Internet use: Perceptions and experiences of visually impaired older adults

Many older people are increasingly using the internet. This study investigated the experiences of visually impaired older people on internet use and explored how it fits into their lives. 20 visually impaired older people aged 60 years and over were recruited from a voluntary organisation for blind people. Qualitative interviews were conducted with all participants to investigate how they perceive the relevance of internet use to their daily lives. Findings suggest that the internet not only has potential to promote their ability to perform daily tasks, cope with vision impairment and feel socially included. However, the rapid pace of technological advancement is feared as a development that could further widen the digital divide if they are not carried along by addressing barriers to their internet.


Introduction
In the same vein as global population ageing and vision impairment, the number of older adult users of the internet is increasing (Madden, 2010). Many older adults now rely on the internet to help manage their daily communication, access social care services and gain social involvement (Cook et al., 2010). Although technological advances in computer software and digital assistive technologies have enhanced access to the internet for visually impaired older people, their adoption of the internet is less than their sighted peers (RNIB, 2013). Paucity of research on use of Information and Communication Technology (ICT) by older people with vision impairment has made it more difficult to tackle the digital divide (Hollier, 2007;Kane, 2011). This study explores the perceptions and experiences of visually impaired older people on how computer use fits into their daily lives. By understanding how the internet is utilised by visually impaired older people, knowledge gathered may contribute to more effectively addressing their perception on digital inclusion.

Background
The term "vision impairment" describes a range of conditions affecting visual acuity (clarity of vision) and visual field; and leading to irreversible loss of vision. Many studies have shown that the internet has the potential to enhance communication and daily tasks for people living with disabilities. Bishop, Taylor and Froy (2000) investigated the potential of Computer Mediated Communication (CMC) to relieve social isolation among a sample of participants with hearing impairment. The study found that it was easier for participants to communicate online than face-to-face contexts. Swindell (2002) reported that communication technologies have potential to minimize social isolation and thereby improve quality of life. Online social and emotional support from family and friends have been linked to lower stress, better adaptation and having a sense of belonging (Hageboom, McDermott,Perrin, Osman, & Bell-Ellison, 2010;Russell, Cambell, & Huges, 2009;Sum, Mark, Pourghason, & Huges, 2009). Egan, Chenoweth and McAuliffe (2006) found that email enabled participants to compensate for challenges posed by impairments that affected information processing, response formulation, concentration and recall. Many other studies suggest that older people can connect to people who are having similar experiences and receive practical help in adjusting to life with disability (Eysenbach, 2008;Sayago & Blat, 2010;Sayago, Sloan, & Blat, 2013). However, despite these benefits, not all older people use computers. Evidence suggests that older people with disabilities such as vision impairment are much less likely to use the internet due to the myriad of challenges hindering their access (Gerber & Corinne, 2001;Hollier, 2007;Kane, 2011;RNIB, 2013).
As computers are increasingly becoming integral to modern living, it is very important that older people learn how to adapt to new computer-based technologies in order to be part of the current information society (European Commission, 2007).
In recent years, many technologies are operated through computer systems as seen in smart phones, Automatic Teller Machines (ATMs), ticket machines, hospital check-in services, etc. Operating these technologies require an understanding of their underlying systems of operation; that of networked digital devices, the internet and the World Wide Web.
Research suggests that many older people have never used the internet (Niehaves & Plattfault, 2014;Office of National Statistics, 2013). According to a recent report by Age UK (2013), older people aged 60 and over in the North of England are less likely to be online compared to those in the South. The report suggests that only 28% of older people in Tyne and Wear use the internet. This contrasted sharply with their peers in Surrey, where 63% of older adults reported using the internet. In other Southern parts of the country (such as Bedfordshire, Suffolk, Oxfordshire, Buckinghamshire), not less than 50% of older people aged 65 and over use the internet. The Age UK (2013) report raised concerns over the North-South divide and highlighted the need for the government, local authorities and private organisations to help older adults get online.
Some attitudes among older people have been identified as indicators of a decision to adopt computer use. For example, within the Technology Acceptance Model (Bagozzi, Davis, & Warshaw, 1992), perceived usefulness (a measure of the subjectively defined benefits of technology use) and perceived ease-of-use (a measure of user's degree of satisfaction with accessibility) have been argued to be a strong determinant of older people's rational intention to use ICTs (Ryu, Kim, & Lee, 2009). Davis (1989) defined "perceived usefulness" as "the degree to which a person believes that using a particular technology would enhance his or her job performance" and "perceived ease-of-use" as "the degree to which a person believes that using a particular system would be free from effort" (p. 320). In essence, the perceived relevance and benefits of computer use is an important decisional factor among many older people (Melenhorst, Rogers, & Bouwhuis, 2006;Selwyn, Gorad, Furlong, & Madden, 2003;Sharit, Czaja, Perdomo, & Lee, 2004). However, older adults may also have strong emotional reactions, such as fear and "computer anxiety" to using computers. Such reactions could influence their decision making process when they are inexperienced, and negatively affect initial use and adoption (Czaja et al., 2006;Ellis & Allaire, 1999). Furthermore, older people's computer and internet literacy levels are diverse. As older people are a very heterogeneous group (Neves & Amaro, 2012;Wagner, Hassanein, & Head, 2010), the challenges that they experience through computer learning processes are diverse (Wagner, Hassanein, & Head, 2010) and there is a need to understand the scope of such diversity and how it may affect the adoption of ICTs. For example, many visually impaired older adults are in the position of having to learn how to use adaptive technological devices from scratch before they can explore their potential. The absence of prerequisite technical literacy can exclude them from the benefits of computers and the internet.
While there has been a growing body of work focussing on the barriers to internet access for older people over the past decade (Gerber, 2003;Hayhoe, 2011;Murphy, Kuber, McAllister, Strain, & Yu, 2008;Papadoupoulos & Goudiras, 2005;Yu, McAlister, & Dodds, 2004) and a few exploring their experiences (Douglas, Cocoran, & Pavey, 2007;Fuglenid, 2011), there seems to be paucity of research focussing on older age group with vision impairment. In essence, despite being a group less likely to use the internet, less attention has been paid to capturing their experiences and perceptions, as an approach to understanding how the internet may be of relevance to their day-to-day lives (RNIB, 2013).
Although some studies emphasised that the internet could enable older people with disabilities to live autonomously and cope with challenges of daily living (Comyn, Olsson, & Guenzier, 2006;Simpson, 2009), to what extent such benefits may be applicable to visually impaired older users remains unknown. Difficulties with making adjustments to functional loss as a result of vision impairment could cause feeling dependent on others or frustrations at having to solicit for assistance (Percival & Hanson, 2005). A visually impaired person who is unable to make necessary adjustments to adapt or compensate for such losses might go through symptoms such as anxiety, stress, adjustment disorder, and major depression which might ultimately affect their ability to socialise with others (Casten & Rovner, 2006;Rovner, Casten, Leiby, & Tasman, 2009).The most common outcome of these processes is a diminished sense of independence and self-esteem.
As older adults with vision impairments require assistive devices to access the internet, they are a group with distinct patterns of internet access. The World Wide Web Consortium (W3C), international community led by Tim Berners-Lee, inventor of the World Wide Web, and supported by a staff of technical experts coordinates web standards based on community consensus (World Wide Web Consortium, 2014).
Properly designed websites which conform to guidelines stipulated by W3C, can be used by people with disabilities (World Wide Web Consortium, 2014). However, many sites are designed without adherence to the W3C protocols and guidelines thereby making it difficult or impossible for some people to use them. There is a need to understand how visually impaired older people use the internet and how it fits into their daily lives in order for policies and advances in technology to adopt a functional approach to bridging the digital divide (Kane, 2011;Kane, Bigham, & Wobbroack, 2012). In considering the paucity of research on the context of internet use among visually impaired older people, the current study explored their experiences and perception with a view to highlighting the benefits and the challenges it currently holds for them.

Method
The sample for this study consisted of 20 respondents, all of whom were members of a voluntary organisation for blind people in Newcastle (North-East of England). The participants were aged between 60 and 92. They consisted of 12 women and eight men. Respondents possessed a wide range of age-related vision impairments and visual condition, varying from partial sight to total blindness. Participants who had Cornea dystrophies were partially sighted while participants with Age Related Macular Degeneration (ARMD), Glaucoma and Retinitis Pigmentosa were totally blind. Participants' experiences with internet use ranged from complete beginners to advanced users. The sample was not intended to be representative of the visually impaired community, but to be contextually sympathetic to the visually impaired students at the centre at the time the research was conducted.
The research framework used in this study is the Qualitative paradigm (Williams, 2007), using an ethnographic approach of mainly interviews and observations. The interviews were topic-guided. This design was adopted in order to be able to explore other topics and questions as they emerged (Phillimore & Godson, 2004). It is a more suitable method for gaining tacit knowledge of the social context of systems use, and real life interactions and experiences (Bodker, 2006;Seidman, 1998). The approach emphasises the understanding of meaning in context, and that meaning is created through interaction with a conversational partner. The concepts of multiple experiences narrated by different respondents and the importance of contextualising reality based on respondents' experiences are further characteristics of this approach (Moggridge, 2007).
All participants used the screen readers. With permission from participants, interviews were audio recorded. Interviews were conducted with participants over a period of 6 months; and a second interview was scheduled when there was need to build on emerging findings from the first. The repeat interviews were held about 4-6 weeks apart, enabling participants to reflect on what they said. In other words, the second interviews gave a potential for a more reflective interview (Seidman, 1998).
Before the commencement of the second interviews, analyses of first interview transcripts were verbally reported to participants. This was to ensure that there were no misinterpretations (Polit & Beck, 2004). This iterative design aimed at generating clearly guided and detailed data from participants (Seidman, 1998). Interviews focused on background information about the participants and their experiences with internet use. The open-ended natures of questions enhanced exploration of narratives (stories) of participants from their experiences and also helped to develop a rapport with them about the meanings they attached to internet use. Pseudonyms have been used to preserve anonymity. Participants' ages and types of vision impairments are presented in parenthesis after quotes. Ethical approval for this study was granted by Northumbria University.

Data analysis
Interviews were thematically analysed, through the creation and application of "codes" to data from interview transcripts (Strauss & Corbin, 1998), and following Grounded Theory principles (Glaser & Strauss, 1967). Audio taped interviews were transcribed and analysed using qualitative data analysis software (Nvivo). The methodological principles of "open and axial coding" were used to draw related patterns from participants' comments (Strauss & Corbin, 1998). Relevant thematic codes were identified by constant examination of themes and crosschecking of these through referencing to individual transcripts and the collective data set.

Results
Five themes emerged from the study, namely: Keeping in touch, Barriers to internet use, Maintaining independence and social inclusion, Coping with vision impairment, and Hopes and fears.

Keeping in touch
Many participants reported that their main motivation for using the internet was to enable them keep in touch with their social networks. They felt that the ability to stay connected to people enhanced their sense of belonging to society and also gave them the opportunity to contribute to the social well-being of others and be active social participants. They reported that using emails enabled them to manage their social engagements with other people in better ways. Some participants who lived alone said that the internet helped them to supplement offline interpersonal interactions and reduce the feeling of loneliness and social isolation: Such social interactions start from understanding collective interests which provide opportunities to discuss subjects that may be difficult to approach in the real world (Lindlif & Shatzer, 1998). Participants seemed not to feel the constraints of the media lacking visual cues because they had already become used to communicating without visual cues.

Barriers to internet use
Many participants expressed their frustrations with internet use. They felt that it was fraught with so many challenges that discouraged them from using the internet as much as they would like to.

Internet interface designs
Although there are guidelines stipulated by the worldwide web consortium on how to make websites accessible to people with disabilities, comments from participants suggested that web pages still remained difficult to access for many visually impaired older adults. Their responses indicated that many web lay-outs presented a major barrier to their ability to use the internet. Despite using large fonts, participants in this study criticized distractions on web-pages. Many participants regarded some interface designs as not being fair to visually impaired people and criticised them as not being "inclusive designs" because visually impaired people had not been duly considered. In particular, they complained about the website lay-out design of social networking sites. They felt that the lay-out is usually confusing because the fonts were not tailored to support usability by visually impaired people. This suggests that the increasing use of social network sites (SNSs) for socialisation among older adults (Madden, 2010) may not be applicable to this group. For many other participants, they believed that because they did not grow up in a technological era, it would be more difficult to learn how to use them in more Vivian's comments suggested that the indifference of many visually impaired people about social media was not always due to vision impairment or lack of awareness but could also be attributed to apathy towards use of social media because they attached little relevance to it.

Cost of assistive devices and training
The cost of screen readers was perceived as a barrier to internet access and was a recurrent issue in participants' comments. Many earlier studies have highlighted this particular factor as contributing significantly to the disability divide (Hollier, 2007;Lazar & Jaeger, 2011;Shaw Trust, 2013). Participants however, noted that they were not advocating for pricing in their favour but for an affordable price that will enhance equality of internet access.

"I think there needs to be a good look at where equipments and assistive devices can be purchased at a lot more affordable prices for visually impaired people. The costs are outrageous!'' [Newton, 68, ARMD].
The issue of cost thus remains a recurring barrier for people with disabilities.
Many participants believed that having a universal design could be a strategic approach toward integrating people with disability and also reducing the price. They argued that if the same design were made for everyone, manufacturers could effectively manage the cost of production and control the exorbitant prices of specialist devices for people with vision impairment. There were also concerns about skill acquisition for use of computers.
Although training and support could help older people overcome some of their anxieties, enable them to build skills and develop their confidence using the computer, some participants perceived computer training as difficult. In their opinion, the actual difficulty was not only due to vision impairment, but to ageing as well.
Kimberly felt that as a visually impaired older person, learning to use the computer has been one of the most challenging tasks for her to overcome because she was not brought up with computers. In her comments: While these barriers continue to hinder equitable internet access to the blind and partially sighted, those who can afford assistive devices also face many challenges. The next section describes in details report of participants' experiences of internet use has not been too helpful for them to feel socially integrated.

Maintaining independence and social inclusion
The role of the internet and ICT in general in enhancing their social inclusion and participation in today's dynamic ICT world was perceived as crucial by many participants. However this comment was commonly mentioned by participants aged between 60 and 70 years. They believed that they were unable to participate as fully as sighted people did in the current advancing ICT age. Issues raised included the ease of use of the internet to perform daily tasks, such as paying their bills online, banking and shopping. These are discussed in-details below:

Reading bills online
While internet facilities help many users to make online payments and afford them many more advantages due to the convenience, such benefits elude many people with vision impairment because they do not have the same internet access as sighted users. For example, a participant complained of not being able to read her bills despite using a screen reader: These comments suggested that some participants recognised the central role of computers in their daily lives and its potential to make them do things conveniently; unfortunately they felt that they were not getting the best they could get from computer use. Access to carry out their day-to-day activities remained limited.
They believed that this might hinder their chances of being fully integrated into society.
Some participants who got assistance from their family or friends to the supermarket believed that it gave them opportunities to meet people and to socialise. However, they voiced concerns that the rise in online shopping might lead to more segregation of visually impaired people and other people with disability because they did not have the same internet access as sighted people. Many of the participants made comments suggesting that, while they could accept giving up certain luxuries such as driving a car or gardening, they did not want to compromise their

Coping with vision impairment
Many participants described how they used internet to compensate for their sight impairment, such as difficulties with reading, writing or in some cases, compensating for relinquished activities of interest. From participants' views, writing guides may not be sufficient to make writing easier. Keeping social contacts through hand written mail was described as nearly impossible without vision. In addition to poor hand writing and inability to see what they were writing, they also cited many other difficulties such as inability to go to the post-office due to limited mobility. Kimberly, complained about having bad hand-writing, and cited this shortcoming as her primary motivation for her interest to learn to use emails: Many participants had given up some activities they enjoyed doing as a hobby because of vision impairment. Previous studies suggest that relinquishing valued activities is associated with increased risk of cognitive decline and depression in older adults with vision impairment (Casten & Rovner, 2006;Rovner et al., 2009).
Findings suggested that many participants were able to successfully find a substitute for lost hobbies in computer use and were successfully adjusting to such losses via internet use. This is illustrated in Rosaline's comment:

Hopes and fears
Many comments by participants reflected their fears about being excluded from participating in rapidly advancing ICT world. Typically, such comments portrayed apprehension that as many technological devices take haptic forms (touch screens), it could potentially make a bad situation worse. Hence, they expressed so much concern that such innovation might marginalise them from the potential benefits of internet use. The following quotes illustrated apprehension in their responses: "You just got that touch screen things now…so my concern is if it all goes to touch things, I've got arthritis in my hands and I find it hard to do the touch thing. You all happen to forget those who have difficulty in using hands/palms, how would that relate to those palms with hands that don't always...it took me an hour to get that up. As I couldn't feel the touch because as you get older they feeling is not as good but I find that very difficult'' [Samantha,64,Cornea dystrophy].
Finally, as it is often argued that the speedy rate of advancement in ICT innovation and web-designs render accumulated knowledge and skills of older people redundant thereby contributing to their relegation to obsolete technologies (Simpson, 2009). The progress being experienced by sighted users as technology undergoes constant modification and improvement may not necessarily be regarded as progress for this group. Some of the participants had suggestions for the technologies they would like to see developed in the future in order to enhance not just their access, but guarantee easy access for every user without discrimination on disability: "I think apple one of their selling point is that the accessibility is built in . These findings reveal that whilst computing technologies continue to advance rapidly, many visually impaired older adults struggle to catch up. Participants nursed fears of being left behind and of not fully benefiting from the internet.

Discussion
This study suggests that visually impaired older people believe that they can manage their daily tasks better through internet use. Many of them successfully used online socialisation processes to keep in touch with family and friends. Physical meetings with others can be difficult due to the challenges of mobility and identifying people.
They believed that online environments provided exciting virtual platforms to socialise, and seek vital information from others in a similar situation. Another perceived usefulness of online forums was that it afforded them opportunities to share their interests with others. In essence, considering the difficulty in connecting with people of similar condition offline, the online environment was perceived as a platform that supported such levels of connectivity and enabled mutual sharing of life events and social support.
Although internet use helped visually impaired older adults in this study to make needed adjustments and to cope with functional losses associated with vision impairment (such as losses relating to leisure activities, reading and writing), they however, did not achieve such feat without struggle. While participants were eager to use the internet to make life easier, their awareness about the difficulties surrounding access made them apprehensive about how they could participate in society. The implication is that inequity in internet access remains a hindrance to social integration of this user group particularly as the internet revolution is currently taking many social activities into online media. The issue of cost as a barrier to internet uptake by visually impaired people seem to be a recurrent problem contributing to the digital divide. There is a real danger that such socially constructed inhibiting factors may leave visually impaired older people further disadvantaged and less capable of using the internet (Krishna & Panchanathan, 2010). The ability to perform instrumental activities of daily living such as shopping, paying their bills online and communicating with others, were interpreted by participants as integral to their sense of integration into society. Thus, the themes demonstrated aspect of the lives of visually impaired older adults that they perceived internet use was invaluable.
Drawing on the experiences of participants in this study, findings support previously reported findings from studies on older people and computer use that, the internet can enable older people to maintain existing social relationships, expand their social networks and facilitate communication with others (Bargh & McKenna, 2004;Ellison, Steinfield, & Lampe, 2007;Godfrey & Johnson, 2009;Pfeil, Zaphiris, & Wilson, 2009;Sayago & Blat, 2010;Xie, 2007). Nevertheless, findings emphasized that the increasing technological complexity seems to be adding more difficulties to internet access for this group. Such difficulties reported by participants in this study included complex website interface designs that did not consider their vision needs, increasing cost of some assistive device such as screen readers, inadequate training, and lack of inclusive designs in technology development. From experiences of visually impaired older people, the complexity of internet use as technological advancements progress rapidly presents an enormous challenge. In the disappearance of simpler, more self-explanatory systems, adequate training and support is constantly needed for this group.

Implications of findings
Although many free screen readers exist, they are not effective for all users or on all websites. Thus, the removal of more traditionally disabling barriers such as the prohibitive cost of screen readers, and provision of adequate training and awareness on appropriate screen readers would be an important strategic approach to tackling the burden of the digital divide. There is a need for policy geared at bridging the digital divide to focus on enhancing web accessibility and promoting availability of affordable assistive devices for internet access. As emphasised in this study, poor access to online services in the light of rapid technological advancement further complicates the digital divide and social exclusion of people with vision impairment.
The findings also emphasize the existence of a continuum in the development and adoption of technologies. At one end of the continuum, for instance, is the creation of ICT facilities that can be used by visually impaired people and people with other forms of disabilities to cope with functional loss and overcome the challenges they face with daily living. At the other end of the continuum is the fundamental question about social dimensions of technology design, diverse criteria for instrumentation that must function in diverse characteristics of disabilities, and creation of effective policies that are essentials to the promotion of values-sensitive adaptive technologies (Bilbao-Osorio, Soumitra, & Lan, 2014;Sandler, 2012). For example, it is important to understand the different needs of people with different types of vision impairment in creation of ICT facilities for them. There are debates that the development and adoption of assistive technologies will be associated with public view of ageing and disability as problematic. Many of such arguments point out that, such adaptive device could automatically define disability and may compound stigmatisation of disability because their designs are not universal and integrative (Gaffney, 2010). In considering such arguments, it might be important that ICT developers begin to explore inclusive technologies.
Findings from this study have implications not only for ICT practitioners, but also professionals in ocular rehabilitation. It is hoped that they can contribute to knowledge on the social context of internet use among visually impaired older persons so that awareness on sustaining independent living through use of CMC after sight loss could be further promoted. The understanding created by this study to expose the domains of internet use for activities of daily living and complexities surrounding internet access for this group will help channel concerted efforts in bridging the digital divide.
The current study has several limitations which can be overcome in future research. Firstly, the study did not explore how the different types of vision impairment could have played a role in participants' ability to use the internet. It is possible that the different kinds of vision impairment or the severity of vision impairment might have influenced how participants respond to dynamics of internet use, what daily tasks they prioritise, their coping skills and their perceptions of the usefulness of the internet. The qualitative nature of the study makes it impossible to generalise findings from the current study to other visually impaired older internet users.

Conclusion
In summary, the themes specifically reveal aspects of their social needs which they considered as goals that could be met via internet use. Findings suggested that the internet could be a potentially enabling tool for visually impaired older people to cope with challenges posed by vision impairment and to maintain their independence. In particular, it afforded participants opportunities to maintain social contacts and perform daily tasks in ways that would be otherwise difficult in physical world due to vision impairment. However, while the benefits of use of the Internet for older people with vision impairment seem to be consistent with reported benefits among their sighted peers, the difficulties caused by vision impairment seem to be more than the