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From the Department of Optometry and Vision Sciences, The University of Melbourne, Carlton, Victoria, Australia.
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Abstract |
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 Top Abstract IntroductionMethodsResultsDiscussionAppendix 1References |
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METHODS. The MLVAI was designed as a desk-based clinical assessment, comprising 18 observed items on complex ADLs in part (a) and 9 questions on broad self-care ADLs in part (b). Each item was rated on a five-level descriptive scale from 0 to 4, based on independence, speed, and accuracy of performance. It was designed to be administered under standardized conditions with regard to the instructions, illumination, and working distances. The validity and reliability of the new MLVAI was determined for 122 subjects who were representative of the general low-vision population, in a cross-sectional study.
RESULTS. Two items were found to be redundant and were eliminated from the test.
Thus, the final test comprised 25 items, with 100 being the highest
possible score. Cronbach’s 
indicated an internal reliability of
0.96, and an intraclass correlation coefficient indicated an overall
reliability of 0.95. The SE of measurement was 4.5. According to
Spearman’s correlation coefficient, the test–retest reliability was
0.94 (P < 0.001), and the interpractitioner
reliability for five different pairs of practitioners was 0.90 or
higher (P < 0.001). With regard to validity, there
was a moderately high correlation with vision impairment
(r = -0.68, P < 0.001). Using
Rasch analysis, content validity was also demonstrated by good
separation indexes (4.70 and 9.88) and high reliability scores (0.96
and 0.99) for the person and items parameters, respectively. Separate
calculation of indexes and reliability scores for parts (a) and (b)
indicated high content validity and reliability of each part. However,
the separation indexes and reliability scores were higher for part (a)
than for part (b). The correlation coefficient for part (a) and part
(b) was 0.68.
CONCLUSIONS. The MLVAI is a highly valid and reliable standardized test of ADL performance for the general low-vision population. It may be used to assess patients with low vision and has the potential to be used as a measure of low-vision rehabilitation outcomes.
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Introduction |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1References |
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Approximately 50 ADL instruments have been developed for use in the aged and physically impaired and have been reviewed by several groups.1 2 3 Generally, these instruments cover the basic self-care ADLs and do not cover the more complex ADLs (strictly referred to as instrumental ADLs or IADLs) relevant in low-vision rehabilitation. However, fewer than 15 disability or ADL instruments have been developed for use in low-vision rehabilitation. Some were developed to evaluate cataract surgery4 5 6 7 and others to measure vision-related ADLs in the general elderly population,8 9 to evaluate outcomes of low-vision programs,10 11 12 and to study the relationship between vision and ADL performance.13 14 15 16 17 18 Although some are applicable to the general low-vision population, many have unknown psychometric properties or do not cover adequately the relevant ADLs. Thus, existing instruments lack validity and demonstrated reliability for the low-vision population.
Therefore, the purpose of this study was to develop and to investigate the psychometric properties of a new ADL test appropriate for the low-vision population: the Melbourne Low-Vision ADL Index (MLVAI). The test was intended to be used primarily to measure ability to perform ADLs and secondarily to measure low-vision rehabilitation outcomes.
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Methods |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1References |
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We considered the frequency with which various ADLs appeared as items on these ADL instruments and whether they were consistent with research on the daily living problems reported by people with vision impairment.37 38 39 From a pool of 75 potential items, the selection criteria were further refined as follows: importance in daily living, relevance in low-vision rehabilitation, and ability to distinguish between people with different amounts of vision impairment. Also our goal was, when possible, to select items for which performance could be observed, because observed performance is more verifiable than self-reported performance. Although no systematic studies have demonstrated that observed performance measures are better than self-report measures, the theoretical advantages are increased reliability and validity (patients without insight into their impairments may under- or overreport their ability25 ), greater sensitivity to change, and less influence of poor cognitive functioning, culture, language, and education.40
Of the final 27 items selected, 9 items were related to self-care ADLs and 18 to more complex IADLs (Table 1) . Both self-care ADLs and complex IADLs were included to increase the range of ability that could be measured. Ability on each of the 18 IADL items was to be assessed by observing performance. Although it would be more accurate to also observe performance of the nine self-care ADL items, it would be highly time consuming and impractical. Therefore, ability on each of the nine self-care ADL items was assessed using a self-report questionnaire format.
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We next considered having practitioners assign a performance-rating score. Using this method, it would be possible to assess combined aspects of performance and to deal with inability to perform an item. Furthermore, we considered it important to use the same scale for the questionnaire items and the observed performance items, which would be feasible using practitioner ratings. The disadvantages are that the method is variable, and two practitioners may make different decisions about how several aspects of performance should be combined to assign a rating. However, providing standardized descriptive criteria for each rating level is thought to reduce the variability of practitioner judgments. Thus, a five-level adjectival Likert-type rating scale was selected. It ranged from 0 to 4 and was used for all items. Standardized descriptive criteria were assigned to each level, based on the speed, accuracy, and independence with which a subject was able to perform the item. The general form of the rating scale is presented in Table 2 . We also chose to have the practitioner, when applicable, measure performance time for each item. The purpose of this was to facilitate accurate judgments regarding the speed of performance. The total score for the MLVAI was derived by summing the rating for each item. Thus, the maximum possible total score was 108.
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Administration of the Test
Standardized instructions were given for every item. All the
observed items were to be performed at 25 cm, using habitual
spectacles, except for recognizing faces and telling the time using a
wall clock, which were to be performed at 1 m. The use of
low-vision devices was not allowed, so that disability could be
determined as defined by the World Health Organization: the subject’s
inability to perform the activity in the manner considered normal for
human being.42
The test was administered under standard
illumination conditions of 240 lux, as recommended in the
Australian Standard, 1680.1,43
for
moderately difficult indoor tasks. Pilot studies conducted in eight
normal subjects with simulated vision impairment44
indicated that the test would take approximately 20 minutes.
Subjects
We recruited 126 subjects with impaired vision from several
sources: the Vision Australia Foundation Kooyong Low-Vision Clinic, the
Macular Vision Loss Support Society of Australia, and Retina Australia.
The criteria for inclusion were: more than 18 years of age, any type of
ocular disease, stable vision impairment (over the previous 12 months),
and ability to speak and read English. Subjects were excluded if they
had total blindness, cognitive impairment, physical impairment, or
hearing impairment so that they were not able to manage a conversation
in a quiet room. All the subjects had been to a low-vision
rehabilitation clinic in the past. Informed consent to participate was
obtained, and the research was approved by The University of Melbourne
Human Research Ethics Committee. The study was conducted in accordance
with the tenets of the Declaration of Helsinki.
Test Administrators
Four practitioners were recruited to administer the MLVAI: one
optometrist, one occupational therapist, and two orthoptists at the
Kooyong Low-Vision Clinic. A further 15 occupational therapists were
recruited from regional clinics to score the video-recorded
performances of two subjects.
Demographics and Vision Measures
The following demographics were recorded: age, gender, and
ocular disorder (from clinical records or confirmed by examination).
Binocular distance visual acuity was measured using a Bailey–Lovie log
minimum angle of resolution (logMAR) chart45
and scored
using the per-letter method.46
In addition, the binocular
visual field was assessed, using the Goldmann perimeter (III-4e
target). Using the distance visual acuity and visual field measures
obtained, the level of vision impairment was then categorized according
to Johnston’s table of vision impairment,47
which is
based on the World Health Organization42
classification of
vision impairment. Each of the seven categories may be assigned based
on visual acuity or visual fields. Subjects were categorized according
to the worse of these two results.
Procedure
In the main study, all subjects were administered the MLVAI on
two occasions. On one occasion the original version, already described,
was administered. On the other occasion, an alternative version was
administered. The purpose of the alternative version was to minimize
the practice effect when a subject repeated the test.48
The alternative version was constructed by making minor alterations to
the original, while keeping the alternative items similar in structure
and intention to the original items.
Testing took place over two sessions at the Kooyong Low-Vision Clinic. The presentation order of the original and alternative versions of the MLVAI was randomized. In the first session, one version of the MLVAI was administered, demographics were recorded, and distance visual acuity was measured. In the second session, the other version of the MLVAI was administered, the binocular visual field was assessed, and distance visual acuity was remeasured to ensure that there had been no sudden vision loss. The median duration between the two sessions was 2 weeks, with the interquartile range being between 1.5 and 3 weeks.
Although the optometrist administered both versions of the MLVAI to approximately half of the subjects, the three additional practitioners were involved in administering the test to the remainder of the subjects. By using all four practitioners for the remainder of the subjects, the results of six different pairs of practitioners could be compared. The order in which each one of a pair of practitioners administered the MLVAI to subjects was randomized. Each pair of practitioners tested between 6 and 16 subjects.
In the minor study, one male subject and one female subject with age-related macular degeneration were selected from the group. The male subject was aged 82 years, with binocular distance visual acuity of 6/30 (20/100), and the female subject was aged 79 years, with binocular distance visual acuity of 6/15 (20/50). One practitioner administered the MLVAI to each subject and recorded the sessions on videotape. The 15 practitioners previously described were asked to view the videotape and rate the performance of each subject. The purpose was to determine the interpractitioner reliability using a larger group of practitioners.
Analysis
First, the results were analyzed using classic test theory to
allow comparison with other instruments, in that most vision-related
ADL instruments to date have been developed using classic test theory.
The data were double entered into a spreadsheet (Excel ver. 6.0;
Microsoft, Redmond, WA) and analyzed with statistical analysis software
(Minitab for Windows, ver. 12.0; Minitab, University Park, PA). Both
parametric and nonparametric statistical methods were used to analyze
the data. In every instance, there was little difference between the
results. Mostly the results using nonparametric statistical methods are
reported, because the distributions of several of the variables
measured were not strictly normal. However, some parametric statistics
are reported on the assumption that they are relatively insensitive to
departures from normality.
Second, the results were analyzed using item-response theory (IRT).
Most ADL instruments have been developed using classic test
theory,49
but it has several shortcomings. The main ones
are that the results are dependent on the sample of subjects tested,
that every item is assumed to have the same difficulty, and that the
ordinal ratings used produce an interval scale. IRT is a powerful
statistical tool that overcomes these problems and has gained wide
acceptance in the development of educational and psychological
instruments.50
Recently, Massof51
advocated its use in the development of vision disability measures and
Turano et al.52
applied it to a low-vision mobility
measure. IRT assumes that there is an unobserved (latent) continuous
dimension of ability (
) and that each person can be placed along
this dimension at a point that reflects the extent of his or her
ability. IRT estimates item characteristic curves for each item that
show the probability of a positive response on a specific item as a
function of ability ().53
The shape of the curve for
each item is determined by two item parameters
ßi and i. Parameter
ßi represents the item difficulty, and
i represents the item discriminating ability
of item i. Formally, the proportion of people who have
amount of the ability who answer item i correctly is given
as:
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i). Thus, the
important parameters are person ability and item difficulty. Each of
these parameters may be transformed to an interval scale using the
logarithm of the odds ratio (log-odds), where the mean value is 0 and
the SD 1. The units on the log-odds scale are called logits. (See
Hambleton et al.53
for a detailed description of IRT and
Massof51
for a description of using the Rasch model
to develop a vision disabilty measure.) We used another statistical
analysis program (Bigsteps, ver. 2.82; Mesa Press, Chicago, IL) to
perform a Rasch analysis on the data. |
Results |
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We further analyzed the data to determine whether these items should be
eliminated from the test using item-total correlations and Cronbach’s
. The basis of both these tests is the correlations between items
and the correlation between each item and the total test score. None of
the item–total correlations obtained were less than 0.20, which is the
usual cutoff criterion for indicating that items should be eliminated
from a test.49
However, the lowest item–total correlation
of 0.24 was obtained for the shirt item, giving support to eliminating
it from the test. The other approach, which also indicates the internal
reliability of a test, is to calculate Cronbach’s , which can be
calculated eliminating one item at a time. If significantly
increases, that item should be discarded from the test.49
The elimination of any one item did not make any difference to the
Cronbachs’s . Cronbach’s was 0.96 for the full 27-item MLVAI.
These findings supported the elimination of the shirt item from the
test. Moreover, this item was not practicable, because it was awkward
for subjects to put on a shirt over existing clothing. We also chose to
eliminate the color identification item from the final score because,
of all the items, the rating distribution for this item was the most
highly skewed, indicating it was adding little discriminative value to
the test. Furthermore, this item correlated perfectly with the digital
display item, suggesting that both items were unnecessary. The final
selection of just 25 items achieved a balance between making the test
short and clinically useful and retaining enough items to maintain
reliability. An additional advantage was that the final test comprising
25 items, each scored out of a possible 4, produced a convenient
possible total test score of 100. Cronbach’s was unchanged for the
25-item test. Henceforth, the results reported pertain to the reduced
25-item MLVAI.
Descriptive Statistics
The total raw score for the MLVAI ranged from 23 to 100. The mean
(±SD) total raw score was 63.9 ± 19.5 of 100. The distributions
of part (a) observed items, part (b) questionnaire items, and the total
raw score are shown in Figure 1 .
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We examined plots of the MLVAI test against retest for the total raw scores, the raw scores on parts (a) and (b), and the individual test items. We then computed Spearman correlation coefficients. All test–retest correlation coefficients ranged from rs = 0.47 to 0.91 (P < 0.001). The test–retest Spearman correlation coefficient for total score was rs = 0.94 (P < 0.001; Fig. 2 ).
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0.90, P <
0.001), except for one pair of practitioners who administered the test
to only six subjects (rs = 0.68,
P = 0.14). For the minor study involving 15
practitioners who scored two different subjects with impaired vision on
the MLVAI by observing a video recording, we obtained an intraclass
correlation coefficient of 0.97.
Validity
For the MLVAI to be valid, we would expect a significant
correlation between test score and level of vision impairment. The
Spearman correlation coefficient for test score and level of vision
impairment (visual acuity on a logMAR scale or visual field loss on a
log degrees scale, as described in the Methods section) was
rs = -0.68 (P <
0.001). Similarly, we might expect a difference between the scores of
those with central vision impairment and those with peripheral vision
impairment. There is strong clinical opinion and some scientific
evidence that people with central vision impairment perform more poorly
in general ADLs than people with peripheral vision
impairment.54
Indeed, a two-tailed Mann–Whitney test
showed a statistically significant difference between the two groups
(difference between median scores = -15.0, Wilcoxon
statistic = 3662.5, P = 0.02 adjusted for ties).
Factor analysis was used to explore the theoretical factors (groups of correlated items) underlying the MLVAI and to provide further evidence of the construct validity of the test. Principal-components extraction was used in an initial run to evaluate the assumptions and limitations of factor analysis and to estimate the number of factors from eigenvalues. The first four eigenvalues were 12.55, 2.35, 1.43, and 1.16, respectively, with remaining eigenvalues less than 1.0. This indicated that there was one main factor underlying the MLVAI that explained 50% of the variance in results and that three to four factors yielded the best solution. In subsequent factor analyses, using the maximum likelihood method of extraction with orthogonal varimax rotation, the solution was evaluated specifying three and four factors. Three factors yielded the most interpretable solution (Table 4) . Factor one contained items that were moderately difficult visually. Factor two contained items that were visually difficult, high-spatial-frequency, low-contrast tasks. The first two factors essentially combined to form part (a), the observed items of the MLVAI. Factor three, containing items related to self-care that were visually easy tasks, formed part (b), the questionnaire items. The rotated factor loadings, communalities, and loading plots indicated the items were well defined by this factor solution. Using a loading cut point of 0.45, as suggested by Tabachnick and Fidell,55 all the items except grooming (item b7) loaded on to a factor.
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Table 5 shows the 25 items in order from the most to the least visual ability required to perform the item. If the item logit is positive, the required visual ability for that item is higher than the mean required visual ability of all the items, and the reverse is true if the item logit is negative. Thus, the most difficult item was reading the telephone book, whereas the easiest item was bathing.
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To further investigate the differences evident in the score distributions for part (a) and part (b) (Fig. 1) , and the findings of factor analysis (Table 4) , Rasch analysis was also performed separately for parts (a) and (b).
The mean person ability for part (a) was 0.44 ± 1.93 logits and for part (b) was 2.73 ± 1.71 logits. This indicates that the ability of the subjects in this sample was more than the required ability, particularly for part (b). The most misfitting items for part (a) were as mentioned earlier, except that pouring was not a misfitting item and reading newspaper headlines was a misfitting item in this separate analysis. The only misfitting item for part (b) was eating. The separation indexes and reliability values are given in Table 6 and were higher for part (a) than for part (b). The correlation between the two parts was analyzed by calculating a Pearson correlation coefficient for the person-ability measures. The correlation between parts (a) and (b) was 0.68 (P < 0.001). Also, the correlation coefficient for each part and visual acuity (logMAR) and the test–retest correlation coefficient for each part was calculated (Table 6) .
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1References |
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Melbourne Low-Vision ADL Index Characteristics
The distribution of total raw scores was wide (range, 23–100).
However, although the scores for part (a), the observed items, were
distributed across the possible range from 0 to 64, the scores for part
(b), the basic self-care questionnaire items, were skewed toward the
high end of the range 0 to 36. This indicates part (b) may not
discriminate well between those at the high end—that is, those with
better vision.
Furthermore, factor analysis (Table 4) and Rasch analyses (Tables 5 6) also indicated a difference between performance of part (a) complex IADLs and self-report of part (b) basic self-care ADLs. These findings may have been obtained for three reasons. One is the ceiling effect seen in the distribution of part (b) scores, which resulted in lower correlations, separation indexes, and reliability for part (b) than for part (a). The second reason is that there is a difference between how the items were assessed: performance-based practitioner rating versus self-report questionnaire. Indeed, the correlation obtained between parts (a) and (b) was moderate (r = 0.68). Thus, as in other studies,56 57 performance-based and self-report measures did not entirely agree. The third reason for the difference in part (a) and part (b) findings may be because the self-report items were less difficult and thus required less visual ability than the performance-based items. In fact, the order of the item-difficulty measures supports this suggestion. Complex IADLs, such as reading, recognizing faces, and telling the time, were more difficult for the majority of subjects with impaired vision than were the basic self-care ADLs, such as grooming, eating, dressing, and bathing. This agrees with anecdotal clinical findings, the formal survey findings of Genensky et al.,37 the focus group study by Mangione et al.,58 and the findings of Szlyk et al.54 Thus, for the majority of persons with vision impairment, complex IADLs should be targeted in low-vision rehabilitation.
Reliability
The overall reliability of the MLVAI was high, as indicated by the
intraclass correlation coefficient and Rasch analysis reliability
values. The SE of measurement indicates that 68% of the time, the true
score will lie within ±4.5 points of the obtained score. Given that
the test score is of a possible 100 and the subjective element in
functional measures, this is reasonable. This is further supported by
Rasch analysis. The Rasch analysis person-ability and item-difficulty
parameters also had high reliability values (0.96 and 0.99,
respectively). However, when considered separately, there was a
difference between the reliability value for part (a) and part (b).
Although the person-ability reliability values for each part were both
high, the reliability of part (a) was higher than that for part (b)
(0.95 and 0.86, respectively).
Although the correlation coefficients for five of six different pairs of practitioners indicated a high interpractitioner reliability, the correlation for one pair of practitioners was moderate. However, the results are difficult to generalize, because the number of subjects seen by each pair of practitioners was small. An additional study involving more practitioners, but fewer subjects, indicated a higher interpractitioner reliability. However, again, the interpretation of the results of this minor study are limited, because there were only two subjects. We suggest further investigation of the interpractitioner reliability of the MLVAI.
The few similar instruments that have gained some acceptance in
low-vision ADL assessment and that report reliability coefficients are
the Activities of Daily Vision Scale,5
59
the
VF-14,6
60
and the Visual Disability
Assessment.7
The Cronbach’s coefficients for these
instruments vary from 0.85 to 0.94, compared with 0.96 for the MLVAI.
The high Cronbach’s obtained for the MLVAI may indicate some
redundancy of items, which is supported by the Rasch analysis. The
test–retest reliability coefficients for the Activities of Daily
Vision Scale,5
59
VF-14,6
60
and the Visual
Disability Assessment7
vary from 0.79 to 0.98, compared
with 0.95 for the MLVAI, and the interpractitioner reliability
coefficients vary from 0.94 to 0.97, compared with 0.97 for the MLVAI.
Thus, the reliability of the MLVAI is generally higher than for other
similar low-vision functional instruments. Moreover, the test–retest
and interpractitioner reliability of the MLVAI is higher than that of
the Older American Resource Services Questionnaire,26
a
well-accepted ADL measure used in gerontology.
Validity
The empiric development of the MLVAI implies that its content is
valid. Furthermore, several results obtained provide evidence of
construct validity. First, there was a moderately high, statistically
significant correlation between MLVAI score and level of vision
impairment. As expected, the correlation between visual acuity and part
(a) complex IADLs was higher than the correlation between visual acuity
and part (b) basic self-care ADLs (r = -0.80,
P < 0.001; and r = -0.49,
P < 0.001, respectively). Second, exploratory factor
analysis showed that there was one main factor underlying the MLVAI,
suggesting that the test is tapping one underlying theme: the ability
to perform ADLs. Furthermore, factor analysis showed that the results
could best be interpreted by three sensible underlying factors.
Finally, Rasch analysis yielded high separation indexes for the
person-ability and item-difficulty measures. However, the difference
between parts (a) and (b) was again evident, with the separation index
indicating greater content validity for part (a) than for part (b).
Because all results indicate a difference between part (a) and part (b), the total score for the MLVAI should be interpreted with caution. We suggest that it would be clearest to consider the scores for part (a) and part (b) separately. Although all results indicate that part (a) has higher content validity and reliability than part (b), we consider the results for each part of the test to be acceptable.
Suggested Changes
Notwithstanding the fact that we demonstrated the MLVAI to be
highly reliable and valid in its present state, we suggest changes that
may further improve the test. To enhance reliability, we suggest
determining the normal time taken to perform each observed item for a
group of age-matched subjects with normal vision. With the use of this
information, the objectivity of the scale could be enhanced by
assigning an appropriate range of times to each rating level.
Also, Rasch analysis indicated that some items may be redundant, and in future the test may be improved by eliminating those items. However, at this stage we caution against this, because the accuracy of the item-difficulty parameters depends on the sample size,49 53 which in this study was relatively small for using Rasch analysis. Further investigation is warranted.
Future Studies
In future, we plan to investigate further the validity of the
MLVAI by administering it to a sample size of more than 500 to
determine more accurately the item parameters using item response
theory. This will enable us to refine the content of the existing test
and to identify gaps in the item logit distribution that should be
filled with new items. Also, additional validation of the MLVAI should
be undertaken by determining its correlation with other ADL performance
instruments, such as the Activities of Daily Vision Scale5
and the VF-14.6
Also, its responsiveness to clinically
important changes should be investigated.
Clinical Applications
There are several potential applications for the MLVAI, the first
being to gather standardized baseline information when people enter
rehabilitation programs. The majority of persons with vision impairment
will have greatest difficulty with part (a), complex IADLs. Some will
have sufficiently severe vision impairment to decrease their
performance of part (b), basic self-care ADLs. Part (b) is likely to
become more important in future, because a substantial increase in the
number of elderly people with severe vision impairment is
estimated.61
A second application for the MLVAI is to
guide planning the most appropriate programs. In most cases this will
be the rehabilitation of complex IADL performance. However, when
difficulty in self-care ADLs is indicated on part (b) items, such
activities are likely to take precedence in the rehabilitation plan
because of their fundamental importance in daily living. Third,
depending on the program implemented for a particular person, each part
of the MLVAI has the potential to be used to monitor change in function
and to evaluate the outcomes of low-vision rehabilitation.
Recently, there has been a great effort to develop quality-of-life questionnaires as outcome measures of low-vision rehabilitation programs. We believe that more objective disability measures, such as the new Melbourne Low-Vision ADL Index, should be in place first. Although such a disability measure neither gives a total representation of the person with impaired vision nor a total representation of the outcomes achieved in low-vision rehabilitation programs, we consider that it should be an integral part of outcome measurement.
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Appendix 1 |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1References |
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Item a1: Naming Colors.
Red-, green-, blue-, and yellow-colored cards (13.5 x 16.4 cm)
were generated in the image management software (PhotoShop; Adobe).
Item a2: Writing a Bank Check.
A unique bank check, based on real-world examples, was produced by
computer (Word, ver. 6.0; Microsoft). The font used for the bank title
was dark red 16-point Geneva (height of capital letters, 4 mm). The
font used for the words "Pay", "or bearer", "the sum of,"
and "/19" was black 8-point Geneva (height of capital letters, 2
mm). The lines were dark gray and 0.25-point (0.1 mm). The font used
for the "$" sign was bold black 18-point Geneva (height, 6 mm), and
the line forming the box for writing the numerical form of the amount
was 20% gray and 2-point (0.5 mm). The task was for the subject to
write the check to the company "Gas Works" for $163.55 and to date
and sign the check using a blue medium ballpoint pen.
Item a3: Reading an Account.
The account selected was based on a local utility company account. The
original was scanned and then manipulated to modify the original
company name, the due date, and the amount, by using the image
management software (PhotoShop; Adobe). The height of the solid blue
capital letters in the company name was 10 mm, and the height of the
black numerals in the amount and the due date was 5 mm. The task was
for the subject to read the company name (Gas Works), amount ($163.55),
and due date (09 Jul 1997).
Item a4: Telling Time Using a Wrist Watch.
A wrist watch of moderate visual difficulty was selected, and the image
was produced using image creation software (MacDraw Pro, ver. 1.5;
Claris, Santa Clara, CA). The font used was bold black Arial,
(height of numerals, 1.5 mm). The hour hand was 5 mm long, and the
minute hand was 6 mm long. Both hands were 2-point (0.5 mm). The
diameter of the clock face on the A4-sized white card was 20 mm. The
task was for the subject to read the time of 10:20.
Item a5: Using a Telephone.
An Australian-manufactured standard telephone (Touchfone 200; Telstra,
Melbourne, Australia) was used. The keys were gray with off-white
numbers. The keys measured 17 x 11 mm and the numbers measured 6
mm height x 5 mm width. The task was for the subject to attempt
to call 9470 1263.
Item a6: Using a Telephone Book.
A page from the telephone book62
was reproduced, with
permission from the Telstra Corporation. The original page was
scanned into the computer and printed. The height of the numerals in
the telephone number was 2 mm. The task was for the subject to search
for "I & C Brewer of 5 Darling Street, Oakleigh" and report their
telephone number (9470 1263).
Item a7: Reading Newspaper Print.
A newspaper article that was simple to read for the general population
and of sufficient length to establish reading fluency, was selected.
The original article, with 87 words and a Flesch63
reading-ease score of 65, was scanned and printed. The height of the
capital letters in the main body of the text was 2 mm. The task was for
the subject to read the given section of the Herald Sun
newspaper article entitled "There’s No Place Like
Home."64
Item a8: Reading a Medicine Label.
The original medicine label was reproduced by computer (Word;
Microsoft). The font used for the name of the medication and dosage was
12-point dark gray bold Arial, (height of capital letters, 3 mm). The
font for the instructions was 10-point dark gray bold-italic Arial
Narrow (height of capital letters, 2.5 mm). The font used for the
number of repeat prescriptions and date was 10-point light gray bold
Arial Narrow. The task was for the subject to read the name of the
medication (amoxil or amoxycillin), the dosage, and the instructions
(one capsule, three times daily, or every 8 hours).
Item a9: Reading a Digital Display.
A large and bold display was selected, and the image reproduced by
computer (Word; Microsoft). The font used for the digital display was
64-point white Bookman Old Style, (height of numerals, 16 mm), against
a black background measuring 92 x 56 mm. The task was for the
subject to read the time of 12:58.
Item a10: Recognizing Faces.
Various scientific techniques have been established for such a
task.65
66
67
However, a more expeditious and convenient
task was required for inclusion in the multi-item MLVAI. Therefore, we
chose to have the subject simply recognize and name a famous person
whose face appeared in a photograph at a distance of 1 m. An image
of Princess Diana on the cover of Diana, Her Life in
Photographs68
and an image of President Bill Clinton
from Presidents and First Ladies of the United
States69
was photocopied and enlarged on a color
laser photocopier (resolution, 400 dots per inch; Fuji–Xerox; North
Ryde, New South Wales, Australia). The final life-sized image of the
head of Princess Diana measured approximately 190 mm in height and that
of President Clinton measured 200 mm in height.
Item a11: Reading a Typed Letter.
A letter used by the Victorian College of Optometry to advise patients
that they have an appointment was selected for this item. The original
was copied into a computer (Word; Microsoft). The font used for the
name of the organization was 18-point bold black Times (height of the
capital letters, 4 mm), and the address was 11-point Times (height of
the capital letters, 3 mm). The font of the appointment time and date
was 10-point black Courier (height of the capital letters, 2 mm). The
font of the text included in and below a red information box, was
12-point Times (height of the capital letters, 3 mm). The task was for
the subject to find and read the name and address of the place of
appointment, the date and time of the appointment, and the two health
cards to bring to the appointment.
Item a12: Threading a Sewing Needle.
A medium-sized embroidery-crewel needle size 5 with a 4-mm-long eye
(model 65115; Lincraft, Melbourne, Australia), and 100% polyester
white (color 800) thread (CA02776; Gütermann, Gutach, Germany)
were used. A pale-blue A4-sized card was chosen to provide a standard
contrasting background for all subjects.
Item a13: Reading Newspaper Headlines.
Two newspaper headlines that were simple to read and contained words of
varying length were selected. The headlines were five and six words
long with Flesch63
reading ease scores of 83 and 102,
respectively. The originals were scanned and printed. The height of the
capital letters was 15 mm. The task was for the subject to read both
headlines: "Help to End the Food Nightmare"70
and
"Police Hunt for Armed Robbers."71
Item a14: Pouring.
The subject was required to pour water from a 2-l semitransparent jug
into a 350-ml clear plastic cup, to within approximately 1 cm of the
top of the cup. An opaque white plastic tray was used as the standard
background.
Item a15: Telling Time Using a Wall Clock.
An image of a real wall clock was reproduced using image creation
software (MacDraw Pro; Claris). The font used for the display was bold
black 96-point Times New Roman (height of the numerals, 22 mm). The
hour hand was 50 mm long, the minute hand was 60 mm long, and the
second hand was 70 mm long. The hour and minute hands were 6-point (2.5
mm) and the second hand was 1-point (0.25 mm). The overall diameter of
the clock face was 187 mm on a white A4-sized card. The task was for
the subject to read the time of 1:35.
Item a16: Reading Packet Labels.
A variety of common Melbourne grocery products were chosen. The six
original packet labels were scanned. The height of the capital letters
varied from 7 mm for the type of soup on the soup label to 25 mm for
the height of the type of cereal on the cereal label. The task was for
the subject to give the type and name of the products: bran cereal
(Sultana Bran; Kelloggs, Pagewood, NSW), toothpaste
(Colgate–Palmolive, New York, NY), soup (Creamy Chicken and
Vegetables; Continental, Epping, NSW), bandages (BandAid; Johnson &
Johnson, New Brunswick, NJ), and biscuits (Savoy-Arnotts, Homebush,
NSW).
Item a17: Identifying Coins.
Two of each Australian coin were selected: $2, $1, 20¢, 10¢, and 5¢.
The date on the coins varied from 1977 to 1996. A pale-blue A4 card was
used as a standard background. The task was for subjects to retrieve
$3.55 from the pile of coins.
Item a18: Buttoning a Shirt.
A plain white cotton shirt with white buttons was selected. To avoid
disadvantaging the opposite gender, a male shirt with the buttons on
the right and a female shirt with the buttons on the left were used.
Part B: Questionnaire Items
The questionnaire section of the MLVAI was based on 9 of the 14
items in the ADL subtest of the Duke University Older Americans
Resources and Services Multidimensional Functional Assessment
Questionnaire (OARS MFAQ).26
Item b1: Shopping.
Can you go shopping for groceries or clothes...
Item b2: Preparing Meals.
Can you prepare your own meals...
Item b3: Managing Housework.
Can you do your housework...
Item b4: Managing Medication.
Can you take your own medicine...
Item b5: Eating.
Can you eat...
Item b6: Dressing.
Can you dress and undress yourself...
Item b7: Grooming.
Can you take care of your own appearance—e.g., shaving, hair,
make-up...
Item b8: Mobility.
Can you walk outdoors...
Item b9: Bathing.
Can you take a bath or shower...
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Acknowledgements |
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Footnotes |
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Commercial relationships policy: N.
Corresponding author: Sharon A. Haymes, Department of Optometry and Vision Sciences, The University of Melbourne, Keppel and Cardigan Streets, Carlton VIC, Australia 3053. s.haymes{at}optometry.unimelb.edu.au
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