*
(but many were either not prescribed per se or were )Tj
T*
(prescribed as nonoptical aids. Thus, the number of )Tj
T*
(devices for IADLs that were prescribed is not indicated.)Tj
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(Training was provided for the use of optical aids, )Tj
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(nonoptical aids, and electromechanical devices, and in )Tj
T*
(various IADLs. All persons who had an optical device )Tj
T*
(prescribed received some level of training, with 17% )Tj
T*
(receiving a half hour or less, 27% receiving a half hour )Tj
T*
(to 1 hour, 36% receiving between 1 and 2 hours, and )Tj
T*
(the remaining 20% receiving more than 2 hours. In the )Tj
T*
(case of training in nonoptical aids, 33% received less )Tj
T*
(than a half hour, 48% received between a half hour and )Tj
T*
(1 hour, and the remaining 19% received an hour or )Tj
T*
(more. Training with electromechanical devices was )Tj
T*
(reported for all but one device that was prescribed. Of )Tj
0 -1.3 TD
(those who received training in these devices, 66% )Tj
T*
(received less than a half hour, 5% received from a half )Tj
T*
(hour to 1 hour, 10% received from 1 to 2 hours, and )Tj
T*
(19% received more than 2 hours. Some training was )Tj
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( - November 2004)Tj
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(vision aids. For those who received such training, 48% )Tj
0 -1.3 TD
(received less than a half hour, 33% received from a )Tj
T*
(half hour to 1 hour, 17% received from 1 to 2 hours, )Tj
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(and 2% received more than 2 hours.)Tj
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(Effectiveness of services provided)Tj
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(Of the 139 persons who were seen in the clinics, 93 )Tj
0 -1.3 TD
(who met the criteria for inclusion in the study agreed to )Tj
T*
(participate and were able to complete the pretest )Tj
0 -1.3 TD
(measure in the manner and time prescribed. These 93 )Tj
0 -1.3 TD
(participants were matched with 93 members of the )Tj
T*
(contrast group. The groups were compared at the )Tj
T*
(pretest stage to determine if any differences on the )Tj
T*
(primary dependent variables \(VFQ, ILS, and QOL\) )Tj
0 -1.3 TD
(were present using a one-way, between-groups )Tj
T*
(multivariate analysis of variance. Preliminary )Tj
T*
(assumption testing was conducted to check for )Tj
T*
(normality, linearity, univariate and multivariate )Tj
T*
(outliers, homogeneity of variance-covariance matrices, )Tj
0 -1.3 TD
(and multicollinearity with no serious violations noted. )Tj
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(A statistically significant difference was found )Tj
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(between the groups on the combined dependent )Tj
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(variables: )Tj
/TT2 1 Tf
(F)Tj
/TT0 1 Tf
( \(3, 182\) = 6.17, )Tj
/TT2 1 Tf
(p)Tj
/TT0 1 Tf
( = .001; Wilke\222s lambda )Tj
0 -1.3 TD
(= .91; partial eta squared = .09\). When the results for )Tj
T*
(the three dependent variables were considered )Tj
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(separately, both the IADL \()Tj
/TT2 1 Tf
(F)Tj
/TT0 1 Tf
( \(1, 184\) = 3.94, )Tj
/TT2 1 Tf
(p)Tj
/TT0 1 Tf
( = .049\) )Tj
T*
(and QOL \()Tj
/TT2 1 Tf
(F)Tj
/TT0 1 Tf
( \(1, 184\) = 12.26, )Tj
/TT2 1 Tf
(p)Tj
/TT0 1 Tf
( = .001\) were found to )Tj
0 -1.3 TD
(differ significantly across the groups. An inspection of )Tj
T*
(the means indicated that the contrast group had a )Tj
0 -1.303 TD
(higher mean score \(IADL )Tj
/TT2 1 Tf
(M)Tj
/TT0 1 Tf
( = 48.8, QOL )Tj
/TT2 1 Tf
(M)Tj
/TT0 1 Tf
( = 59.8\) on )Tj
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( - November 2004)Tj
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(both measures than did the experimental group \(IADL )Tj
/TT1 1 Tf
0 -1.303 TD
(M)Tj
/TT0 1 Tf
( = 46.2, QOL )Tj
/TT1 1 Tf
(M)Tj
/TT0 1 Tf
( = 46.2\).)Tj
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(As a result, the pretest scores on all three primary )Tj
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(dependent variables and both secondary dependent )Tj
0 -1.3 TD
(variables were used as baseline measures for )Tj
T*
(subsequent comparisons, with change in scores )Tj
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(computed and compared across groups at the posttest )Tj
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(and follow-up. As can be seen in )Tj
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(Table 1)Tj
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(significant differences were found between the groups )Tj
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(at the posttest or follow-up on the three primary )Tj
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(dependent variables, VFQ, IADL, and QOL. The most )Tj
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(obvious difference between the groups was the )Tj
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(difference in the group mean on QOL that persisted )Tj
T*
(across time, with the contrast group\222s mean remaining )Tj
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(significantly higher than the experimental group\222s at all )Tj
0 -1.3 TD
(three times.)Tj
0 -2.399 TD
(The secondary dependent variables of use of health-)Tj
0 -1.3 TD
(related services, which included the number of visits to )Tj
T*
(physicians and visits from nurses \(outpatient care\) )Tj
T*
(during the past two months and the number of nights )Tj
T*
(spent in a hospital or residential care facility \(inpatient )Tj
T*
(care\) in the same period were also analyzed. In this )Tj
T*
(case, the participants\222 responses to a general health )Tj
T*
(question were used as a covariate to adjust for current )Tj
T*
(state of health. As can be seen in )Tj
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(Table 2)Tj
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(both variables, and a significant difference was noted )Tj
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(on the change score from the pretest to the posttest for )Tj
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(mean frequency of outpatient care.)Tj
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(The Effectiveness of Comprehensive Low Vision Services for Older Persons\
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( - November 2004)Tj
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(As Tables 1 and 2 indicate, the experimental group\222s )Tj
0 -1.3 TD
(scores were relatively stable over time on the primary )Tj
T*
(dependent variables \(VFQ, IADL, and QOL\), as were )Tj
0 -1.3 TD
(the contrast group\222s, and both improved somewhat on )Tj
0 -1.3 TD
(the secondary dependent variables by showing a )Tj
T*
(decrease in the use of outpatient and inpatient services. )Tj
T*
(As noted earlier, there was a significant difference in )Tj
T*
(the frequency of outpatient visits at the posttest even )Tj
0 -1.3 TD
(though both groups had decreased their mean number )Tj
T*
(of visits from the pretest. A slight increase in both )Tj
T*
(variables occurred from the posttest to the follow-up )Tj
T*
(for both groups but remained below that seen at the )Tj
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(baseline in all but one case \(the contrast group\222s mean )Tj
0 -1.3 TD
(rate of outpatient visits increased slightly, from 1.8 to )Tj
0 -1.3 TD
(2.0\). Only minor differences were found between the )Tj
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(groups, with no clear evidence of improvement from )Tj
T*
(the pretest to the posttest for either group.)Tj
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(One explanation for this apparent lack of effect may be )Tj
0 -1.3 TD
(that a control group \(a no-treatment group\) was not )Tj
T*
(established. Thus, the comprehensive clinical low )Tj
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(vision service was being compared with existing )Tj
T*
(services, including those of the RNZFB. On )Tj
T*
(investigation of the composition of the groups, it was )Tj
T*
(found that 91% of those in the contrast group were )Tj
0 -1.3 TD
(members of the RNZFB. However, it was also found )Tj
T*
(that 45% of the experimental groups were members of )Tj
T*
(the RNZFB at the pretest. To complicate this finding )Tj
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(further, the proportion of those in the experimental )Tj
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( - November 2004)Tj
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(RNZFB increased over time to 70% at the posttest and )Tj
0 -1.3 TD
(79% at the follow-up. Thus, it was clear that one set of )Tj
T*
(services was being compared with the other.)Tj
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(To determine if the difference in QOL could be due to )Tj
0 -1.3 TD
(RNZFB membership status, a follow-up analysis was )Tj
T*
(conducted using membership as the independent )Tj
T*
(variable across the two groups. RNZFB members were )Tj
0 -1.303 TD
(found to have significantly higher \()Tj
/TT1 1 Tf
(F)Tj
/TT0 1 Tf
( \(1, 183\) = 1.55, )Tj
/TT1 1 Tf
(p)Tj
/TT0 1 Tf
( )Tj
0 -1.303 TD
(= .029\) QOL scores \()Tj
/TT1 1 Tf
(M)Tj
/TT0 1 Tf
( = 56.0, )Tj
/TT1 1 Tf
(SD)Tj
/TT0 1 Tf
( = 27.3\) than )Tj
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(nonmembers \()Tj
/TT1 1 Tf
(M)Tj
/TT0 1 Tf
( = 26.6, )Tj
/TT1 1 Tf
(SD)Tj
/TT0 1 Tf
( = 25.8\). It was also clear )Tj
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(that the comprehensive low vision intervention )Tj
T*
(increasingly included RNZFB services, especially in )Tj
T*
(light of the finding that the proportion of RNZFB )Tj
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(members in the experimental group increased from )Tj
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(45% to 79% over the course of the study. As a result, a )Tj
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(follow-up analysis was conducted with the )Tj
T*
(experimental group using RNZFB membership as a )Tj
T*
(grouping variable as reported at the time of assessment )Tj
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(\(the pretest, posttest, and follow-up\). As before, the )Tj
T*
(pretest scores were used as a baseline, with change )Tj
T*
(scores used to determine if a significant difference )Tj
T*
(occurred between the groups over time.)Tj
0 -2.399 TD
(As can be seen in )Tj
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(Table 3)Tj
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(\(1, 91\) = )Tj
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(10.53, )Tj
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(p)Tj
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(\(1, 91\) = 5.07, )Tj
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(the pretest, but no difference on QOL \()Tj
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(some deterioration in the scores from the posttest to the )Tj
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(follow-up for both groups, but more so for those who )Tj
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(were not RNZFB members than for those who were, )Tj
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(except for QOL, where the deterioration resulted in a )Tj
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(dependent variables of the use of health-related )Tj
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(This study sought to investigate the effectiveness of the )Tj
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(provision of comprehensive low vision services to an )Tj
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(older population in New Zealand. Its purpose was to )Tj
0 -1.3 TD
(ascertain whether the provision of comprehensive low )Tj
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(vision services offered a benefit over and above the )Tj
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(mix of services that were already available to the )Tj
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(participants. Of the 139 persons who were provided )Tj
T*
(services over a two-year period from four participating )Tj
0 -1.3 TD
(low vision clinics, 93 agreed to participate and were )Tj
T*
(able to be administered a pretest prior to beginning )Tj
T*
(service. A contrast group, matched on age, gender, )Tj
T*
(ethnicity, and perceived visual difficulty, was used for )Tj
T*
(comparison. The participants in the contrast group )Tj
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(received the services that were normally available to )Tj
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(them, including field services from the RNZFB and )Tj
T*
(services from their regular optometrists or )Tj
T*
(ophthalmologists. Thus, the study compared the )Tj
T*
(provision of comprehensive low vision services to )Tj
T*
(existing services and found little or no difference in the )Tj
T*
(three primary dependent variables: VFQ, IADL, and )Tj
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(QOL. The only difference noted was on the secondary )Tj
T*
(dependent variable of the mean frequency of visits to )Tj
T*
(or from physicians or nurses at the posttest. The )Tj
T*
(experimental group reported a significantly greater )Tj
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(change in the number of visits from the pretest to the )Tj
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(posttest \(a decrease in visits\) than did those in the )Tj
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(contrast group. No difference was found on the other )Tj
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(any of the dependent variables was in QOL. The )Tj
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(contrast group had higher mean QOL scores at all three )Tj
T*
(times. One explanation for this finding may have been )Tj
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(the disproportionate representation of RNZFB )Tj
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(members in the contrast group. A follow-up test across )Tj
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(all the participants, regardless of group affiliation, )Tj
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(found that membership in the RNZFB resulted in a )Tj
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(significant difference on QOL, with members scoring )Tj
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(higher than nonmembers. It was also found that the )Tj
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(difference in membership status across groups was )Tj
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(significant. As a result, a follow-up analysis was )Tj
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(experimental group scored lower on all three primary )Tj
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(dependent measures than did the contrast group and )Tj
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(lower than nonmembers on VFQ and IADL but not on )Tj
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(outpatient services than either the contrast group or the )Tj
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(nonmembers in the experimental group. As a result, )Tj
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T*
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(members, and the nonmembers in the experimental )Tj
T*
(group. The scores on the secondary dependent )Tj
T*
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(experimental groups were likely to have had more )Tj
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(compared. However, they also appeared to make )Tj
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(greater improvements on all measures than did the )Tj
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(the nonmembers, in VFQ and IADL, but not in QOL. )Tj
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(Therefore, it appears that the RNZFB members in the )Tj
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(nonmembers.)Tj
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(The increase in the percentage of RNZFB members in )Tj
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(the experimental group from the pretest to the follow-)Tj
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(up \(from about 45% at the pretest to 70% at the )Tj
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(posttest and 79% at the follow-up\) complicates these )Tj
T*
(assumptions. Thus, the increasing proportion of )Tj
T*
(RNZFB members in this group may have masked some )Tj
T*
(of the benefits that could have been attributed to the )Tj
T*
(combination of membership and receipt of )Tj
0 -1.3 TD
(comprehensive low vision services over time. It was )Tj
0 -1.3 TD
(hypothesized that those who received comprehensive )Tj
T*
(low vision services would improve in function in terms )Tj
T*
(of VFQ and IADL and perception of QOL from the )Tj
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(pretest in comparison to the contrast group, or would )Tj
T*
(maintain their VFQ and IADL functioning and )Tj
T*
(perception of QOL over time while the contrast group )Tj
T*
(deteriorated in both VFQ and IADL function and )Tj
T*
(perception of QOL over time. Neither of these )Tj
T*
(scenarios occurred. Nor did either group deteriorate to )Tj
T*
(any great extent over time. Rather, both groups )Tj
T*
(maintained their levels of VFQ and IADL function and )Tj
0 -1.3 TD
(perception of QOL. Two explanations seem logical: \(1\) )Tj
T*
(the comprehensive low vision services had no effect, or )Tj
T*
(\(2\) they had an effect that was roughly equal to that of )Tj
T*
(membership in the RNZFB, which includes access to )Tj
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(When the study was conceptualized, it was expected )Tj
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(that comprehensive low vision services would be )Tj
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(compared to a range of existing services, some of )Tj
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(which would include RNZFB field services. As it )Tj
0 -1.3 TD
(turned out, the comparison was clearly between )Tj
T*
(comprehensive low vision services and member )Tj
T*
(services. It appears that in both cases, there was either )Tj
T*
(no effect over time or both services had the effect of )Tj
0 -1.3 TD
(maintaining visual function and perception of the )Tj
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(quality of life, despite the expectation that both would )Tj
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(deteriorate over time. No significant differences were )Tj
T*
(found when RNZFB members and nonmembers were )Tj
T*
(compared in the experimental group. However, the )Tj
0 -1.3 TD
(expected pattern did emerge with members either )Tj
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(improving in function or remaining stable and )Tj
T*
(nonmembers remaining stable or declining somewhat )Tj
T*
(in function. This finding could indicate an effect of )Tj
T*
(adding comprehensive low vision services to existing )Tj
T*
(services, with an overall improvement in four of the )Tj
T*
(five dependent variables. It may provide some )Tj
T*
(indication that the combination of RNZFB membership )Tj
T*
(status and the provision of comprehensive low vision )Tj
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(services was more effective than the provision of )Tj
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(comprehensive low vision services alone. The former )Tj
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(conceptualized than the latter when these services were )Tj
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(There were a number of limitations to this study. First, )Tj
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(although a contrast group was used to counter the )Tj
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(problems of a single-group pretest\226posttest design, it )Tj
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(effect that the intervention may have over and above )Tj
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(the decline in function that may be expected in this )Tj
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(population over time. However, in this case, the )Tj
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(contrast group and the experimental group may have )Tj
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(The other explanation is that neither set of )Tj
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(interventions had any effect over time, perhaps because )Tj
T*
(neither was effective or because the self-report )Tj
T*
(measures used in the study were not sensitive enough )Tj
T*
(to detect changes that may have occurred. However, )Tj
T*
(differences on all three primary dependent variables )Tj
T*
(and both secondary dependent variables reached )Tj
T*
(significance at some point during the study, so the self-)Tj
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(report measures were sensitive enough to denote )Tj
T*
(differences between the groups with the sample size )Tj
T*
(that was used. Yet, they still may have lacked the )Tj
T*
(necessary sensitivity to denote changes that may have )Tj
T*
(occurred. Finally, the variable that denoted the most )Tj
0 -1.3 TD
(difference across the groups was QOL. Although this )Tj
T*
(variable was drawn from a single question and may )Tj
T*
(therefore be suspect, it proved to be remarkably )Tj
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(consistent across time and across groups. A )Tj
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(also be of value. A no-treatment control group would )Tj
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(be an ideal foil to the problems encountered in this )Tj
T*
(study. Ethically, we were unwilling to assign persons )Tj
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(randomly to a no-treatment group. Practically, we were )Tj
0 -1.3 TD
(unsuccessful in recruiting persons with visual )Tj
T*
(impairments who were not already members of the )Tj
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(RNZFB. As a result, we were limited to an )Tj
T*
(experimental\226contrast group design that appeared to )Tj
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(compare relatively similar services. In the end, we )Tj
T*
(must conclude that no significant or obvious )Tj
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(differences were found between providing )Tj
T*
(comprehensive low vision services, as defined here, to )Tj
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(the participants in this study and providing the mix of )Tj
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(services that were currently available to them.)Tj
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(References)Tj
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(Branch, L. G., Horowitz, A., & Carr, C. \(1989\). The )Tj
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(implications for everyday life of incident self-)Tj
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(reported visual decline among people over age 65 )Tj
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(living in the community. )Tj
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(The Gerontologist, 29,)Tj
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