This study investigates perceived discrimination among people with visual impairment and its association with well-being in a population-based sample of older adults.
Key Points
Questions
How prevalent is perceived discrimination among older people with visual impairment and to what extent is it associated with emotional well-being?
Findings
In this study of 7677 older adults (≥50 years of age), 476 (52.1%) of those with poor eyesight reported discrimination vs 2963 (43.8%) of those with good eyesight, a significant difference. People with poor eyesight who reported discrimination were more likely to be depressed, lonely, and dissatisfied with life, and their quality of life was lower than those who did not report discrimination.
Meaning
The findings suggest that older adults with impaired vision are at increased risk of discrimination, which, if experienced, may be associated with poor well-being.
Abstract
Importance
A significant proportion of individuals with visual impairment report experiences of discrimination. However, evidence comparing perceived discrimination among people with visual impairment with the general population is lacking. In addition, poorer mental health and well-being have been detected in this population, but the association between discrimination and well-being in those with visual impairment is unknown.
Objective
To investigate perceived discrimination among people with visual impairment and its association with well-being in a population-based sample of older adults.
Design, Setting, and Participants
This study collected data from 7677 participants 50 years or older from the English Longitudinal Study of Ageing, a representative sample of older men and women in England. Experiences of perceived discrimination were reported from July 2010 to June 2011. Depressive symptoms, life satisfaction, quality of life, and loneliness were assessed from July 2010 to June 2011 and May 2016 to June 2017. Data analysis was performed from September 27, 2018, to October 10, 2018.
Exposures
Self-rated eyesight, categorized as poor (ratings of fair, poor, or blind) or good (good, very good, or excellent), which was not previously validated for this population.
Main Outcomes and Measures
We used logistic regression to analyze differences in perceived discrimination between participants reporting poor vs good eyesight and cross-sectional and prospective associations between perceived discrimination and well-being in those with poor eyesight.
Results
A total of 7677 participants (mean [SD] age, 66.71 [9.17] years; 4023 [52.4%] female) were included in the study. Participants with poor eyesight had increased odds of reporting perceived discrimination compared with those with good eyesight (odds ratio [OR], 1.41; 95% CI, 1.23-1.63; P < .001). Cross-sectionally, participants who reported poor eyesight and discrimination had increased odds of depressive symptoms (OR, 2.14; 95% CI, 1.57-2.92; P < .001) and loneliness (OR, 2.17; 95% CI, 1.61-2.92; P < .001) and lower quality of life (B = −4.06; 95% CI, −5.29 to −2.84; P < .001) and life satisfaction (B = −2.37; 95% CI, −3.28 to −1.46; P < .001) compared with poor eyesight and no reported discrimination. Prospectively, perceived discrimination was associated with increased risk of depressive symptoms among participants reporting poor eyesight at 6-year follow-up (OR, 1.72; 95% CI, 1.08-2.76; P = .02).
Conclusions and Relevance
These findings suggest that older adults with impaired vision are at increased risk of perceived discrimination. Those who reported experiencing discrimination had higher levels of depressive symptoms and loneliness and lower quality of life and life satisfaction. Action to address discrimination may help mitigate the increased risk of poor well-being in this population.
Introduction
Visual impairment (defined as presenting visual acuity worse than 6/121) is estimated to affect approximately 2 million people in the United Kingdom.2 Approximately 10% of those 65 years or older report some sight loss.3 The prevalence of visual impairment is expected to increase because of population aging and increased diabetes.2,3,4,5 This increase poses concern about the financial consequences of sight loss, estimated at £28.1 billion (US $36.7 billion) annually, and the disease burden involved.2 People with visual impairment commonly experience difficulties with activities of daily living,3 and most require practical support.6
These difficulties may be compounded by discrimination. Charity- and government-commissioned research suggests that discrimination is experienced by a significant proportion of those with visual impairment in the United Kingdom.6,7,8,9 In a survey of more than 1200 individuals with registered visual impairment, 35% reported experiencing negative attitudes from the public and 47% perceived they had been treated unfairly because of their sight loss.6 Observational data revealed that those with sight loss were twice as likely as those with another impairment to have experienced discrimination.7,9
An increasing body of literature suggests that discrimination is a determinant of mental health and well-being.10,11,12,13,14,15,16,17,18 For example, a meta-analysis11 of 110 studies found that discrimination was associated with depression, psychiatric distress, and reduced mental well-being. However, the existing evidence is dominated by studies on racism or experiences of discrimination in general.16
There is evidence that individuals with visual impairment have poorer mental health than their impairment-free counterparts.6,15 In health care settings, an association between visual impairment and depression has been consistently reported.19,20,21 Greater prevalence of depressive symptoms in those with visual impairment has also been reported.7,9,22,23 In a cross-sectional study of 13 900 older adults in Britain, those with visual impairment were 3 times more likely to experience depression than those with good vision,23 with similar rates reported in later population-based studies.7,9,22 Most of the evidence linking depression and visual impairment has been cross-sectional.19,20,21,22,23 However, recent evidence suggests that vision loss may also be associated with new-onset depression.24
Visual impairment has also been linked with poorer outcomes in other domains of well-being. Heightened levels of loneliness in those with visual impairment compared with those with good sight has been reported in Dutch and US samples.25,26,27 However, no significant increase in levels of loneliness was reported in a German study.28 In the United Kingdom, no study has assessed loneliness specifically, but several surveys indicate that social exclusion and reduced social contact may be experienced after sight loss.6,7,9,29
Associations between visual impairment and lower life satisfaction have been reported,7,30,31,32 with UK data suggesting that those with sight loss were 3 times more likely to be dissatisfied than those with no impairment.7 A link between visual impairment and reduced quality of life (QOL) has been documented by a review of qualitative studies.33 Quantitative studies29,32,34,35 have also found evidence of an association cross-sectionally, and longitudinal evidence suggests that improvements in vision may lead to a corresponding increase in QOL.36
Taken together, several reports6,7,8,9 suggest that many individuals with visual impairment experience discrimination and poorer well-being. However, evidence comparing the prevalence of discrimination among people with visual impairment with that in the general population is lacking. The association between discrimination and well-being in those with visual impairment is unknown. Our study, therefore, investigated this issue in a community sample of older English adults.
Methods
Study Population
Data were obtained from the English Longitudinal Study of Ageing (ELSA), a study of adults 50 years or older.37 Participants are followed up every 2 years. The present analyses were not planned before data collection. The present study uses data from wave 5 (collected July 2010 to June 2011; the only wave that assessed discrimination) and wave 8 (May 2016 to June 2017). Of the 9090 participants interviewed in wave 5, a total of 8107 (89.2%) answered the perceived discrimination questions. We excluded 430 participants (5.3%) with missing data on eyesight or covariates, leaving a final sample of 7677 participants. Data analysis was performed from September 27, 2018, to October 10, 2018. Ethical approval was obtained from the National Research Ethics Service. All participants gave full written informed consent, and all data were deidentified.
Measures
Self-rated Eyesight
The measure of visual impairment was a single-item rating: “Is your eyesight (using glasses or corrective lenses, if you use them) excellent, very good, good, fair, or poor?” Spontaneous responses of those who were legally or registered blind were recorded. We dichotomized responses, defining visual impairment as blindness or fair or poor self-rated eyesight. Participants were also asked, “How good is your eyesight for seeing things up close, like reading ordinary newspaper print (excellent, very good, good, fair, or poor)?” Response options were categorized as above. Hereafter, we refer to fair, poor, or blind eyesight as poor eyesight and good, very good, or excellent eyesight as good eyesight. We coded participants who reported being blind as having poor self-rated eyesight up close. Two participants had missing data for eyesight up close, so we imputed these values with their response to the rating of overall eyesight. To our knowledge, these items have not been validated, although they have been used in other publications of ELSA data.38,39
Participants also reported whether they had ever been diagnosed with glaucoma, diabetic eye disease, macular degeneration, or cataracts. We considered those who reported any of these as having a history of eye disease.
Perceived Discrimination
Items on discrimination were based on measures used in other studies.40,41,42 Participants were asked about the frequency of 5 discriminatory experiences: you are treated with less respect or courtesy2; you receive poorer service than other people in restaurants and stores3; people act as if they think you are not clever4; you are threatened or harassed5; or you receive poorer service or treatment than other people from doctors or hospitals (almost every day, at least once a week, a few times a month, a few times a year, less than once a year, or never). Because data were skewed, with most participants reporting never experiencing discrimination, we dichotomized responses to indicate whether participants had experienced discrimination in the past year (a few times or more a year vs less than once a year or never), with the exception of the fifth item, which was dichotomized to indicate whether respondents had ever experienced discrimination from doctors or hospitals (never vs all other options).43
Emotional Well-being
Our primary outcome for analyses of well-being was depressive symptoms. Secondary outcomes were QOL, life satisfaction, and loneliness.
Depressive symptoms were assessed with an 8-item version of the Center for Epidemiologic Studies Depression Scale,44 widely validated for use in older adults.45 This scale asks about feelings during the last week (eg, “Over the last week have you felt sad?”), with binary response options (1 indicating yes and 0 indicating no). Positively framed items were reverse scored. Data were dichotomized using an established cutoff, with scores of 4 or higher indicating significant symptoms.45
Quality of life was assessed with the CASP-19 (control, autonomy, self-realization, and pleasure),46 a scale designed to measure QOL in older people. Respondents are asked how often each statement applies to them (0 indicating often to 3 indicating never). Positively worded items were reverse scored. A higher score indicates higher QOL (range, 0–57).
Life satisfaction was assessed with the Satisfaction With Life Scale,47 which asks respondents to rate the extent to which they agree with 5 statements (eg, “In most ways my life is close to my ideal”) on a scale from 0 (strongly disagree) to 6 (strongly agree). Responses were summed to produce a total score (range, 0-30), with higher scores indicating greater life satisfaction.
Loneliness was measured using the 3-item Revised UCLA Loneliness Scale.48 An example item was, “How often do you feel you lack companionship?” with response options ranging from hardly ever or never (scored 1) to often (scored 3). Total scores ranged from 3 to 9, with higher scores indicating greater loneliness. They were dichotomized at 6 or higher vs lower than 6 to indicate high vs low loneliness.49
Covariates
Information on age, sex, race/ethnicity (white vs nonwhite), marital status (married vs single, separated, divorced, or widowed) and household nonpension wealth (an indicator of socioeconomic status in this population50) was recorded. Objectively measured body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared) (collected in wave 6 because BMI was not assessed in wave 5) was also included in a sensitivity analysis. Trained research nurses measured weight to the nearest 0.1 kg using portable electronic scales and height to the nearest millimeter using a portable stadiometer. Nurses recorded any factors that might have compromised measurement reliability (eg, participant was stooped or unwilling to remove shoes), and these cases were excluded.
Statistical Analysis
All analyses were conducted using SPSS software, version 24 (SPSS Inc). Data were weighted to correct for sampling probabilities and for differential nonresponse and to calibrate back to the 2011 English Census population distributions for age and sex. For cross-sectional analyses, the weights accounted for the differential probability of being included in wave 5 and for nonresponse to the self-completion questionnaire that measured discrimination. For prospective analyses, we applied a longitudinal weight that accounted for nonresponse at wave 8 based on the sample who participated in wave 4.
Our primary outcome was perceived discrimination in any of 5 discriminatory situations. Secondary outcomes were perceptions of discrimination in each of the 5 situations. Logistic regression was used to examine associations between poor eyesight and perceived discrimination, controlling for covariates. In addition, these models were performed again to analyze the odds of reporting perceived discrimination in participants with poor eyesight who reported a history of eye disease and participants with poor eyesight with no history of eye disease compared with the group with good eyesight, adjusting for covariates.
We examined cross-sectional and prospective differences during 6-year follow-up among those who reported poor eyesight in depressive symptoms, QOL, life satisfaction, and loneliness between those who reported perceived discrimination and those who did not. Categorical outcomes were analyzed using logistic regression, and continuous outcomes were analyzed using linear regression. All models controlled for age, sex, race/ethnicity, marital status, and wealth, and prospective analyses also adjusted for baseline status or score on the outcome of interest.
We performed a sensitivity analysis in which models that compared the groups reporting poor vs good eyesight were repeated with additional adjustment for BMI because weight status is known to be associated with conditions associated with visual impairment (eg, diabetes51) and perceived discrimination.52 Body mass index was not included as a covariate in the primary analyses because data were not available in the same wave as discrimination was and we wanted to maximize the sample size. A 1-sided P < .05 was considered to be statistically significant.
Results
Sample Characteristics
A total of 7677 participants (mean [SD] age, 66.71 [9.17] years; 4023 [52.4%] female) were included in the study. Of the 7677 participants in the sample, 913 (11.9%) reported poor overall eyesight and 658 (8.6%) reported poor eyesight up close. Sample characteristics are summarized in Table 1. On average, participants who reported poor eyesight were significantly older than those with good eyesight (70 vs 66 years), and a greater proportion were female, nonwhite, unmarried, and from the lowest wealth quintiles.
Table 1. Sample Characteristics at Baseline in Relation to Self-rated Eyesighta.
| Characteristic | Self-rated Eyesight Overall | Self-rated Eyesight Up Close | ||||
|---|---|---|---|---|---|---|
| Good (n = 6764) | Poor (n = 913) | P Value | Good (n = 6996) | Poor (n = 681) | P Value | |
| Age, mean (SD), y | 66.24 (8.94) | 69.95 (10.08) | <.001 | 66.37 (8.99) | 69.95 (10.24) | <.001 |
| Sex | ||||||
| Men | 3239 (48.3) | 415 (42.8) | .001 | 3328 (47.9) | 326 (44.7) | .10 |
| Women | 3468 (51.7) | 555 (57.2) | 3620 (52.1) | 403 (55.3) | ||
| Race/ethnicity | ||||||
| White | 6470 (96.5) | 919 (94.7) | .007 | 6692 (96.3) | 697 (95.6) | .31 |
| Nonwhite | 236 (3.5) | 51 (5.3) | 255 (3.7) | 32 (4.4) | ||
| Marital status | ||||||
| Married | 4632 (69.1) | 532 (54.6) | <.001 | 4766 (68.6) | 398 (54.6) | <.001 |
| Unmarried | 2074 (30.9) | 439 (45.2) | 2181 (31.4) | 331 (45.4) | ||
| Wealth quintile | ||||||
| 1 (Poorest) | 1101 (16.4) | 343 (35.4) | <.001 | 1207 (17.4) | 237 (32.5) | <.001 |
| 2 | 1324 (19.7) | 217 (22.4) | 1375 (19.8) | 165 (22.7) | ||
| 3 | 1395 (20.8) | 168 (17.3) | 1428 (20.6) | 134 (18.4) | ||
| 4 | 1421 (21.2) | 125 (12.9) | 1454 (20.9) | 92 (12.6) | ||
| 5 (Richest) | 1466 (21.9) | 117 (12.1) | 1483 (21.3) | 100 (13.7) | ||
Data are presented as number (percentage) of participants unless otherwise reported. All figures are weighted for sampling probabilities and differential nonresponse.
Self-rated Eyesight and Perceived Discrimination
Associations between eyesight and discrimination are given in Table 2. Discrimination was more commonly reported by participants with poor eyesight (476 [52.1%]) than those with good eyesight (2963 [43.8%]). After adjustment for covariates, participants with poor eyesight had 1.41 times higher odds of reporting any discrimination than those with good eyesight (95% CI, 1.23-1.63, P < .001). The most common form of discrimination was being treated with less respect or courtesy (331 [36.3%] reported by participants with poor eyesight), and the least common was being threatened or harassed (90 [9.9%]). Poor eyesight was associated with increased odds of reporting discrimination in each of the 5 domains, with odds ratios (ORs) ranging from 1.24 (95% CI, 1.03-1.51, P = .03) for receiving poorer service in restaurants and stores to 1.41 (95% CI, 1.18-1.69; P < .001) for receiving poorer service or treatment in medical settings (Table 2).
Table 2. Associations Between Self-rated Eyesight and Perceived Discriminationa.
| Perceived Discrimination | Self-rated Eyesight Overall | Self-rated Eyesight Up Close | |||||
|---|---|---|---|---|---|---|---|
| Good (n = 6764) | Poor (n = 913) | P Value | Good (n = 6996) | Poor (n = 681) | P Value | ||
| Discrimination in any domain | |||||||
| Mean (SE), % | 43.8 (0.6) | 52.1 (1.6) | <.001 | 44.0 (0.6) | 53.0 (1.8) | <.001 | |
| OR (95% CI) | 1 [Reference] | 1.41 (1.23-1.63) | 1 [Reference] | 1.45 (1.24-1.70) | |||
| Less courtesy | |||||||
| Mean (SE), % | 31.0 (0.5) | 36.3 (1.5) | .001 | 31.1 (0.5) | 36.5 (1.7) | .009 | |
| OR (95% CI) | 1 [Reference] | 1.28 (1.10-1.48) | 1 [Reference] | 1.25 (1.06-1.48) | |||
| Service setting | |||||||
| Mean (SE), % | 14.1 (0.4) | 16.9 (1.1) | .03 | 14.0 (0.4) | 18.3 (1.3) | .001 | |
| OR (95% CI) | 1 [Reference] | 1.24 (1.03-1.51) | 1 [Reference] | 1.42 (1.15-1.75) | |||
| Not clever | |||||||
| Mean (SE), % | 18.1 (0.5) | 23.0 (1.2) | .001 | 18.0 (0.4) | 25.6 (1.4) | <.001 | |
| OR (95% CI) | 1 [Reference] | 1.32 (1.12-1.56) | 1 [Reference] | 1.56 (1.30-1.87) | |||
| Threatened/harassed | |||||||
| Mean (SE), % | 7.9 (0.3) | 9.9 (0.9) | .03 | 7.7 (0.3) | 12.4 (1.0) | <.001 | |
| OR (95% CI) | 1 [Reference] | 1.32 (1.03-1.68) | 1 [Reference] | 1.72 (1.34-2.20) | |||
| Medical setting | |||||||
| Mean (SE), % | 16.3 (0.4) | 20.4 (1.2) | <.001 | 16.4 (0.4) | 20.9 (1.4) | .001 | |
| OR (95% CI) | 1 [Reference] | 1.41 (1.18-1.69) | 1 [Reference] | 1.38 (1.13-1.68) | |||
Abbreviation: OR, odds ratio.
All figures are weighted for sampling probabilities and differential nonresponse and adjusted for age, sex, race/ethnicity, marital status, and wealth.
As for overall ratings of eyesight, participants who reported poor eyesight for seeing things up close had significantly higher odds of perceived discrimination overall (OR, 1.45; 95% CI, 1.24-1.70, P < .001) and in all 5 domains (Table 2). Reports of being treated as if they were not clever were more common among the group with poor eyesight up close (174 [25.6%]) than in the group reporting poor overall eyesight (210 [23.0%]). Reports of being threatened or harassed were also more common among the group with poor eyesight up close (84 [12.4%]) than in the group reporting poor overall eyesight (90 [9.9%]).
Of the 913 participants who reported poor overall eyesight, 527 (57.7%) reported a history of eye disease. Compared with those with good eyesight, the odds of reporting discrimination in any domain were 1.66 times higher (95% CI, 1.30-2.12; P < .001) among participants with poor eyesight but no diagnosed eye disease and 1.39 times higher among those with poor eyesight who had a history of eye disease (95% CI, 1.11-1.74; P = .004).
Perceived Discrimination and Well-being Among Individuals With Poor Eyesight
Associations between discrimination and well-being in those reporting poor eyesight are summarized in Table 3. Cross-sectionally, participants who reported poor eyesight and discrimination had significantly increased odds of depressive symptoms (OR, 2.14; 95% CI, 1.57-2.92, P < .001) and loneliness (OR, 2.17; 95% CI, 1.61-2.92; P < .001) and lower QOL (B = −4.06; 95% CI, −5.29 to −2.84; P < .001) and life satisfaction (B = −2.37; 95% CI, −3.28 to −1.46; P < .001) compared with poor eyesight and no reported discrimination. Prospectively, discrimination was associated with increased risk of depressive symptoms among participants reporting poor eyesight at follow-up (OR, 1.72; 95% CI, 1.08-2.76; P = .02). Perceived discrimination was not significantly associated with other outcomes prospectively.
Table 3. Cross-sectional and Prospective Associations Between Perceived Discrimination and Emotional Well-being Outcomes Among Participants Reporting Poor Eyesight (in Ratings of Overall Eyesight)a.
| Emotional Well-being Outcome | Cross-sectional | Prospective | ||||
|---|---|---|---|---|---|---|
| No Perceived Discrimination (n = 444) | Perceived Discrimination (n = 469) | P Value | No Perceived Discrimination (n = 247) | Perceived Discrimination (n = 316) | P Value | |
| Depressive symptoms above threshold | ||||||
| Mean (SE), % | 22.6 (2.0) | 36.2 (1.9) | <.001 | 20.4 (2.6) | 31.2 (2.2) | .02 |
| OR (95% CI) | 1 [Reference] | 2.14 (1.57 to 2.92) | 1 [Reference] | 1.72 (1.08 to 2.76) | ||
| Quality of life | ||||||
| Mean score (SE) | 37.46 (0.43) | 33.58 (0.41) | <.001 | 36.76 (0.51) | 36.17 (0.42) | .88 |
| B (95% CI) | 1 [Reference] | −4.06 (−5.29 to −2.84) | 1 [Reference] | −0.11 (−1.56 to 1.35) | ||
| Life satisfaction | ||||||
| Mean score (SE) | 19.21 (0.32) | 16.95 (0.31) | <.001 | 18.64 (0.38) | 18.20 (0.32) | .32 |
| B (95% CI) | 1 [Reference] | −2.37 (−3.28 to −1.46) | 1 [Reference] | −0.53 (−1.57 to 0.52) | ||
| High loneliness | ||||||
| Mean (SE), % | 27.0 (2.1) | 41.2 (2.0) | <.001 | 27.8 (2.8) | 33.6 (2.4) | .23 |
| OR (95% CI) | 1 [Reference] | 2.17 (1.61 to 2.92) | 1 [Reference] | 1.38 (0.82 to 2.34) | ||
Abbreviation: OR, odds ratio.
All figures are weighted for sampling probabilities and differential nonresponse and adjusted for age, sex, race/ethnicity, marital status, and wealth. Prospective figures are additionally adjusted for baseline status or score. Possible scores range from 0 to 57 for quality of life and 0 to 30 for life satisfaction.
Sensitivity Analysis
In a subsample of 5931 participants whose BMI was measured 2 years after baseline, additional adjustment for BMI revealed no notable differences in associations between eyesight and discrimination or discrimination and well-being among the group with poor eyesight.
Discussion
In this population-based sample of older adults in England, participants with poor eyesight were 40% more likely to report perceived discrimination compared with those who rated their eyesight as good. Participants who reported poor eyesight and had experienced discrimination were more likely to report depressive symptoms both cross-sectionally and prospectively during 6-year follow-up than those with poor eyesight who did not report discrimination. They were also more likely to be lonely and reported poorer QOL and life satisfaction in cross-sectional analyses, although prospective associations were not significant.
More than half (52.1%) of the sample who reported poor eyesight experienced discrimination in their day-to-day life. More than one-third believed they were treated with less respect than other people: 1 in 4 felt people acted as if they were not clever, 1 in 5 reported receiving poorer treatment than other people from doctors or hospitals, 1 in 6 believed they received poorer service than other people in restaurants and shops, and 1 in 10 reported being threatened or harassed. These findings are in line with a previous report6 in which 47% of people with visual impairment reported perceived discrimination, 35% reported negative attitudes from members of the public, and 14% reported unfair treatment from health care workers. We also found that prevalence of perceived discrimination in each domain was significantly higher among people with poor eyesight than in a control group with good eyesight despite relatively high prevalence of reports of discrimination among this control group (43.8%). Results also reveal that the association between poor eyesight and discrimination was not limited to participants with a history of eye disease, with associations at least as strong among participants with poor eyesight but no diagnosed eye disease.
Among participants with poor eyesight, discrimination was associated with significantly poorer well-being. In cross-sectional and prospective analyses, we found that individuals with poor eyesight who had experienced discrimination were twice as likely to have depressive symptoms above threshold. Previous studies7,9,19,20,21,22,23 have reported an association between visual impairment and depression, with some evidence suggesting that vision loss is associated with the onset of depression.24 Our results demonstrating a longitudinal association between discrimination and increased depressive symptoms among individuals with poor vision point to a potential role of perceived discrimination in the onset and maintenance of depression in this population group.
In addition to having a higher rate of depressive symptoms, people with poor vision who had experienced perceived discrimination were twice as likely to be lonely and reported poorer QOL and life satisfaction. This finding suggests that higher levels of discrimination may contribute to previously reported associations between visual impairment and increased loneliness, social exclusion and reduced social contact,6,7,9,25,26,27,29 lower QOL,29,32 and life dissatisfaction.7,30,31,32 Although these associations were significant in cross-sectional analyses, no prospective associations were observed with the onset of loneliness or decline in QOL or life satisfaction during 6-year follow-up. It seems plausible that the association between discrimination and these outcomes had been established by the time of the baseline assessment; thus, little change was evident over and above the cross-sectional results.
Strengths and Limitations
Strengths of this study include the large, representative sample, prospective design, and assessment of well-being using a range of measures. However, there were also limitations. Potential limitations are that poor eyesight was self-reported and that these data have not been compared directly with objective measures. However, similar self-reported ratings of eyesight have been validated.53 Further research is needed to validate our findings using an objective measure of visual acuity. Perceived discrimination was determined by self-reports of past experiences and thus may be subject to recall bias. Recall bias may be a particular concern among participants at the older end of the age spectrum, who are also at increased risk of visual impairment,54 which may have led to underestimation of the prevalence of discrimination in the group with poor eyesight. The discrimination questions asked about 5 situations, but there may be others relevant to visual impairment that were not assessed. Prospective analyses were restricted to participants with data at follow-up. Consistent with retention in other studies,55 the analyzed sample was younger and wealthier than the total ELSA sample; thus, results may not be representative of the entire population.
Conclusions
The results of this study suggest that older adults with impaired vision are at increased risk of discrimination across a range of domains compared with those with good vision. In addition, those who experience discrimination reported higher levels of depressive symptoms and loneliness and lower QOL and life satisfaction. Action to address discrimination against people with visual impairment may help mitigate the increased risk of poor well-being in this population group. Health care practitioners may consider querying patients with visual impairment about their well-being to identify those who would benefit from additional support.
References
- 1.World Health Organization . Blindness and vision impairment [Internet]. 2018. https://www.who.int/news-room/fact-sheets/detail/blindness-and-visual-impairment. Accessed November 1, 2018.
- 2.Pezzullo L, Streatfeild J, Simkiss P, Shickle D. The economic impact of sight loss and blindness in the UK adult population. BMC Health Serv Res. 2018;18(1):63. doi: 10.1186/s12913-018-2836-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Royal National Institute of Blind People . People With Sight Loss in Later Life: RNIB Evidence-Based Review. London, England: Royal National Institute of Blind People; 2015. [Google Scholar]
- 4.Minassian D, Reidy A. Future Sight Loss UK 2: An Epidemiological and Economic Model for Sight Loss in the Decade 2010-2020. London, England: EpiVision and RNIB; 2009. [Google Scholar]
- 5.Office for National Statistics . 2014-Based National Population Projections: Principle Projections. London, England: Office for National Statistics; 2015. [Google Scholar]
- 6.Slade J, Edwards R. My Voice 2015: The Views and Experiences of Blind and Partially Sighted People in the UK. London, England: Royal National Institute for Blind People; 2015. [Google Scholar]
- 7.McManus S, Lord C. Circumstances for people with sight loss: secondary analysis of Understanding Society and the Life Opportunities Survey. London, England: Natcen and Royal National Institute of Blind People; 2012. [Google Scholar]
- 8.Williams B, Copestake P, Eversley J, Stafford B. Experiences and Expectations of Disabled People. London, England: Office for Disability Issues; 2008. [Google Scholar]
- 9.Flynn K, Lord C. Living With Sight Loss: Updating the National Picture. London, England: RNIB and Natcen Social Research; 2015. [Google Scholar]
- 10.Goto JB, Couto PFM, Bastos JL. Revisão sistemática dos estudos epidemiológicos sobre discriminação interpessoal e saúde mental. Cad Saude Publica. 2013;29(3):445-459. doi: 10.1590/S0102-311X2013000300004 [DOI] [PubMed] [Google Scholar]
- 11.Pascoe EA, Smart Richman L. Perceived discrimination and health: a meta-analytic review. Psychol Bull. 2009;135(4):531-554. doi: 10.1037/a0016059 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Paradies Y. A systematic review of empirical research on self-reported racism and health. Int J Epidemiol. 2006;35(4):888-901. doi: 10.1093/ije/dyl056 [DOI] [PubMed] [Google Scholar]
- 13.Williams DR, Neighbors HW, Jackson JS. Racial/ethnic discrimination and health: findings from community studies. Am J Public Health. 2003;93(2):200-208. doi: 10.2105/AJPH.93.2.200 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Ory M, Kinney Hoffman M, Hawkins M, Sanner B, Mockenhaupt R. Challenging aging stereotypes: strategies for creating a more active society. Am J Prev Med. 2003;25(3)(suppl 2):164-171. doi: 10.1016/S0749-3797(03)00181-8 [DOI] [PubMed] [Google Scholar]
- 15.Emerson E, Madden R, Robertson J, Graham H, Hatton C, Llewellyn G. Intellectual and physical disability, social mobility, social inclusion and health: background paper for the Marmot Review [Internet]. Lancaster, UK: Center for Disability Research (CeDR); 2009. http://eprints.lancs.ac.uk/26403/1/Disability_Social_Mobility_Social_Inclusion.pdf. Accessed November 1, 2018.
- 16.Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129(5):674-697. doi: 10.1037/0033-2909.129.5.674 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Newcomb ME, Mustanski B. Internalized homophobia and internalizing mental health problems: a meta-analytic review. Clin Psychol Rev. 2010;30(8):1019-1029. doi: 10.1016/j.cpr.2010.07.003 [DOI] [PubMed] [Google Scholar]
- 18.McDonald P. Workplace sexual harassment 30 years on: a review of the literature. Int J Manag Rev. 2012;14(1):1-17. doi: 10.1111/j.1468-2370.2011.00300.x [DOI] [Google Scholar]
- 19.Rovner BW, Shmuely-Dulitzki Y. Screening for depression in low-vision elderly. Int J Geriatr Psychiatry. 1997;12(9):955-959. doi: [DOI] [PubMed] [Google Scholar]
- 20.Goldstein JE, Massof RW, Deremeik JT, et al. ; Low Vision Research Network Study Group . Baseline traits of low vision patients served by private outpatient clinical centers in the United States. Arch Ophthalmol. 2012;130(8):1028-1037. doi: 10.1001/archophthalmol.2012.1197 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.van der Aa HPA, Comijs HC, Penninx BWJH, van Rens GHMB, van Nispen RMA. Major depressive and anxiety disorders in visually impaired older adults. Invest Ophthalmol Vis Sci. 2015;56(2):849-854. doi: 10.1167/iovs.14-15848 [DOI] [PubMed] [Google Scholar]
- 22.Zimdars A, Nazroo J, Gjonça E. The circumstances of older people in England with self-reported visual impairment: a secondary analysis of the English Longitudinal Study of Ageing (ELSA). Br J Vis Impairment. 2012;30(1):22-30. doi: 10.1177/0264619611427374 [DOI] [Google Scholar]
- 23.Evans JR, Fletcher AE, Wormald RPL. Depression and anxiety in visually impaired older people. Ophthalmology. 2007;114(2):283-288. doi: 10.1016/j.ophtha.2006.10.006 [DOI] [PubMed] [Google Scholar]
- 24.Choi HG, Lee MJ, Lee S-M. Visual impairment and risk of depression: a longitudinal follow-up study using a national sample cohort. Sci Rep. 2018;8(1):2083. doi: 10.1038/s41598-018-20374-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Verstraten PFJ, Brinkmann WLJH, Stevens NL, Schouten JSAG. Loneliness, adaptation to vision impairment, social support and depression among visually impaired elderly. Int Congr Ser. 2005;1282:317-321. doi: 10.1016/j.ics.2005.04.017 [DOI] [Google Scholar]
- 26.Alma MA, Van der Mei SF, Feitsma WN, Groothoff JW, Van Tilburg TG, Suurmeijer TPBM. Loneliness and self-management abilities in the visually impaired elderly. J Aging Health. 2011;23(5):843-861. doi: 10.1177/0898264311399758 [DOI] [PubMed] [Google Scholar]
- 27.Perissinotto CM, Stijacic Cenzer I, Covinsky KE. Loneliness in older persons: a predictor of functional decline and death. Arch Intern Med. 2012;172(14):1078-1083. doi: 10.1001/archinternmed.2012.1993 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Wahl H-W, Heyl V, Drapaniotis PM, et al. Severe vision and hearing impairment and successful aging: a multidimensional view. Gerontologist. 2013;53(6):950-962. doi: 10.1093/geront/gnt013 [DOI] [PubMed] [Google Scholar]
- 29.Liljas AEM, Wannamethee SG, Whincup PH, et al. Socio-demographic characteristics, lifestyle factors and burden of morbidity associated with self-reported hearing and vision impairments in older British community-dwelling men: a cross-sectional study. J Public Health (Oxf). 2016;38(2):e21-e28. doi: 10.1093/pubmed/fdv095 [DOI] [PubMed] [Google Scholar]
- 30.Liu Z, Wu D, Huang J, et al. Visual impairment, but not hearing impairment, is independently associated with lower subjective well-being among individuals over 95 years of age: a population-based study. Arch Gerontol Geriatr. 2016;62:30-35. doi: 10.1016/j.archger.2015.10.011 [DOI] [PubMed] [Google Scholar]
- 31.Crews JE, Chou C-F, Zhang X, Zack MM, Saaddine JB. Health-related quality of life among people aged ≥65 years with self-reported visual impairment: findings from the 2006-2010 behavioral risk factor surveillance system. Ophthalmic Epidemiol. 2014;21(5):287-296. doi: 10.3109/09286586.2014.926556 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Chia E-M, Wang JJ, Rochtchina E, Smith W, Cumming RR, Mitchell P. Impact of bilateral visual impairment on health-related quality of life: the Blue Mountains Eye Study. Invest Ophthalmol Vis Sci. 2004;45(1):71-76. doi: 10.1167/iovs.03-0661 [DOI] [PubMed] [Google Scholar]
- 33.Senra H, Barbosa F, Ferreira P, et al. Psychologic adjustment to irreversible vision loss in adults: a systematic review. Ophthalmology. 2015;122(4):851-861. doi: 10.1016/j.ophtha.2014.10.022 [DOI] [PubMed] [Google Scholar]
- 34.Lamoureux E, Pesudovs K. Vision-specific quality-of-life research: a need to improve the quality. Am J Ophthalmol. 2011;151(2):195-197.e2. doi: 10.1016/j.ajo.2010.09.020 [DOI] [PubMed] [Google Scholar]
- 35.Rees G, Tee HW, Marella M, Fenwick E, Dirani M, Lamoureux EL. Vision-specific distress and depressive symptoms in people with vision impairment. Invest Ophthalmol Vis Sci. 2010;51(6):2891-2896. doi: 10.1167/iovs.09-5080 [DOI] [PubMed] [Google Scholar]
- 36.Matthews K, Nazroo J, Whillans J. The consequences of self-reported vision change in later-life: evidence from the English Longitudinal Study of Ageing. Public Health. 2017;142:7-14. doi: 10.1016/j.puhe.2016.09.034 [DOI] [PubMed] [Google Scholar]
- 37.Steptoe A, Breeze E, Banks J, Nazroo J. Cohort profile: the English longitudinal study of ageing. Int J Epidemiol. 2013;42(6):1640-1648. doi: 10.1093/ije/dys168 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Davies-Kershaw HR, Hackett RA, Cadar D, Herbert A, Orrell M, Steptoe A. Vision impairment and risk of dementia: findings from the English Longitudinal Study of Ageing. J Am Geriatr Soc. 2018;66(9):1823-1829. doi: 10.1111/jgs.15456 [DOI] [PubMed] [Google Scholar]
- 39.Smith L, Timmis MA, Pardhan S, Latham K, Johnstone J, Hamer M. Physical inactivity in relation to self-rated eyesight: cross-sectional analysis from the English Longitudinal Study of Ageing. BMJ Open Ophthalmol. 2017;1(1):e000046. doi: 10.1136/bmjophth-2016-000046 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Yuan ASV. Perceived age discrimination and mental health. Soc Forces. 2007;86(1):291-311. doi: 10.1353/sof.2007.0113 [DOI] [Google Scholar]
- 41.Luo Y, Xu J, Granberg E, Wentworth WM. A longitudinal study of social status, perceived discrimination, and physical and emotional health among older adults. Res Aging. 2012;34(3):275-301. doi: 10.1177/0164027511426151 [DOI] [Google Scholar]
- 42.Smith J, Ryan L, Sonnega A, Weir D; HRS Psychosocial Working Group . Psychosocial and Lifestyle Questionnaire 2006-2016. Ann Arbor, MI: Survey Research Center, Institute for Social Research; 2017. [Google Scholar]
- 43.Rippon I, Kneale D, de Oliveira C, Demakakos P, Steptoe A. Perceived age discrimination in older adults. Age Ageing. 2014;43(3):379-386. doi: 10.1093/ageing/aft146 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 44.Radloff LS. The CES-D scale. Appl Psychol Meas. 1977;1(3):385-401. doi: 10.1177/014662167700100306 [DOI] [Google Scholar]
- 45.Steffick DE. Documentation of Affective Functioning Measures in the Health and Retirement Study. Ann Arbor: Institute for Social Research, University of Michigan; 2000. HRS Documentation Report DR-005 [Google Scholar]
- 46.Hyde M, Wiggins RD, Higgs P, Blane DB. A measure of quality of life in early old age: the theory, development and properties of a needs satisfaction model (CASP-19). Aging Ment Health. 2003;7(3):186-194. doi: 10.1080/1360786031000101157 [DOI] [PubMed] [Google Scholar]
- 47.Diener E, Emmons RA, Larsen RJ, Griffin S. The satisfaction with life scale. J Pers Assess. 1985;49(1):71-75. doi: 10.1207/s15327752jpa4901_13 [DOI] [PubMed] [Google Scholar]
- 48.Russell DW. UCLA Loneliness Scale (version 3): reliability, validity, and factor structure. J Pers Assess. 1996;66(1):20-40. doi: 10.1207/s15327752jpa6601_2 [DOI] [PubMed] [Google Scholar]
- 49.Steptoe A, Shankar A, Demakakos P, Wardle J. Social isolation, loneliness, and all-cause mortality in older men and women. Proc Natl Acad Sci U S A. 2013;110(15):5797-5801. doi: 10.1073/pnas.1219686110 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 50.Banks J, Karlsen S, Oldfield Z. Socio-economic position. 2003. http://discovery.ucl.ac.uk/15366/1/15366.pdf. Accessed November 1, 2018.
- 51.Mokdad AH, Ford ES, Bowman BA, et al. Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. JAMA. 2003;289(1):76-79. doi: 10.1001/jama.289.1.76 [DOI] [PubMed] [Google Scholar]
- 52.Jackson SE, Steptoe A, Beeken RJ, Croker H, Wardle J. Perceived weight discrimination in England: a population-based study of adults aged ≥50 years. Int J Obes (Lond). 2015;39(5):858-864. doi: 10.1038/ijo.2014.186 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 53.Coren S, Hakstian AR. Validation of a self-report inventory for the measurement of visual acuity. Int J Epidemiol. 1989;18(2):451-456. doi: 10.1093/ije/18.2.451 [DOI] [PubMed] [Google Scholar]
- 54.Pascolini D, Mariotti SP. Global estimates of visual impairment: 2010. Br J Ophthalmol. 2012;96(5):614-618. doi: 10.1136/bjophthalmol-2011-300539 [DOI] [PubMed] [Google Scholar]
- 55.Mendes de Leon CF. Aging and the elapse of time: a comment on the analysis of change. J Gerontol B Psychol Sci Soc Sci. 2007;62(3):S198-S202. doi: 10.1093/geronb/62.3.S198 [DOI] [PubMed] [Google Scholar]