Aging & Mental Health

ISSN: 1360-7863 (Print) 1364-6915 (Online) Journal homepage: https://www.tandfonline.com/loi/camh20

Subjective well-being of visually impaired older

adults living in the community

Liran Rafaely, Sara Carmel & Yaacov G. Bachner

To cite this article: Liran Rafaely, Sara Carmel & Yaacov G. Bachner (2018) Subjective well-being
of visually impaired older adults living in the community, Aging & Mental Health, 22:9, 1229-1236,
DOI: 10.1080/13607863.2017.1341469

To link to this article: https://doi.org/10.1080/13607863.2017.1341469

Published online: 21 Jun 2017.

Submit your article to this journal

Article views: 579

View related articles

View Crossmark data

Citing articles: 7 View citing articles

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=camh20
AGING & MENTAL HEALTH
2018, VOL. 22, NO. 9, 1229–1236
https://doi.org/10.1080/13607863.2017.1341469

Subjective well-being of visually impaired older adults living in the community

Liran Rafaely, Sara Carmel and Yaacov G. Bachner
Department of Public Health, Faculty of Health Science, Ben-Gurion University of the Negev, Beer Sheva, Israel

ABSTRACT ARTICLE HISTORY

Objectives: Vision impairment is one of the most common disabilities among older adults, and it has a Received 18 January 2017
substantial impact on well-being. The present study constructs an integrative model to identify which Accepted 7 June 2017
variables derived from four dimensions of life (physical/functional, social, psychological and KEYWORDS
environmental) combined with sociodemographic variables explain the overall subjective well-being Vision impairment; subjective
(SWB) visually impaired older adults living in the community. well-being; life dimensions;
Method: A total of 121 severe visually impaired persons, aged 60 and over (M = 77.4, range 60–95), disabilities; older adults
participated in the study. Personal, face-to-face interviews were conducted with participants at social
centers or at their homes. Research tools consisted of valid and reliable questionnaires.
Results: Five variables explained the older adults’ variability in SWB: self-rated health, sense of
meaning in life, functional independence in activity of daily living (ADL), sense of control of one’s
environment (Mastery) and the participant’s age. The explained variance percentage was found to be
high (61%). In contrast to expectations, social-environmental variables proved to be only of secondary
significance in explaining SWB variability.
Discussion: Variables derived from the psychological dimension appear more significant than the
social-environmental variables in explaining SWB among visually impaired older adults. These
variables should be considered when developing intervention programs intended to increase SWB
within this unique population group.

Severe vision impairment, possibly terminating in total blind-
ness, is among the most common sensory disabilities in mod-
ern Western society (Brown & Barrett, 2011; Heyl & Wahl,
2014; Wahl, 2013). According to an American Foundation for
the Blind (2013) report, by 2030, the number of older adults in
Western countries will reach twice its 1950s value, entailing a
similar increase in the percentage of vision-impaired persons.
The range of diseases causing severe vision impairment
crosses geographic, ethnic, gender, class and sociodemo-
graphic boundaries (Bazargan, Baker, & Bazargan, 2001; Ram-
rattan et al., 2001; Verdugo, Prieto, Caballo, & Pel
aez, 2005;
Williams, Brody, Thomas, Kaplan, & Brown, 1998; Zhang et al.,
2009) and consequently demands worldwide attention. Loss
of normal vision engenders complex realities with which
those affected must cope as their living environment changes
constantly (Cimarolli, Boerner, Brennan-ing, Reinhardt, & Hor-
owitz, 2012). The likelihood of vision impairment rises with
age (Ramrattan et al., 2001), tends to threaten everyday func-
tional competence (Wahl et al., 2013), tends to be associated
with depression symptoms and lower level of life satisfaction
(Brown & Barrett, 2011) and consequently affects people’s
subjective well-being (SWB) (Heyl & Wahl, 2014). This concept
reflects one’s personal evaluation and feelings concerning
life, manifested at the cognitive-intellectual level – at which
people judge their lives in general and at the emotional level,
wherein they report of the relative prominence of positive
affects over negative ones in the present or the recent past
(Diener et al, 1999). SWB is characterized by over-all content-
ment, as contrasted with feelings of sadness and despair. An
older adult’s SWB is of major significance regarding adapta-
tion and functional skills within one’s environment, including
active involvement in society, it is considered a substantial
component of quality of life (QOL) in later life (Diener &
Diener, 2002; Sarvimaki & Stenbok-Halt, 2000).
A high positive self-evaluation of well-being is important
during old age with regard to disease prevention, construc-
tive approaches to chronic illness and disabilities, acceleration
of rehabilitative processes, and for the promotion of positive
health (Ryff, Singer, & Love, 2004). Studies point to the signifi-
cant association between decline in vision ability and poor
SWB among older adults (Bazargan et al., 2001; Zhang et al.,
2009). A review of the literature indicates that four key dimen-
sions of life are correlated with SWB among older adults (func-
tional/physical, social, psychological, environmental).
Therefore we constructed an integrative model using well-
established variables for each of the four dimensions (see
Figure 1).
Functional–physical. The functional/physical dimension
addresses physical health and extent of functional indepen-
dence (or the level of disability). Numerous studies report
high SWB among older adults who are in good physical health
and function well independently (Bowling, Banister, Sutton,
Evans, & Windsor, 2002; Hilleras, Jorm, Herlitz, & Winblad,
2001), while those who have lost their sight may experience a
decline in everyday functionality (Brown & Barrett, 2011; Heyl
& Wahl, 2012) and may suffer from increased risk of falling
(Ramrattan et al., 2001). These may negatively affect SWB.
Thus, for old persons who suffer from severe vision
impairment, overall state of health and functioning are of par-
amount importance for maintaining SWB (Wahl et al., 2013).
The ability to handle with one’s environment and function
safely therein is adversely affected by severe sensory

CONTACT Yaacov G. Bachner bachner@bgu.ac.il

© 2017 Informa UK Limited, trading as Taylor & Francis Group
1230 L. RAFAELY ET AL.
Functional-Physical
Functional independence (-)
(level of disability)
Social
Social Support (+)
Social Involvement (+)
Overall
Subjective
Psychological Well-being
Mastery (+) (SWB)
Meaning /purpose in life (+)
Optimism (+)
Environmental
Physical home environment(+)
Figure 1. The four life dimensions and their assumed associations with older
adults’ SWB. (+) positive association (–) negative association.
deprivation and requires considerable physical and mental
strength for the development and adoption of compensatory
skills to cope with everyday challenges.
Social. The social dimension addresses the importance of
social support and involvement with regard to life ethos and
interpersonal functioning, especially among older adults.
High levels of mental well-being were found among older
adults who reported provision and/or receipt of social support
and high levels of community and municipal involvement
(Diener, Suh, Lucas, & Smith, 1999; Pinquart & Sorensen, 2000;
Thomas, 2010). High levels of social support were also found
to moderate well-being measures such as tension, pressure,
distress, and depression among the elderly population
(George, 2006; Piferi & Lawler, 2006). Moreover, the potential
damage inherent in reducing the frequency and intensity of
social support and activity among visually impaired older
adults can be expressed by increasing levels of anxiety
(Kempen, Ballemans, Ranchor, Van Rens, & Zijlstra, 2012),
loneliness, and reduced ability to adapt to their loss of vision
(Verstraten et al., 2005) and fulfill roles in their community
and living environment.
Psychological. Various personality characteristics and inter-
nal resources are involved in adjustment to processes of
aging and in coping with chronic illness, strain, and mental
distress. Coping strategies and cognitive abilities are of high
importance for maintaining everyday functioning and in turn,
promoting overall well-being in sensory impaired older adults
(Heyl & Wahl, 2012). Internal personality strengths, such as
higher sense of control, meaning in life and optimism, were
found to promote levels of SWB among older adults (Allison,
Guichard, & Gilain, 2000; Ardelt, 2003; Heo & Lee, 2010;
Krause, 2009; Smith, Young, & Lee, 2004). Severe vision
impairment in advancing years is generally accompanied by
cognitive loss (e.g. lower information-processing speed, key
memory, and executive control functions) (Wahl, 2013). This
decline is steeper among older adults with severe vision
impairment, compared to the general elderly population
(Reyes-Ortiz et al., 2005; Valentijn et al., 2005). Personal losses,
such as damage to one’s self-image and integrity as a human
being, are another complex challenge of older adults with
vision impairment (Ainlay, 1989). These cognitive and per-
sonal resources are key elements in reinforcing mental health
among older adults.
Environmental. The environment exerts a critical effect on the
individual’s well-being. The balance between an older adult’s
needs and lifestyle and the characteristics of the environment
has an important contribution to his SWB (Lowenstein, 2003).
As Lawton has shown more specifically in his ‘competence-envi-
ronmental press model’ (Lawton, 1982; Lawton & Nahemow,
1973), fit between the personal competences and environmen-
tal press can result in positive outcomes, while a mismatch may
result in poor adaptation (‘maladaptation’). Many studies under-
score the importance of appropriate physical, functional and
mental responses to the needs of older adults in the physical
home environment regarding the improvement of their well-
being (Brawley, 2001, 2002; WHOQOL Group, 1998; Zilberman,
2002). Constant variation in the living environment outside the
home and the fixed nature of the home structure, irrespective
of changes in the aging person’s everyday needs, pose increas-
ing problems and challenges for people coping with loss of
sight during the autumn of their lives.
In spite of the research noted above and a recent increase
in awareness of the centrality of SWB to the life ethos of older
adults, more studies are needed that focus on the SWB of
visually impaired older adults. A better understanding of the
components associated with SWB among the ever-increasing
group of older adults affected by severe vision impairment or
total loss of sight is needed. This will enable the development
of intervention programs which are aimed specifically for this
group.
Hence, the purpose of the present study is to identify the
significant elements associated with overall SWB of older
adults with severe vision impairment living in the community.
For this purpose, we constructed a model assessing the corre-
lations between the four stipulated dimensions of life and
overall SWB. Variables that strongly correlated with SWB in
previous studies were selected for each dimension.
Method
Participants
A total of 121 persons participated in the study. Participants
were recruited from a convenience sample at multiservice
centers for the visually impaired operated by organizations
for the blind throughout Israel. In order to increase the sample
size, others were sampled randomly from a national list of
older adults who possess certificates attesting to severe vision
impairment (issued by the Center for the Blind in Israel). This
combination yielded a geographically heterogeneous sample,
meaning that participants came from all three districts of
Israel – Southern, Central and Northern. No significant differ-
ences were found between the two participants groups in
regard to the sociodemographic characteristics of age and
gender.
Inclusion criteria
Age 60+; official Israeli certificate of severe vision impairment
based on the following criteria: (A) Visual acuity equal to 3/60
or less in the better eye or with corrective lenses. (B) Vision’s
field of 20 degrees or less. (C) Fully blindness; no significant
cognitive loss (MMSE – this scale contains 30 items. The last
three items require visual ability so participants were not
asked to perform them. Hence, the score range was 0–27
points. We selected participants who scored 22+/27 points to
 AGING & MENTAL HEALTH 1231

ensure they are cognitively normal); living in the community;
ability to understand the questionnaire and having been diag-
nosed with severe vision impairment at least a year before
participation in the study. Individuals who report severe hear-
ing loss were excluded from the study because previous stud-
ies report that older adults with dual sensory impairment
(hearing and vision loss) are particularly disadvantaged with
regard to well-being outcomes.
The response rate was 67% (121 out of 180). Most refusals
were due to skepticism about the study’s contribution to
improving the situation of the overall vision-impaired popula-
tion. No significant differences were found between partici-
pants and those who declined to participate in regard to age
and gender.
Sociodemographic and medical characteristics of the study
participants are described in Table 1. The sample (like the
total elderly population of Israel) has a higher percentage of
women than men; the average age of participants was
77.4 years (range 60–95); most were born in Israel, Europe, or
the Americas and are non-religious and married with two or
more children; a minority had academic education; their aver-
age subjectively perceived financial and health status was sat-
isfactory. Finally, about half had been diagnosed with severe
vision impairment for 11 or more years, and the leading cause
of the vision impairment was the age-related macular degen-
eration (AMD), resulting in blurred vision – or none at all – in
the center of the visual field.

Procedure
After obtaining all necessary permits from the multiservice
center directors, research assistants attended the centers and
introduced the purpose of the study to potential participants.
Personal face-to-face interviews were conducted with those
who agreed to participate by a sole-experienced interviewer
specializing in gerontology. At the beginning of the interview,
candidates were informed that they are not obligated to par-
ticipate in the study and are free to stop the interview at any
time, for any reason whatsoever. Interviews ranged between
60 and 90 min. The study was approved by the ethics commit-
tee of the Faculty of Health Sciences at Ben-Gurion University
of the Negev.
Measures
Subjective well-being
World Health Organization (WHO) Well-Being Index
This index, developed by the WHO and validated for the older
adults population by Bonsignore, Barkow, Jessen, and Heun
(2001), evaluates participants’ over-all sense of well-being.
The index comprises five statements addressing three aspects
of the participant’s feelings over the previous two weeks:
Mood (‘I felt cheerful and in good spirits’), vitality (‘I felt active
and vigorous’), and interest in everyday matters (‘My daily life
was filled with things that interest me’). Responses range over
a 6-point Likert scale from 0 (at no time) to 5 (all the time).
The higher the score, the greater the SWB (a = 0.82).

Table 1. Description of sociodemographic and medical characteristics of the

Independent variables
participants (N = 121).
Sociodemographic and medical characteristics
Variable N (%) M SD
Gender, age, country of birth, marital status, number of chil-
Age 77 7.60
Gender dren, employment status, financial status, education level, reli-
Woman 65 (53.7) giosity, number of diseases, years with severe vision
vman 56 (46.3) impairment (1–5, 6–10, 11, and above) and cause of severe
Country of birth
Israel 43 (35.5) vision impairment. Perception of estimate state of general
Asia–Africa 34 (28.0) health (self-rated health) was measured according to two
Europe–America 44 (36.5) items: ‘Generally speaking, how is your health status?’ and
Marital status
Married 69 (57.0) ‘How is your health status compared with that of other severe
Not married (single/divorced/widowed) 52 (43.0) vision-impaired people your age?’ (This item was worded spe-
Number of children cific to visually impaired older adults for greater reliability of
none 9 (7.5)
1–2 57 (47.0) measurement based on pilot study findings). Responses
3+ 55 (45.5) ranged from 1 (very poor) to 6 (excellent). The correlation
Education level coefficient between the two items was found to be high (r =
Elementary school 60 (49.6)
High school 39 (32.2) 0.74, p < 0.001).
Academic 22 (18.2)
Economic status 3.78 0.92
Religiosity
Secular 72 (59.5) Functional–physical
Traditional-orthodox 49 (40.5)
Self-rated health 3.64 0.85 Functional independence
Years with vision impairment The scale, taken from Cohen and Carmel’s (2003) study of the
1–5 29 (24.0)
6–10 28 (23.1) elderly population in Israel, comprises eight questions and
11+ 54 (52.9) assesses the extent of functional independence of visually
Cause of vision impairment impaired older adults according to their subjective perception
AMD 43 (30.5)
RP 16 (13.0) of their functional limitations. The eight daily activities such
Glaucoma 15 (12.5) as ascending or descending stairs, eating and getting dressed,
Diabetes 13 (11.0) reading and listening to the radio, are rated along a 5-point
Other 34 (29.0)
Vision ability Likert scale from 1 (no constraints on activity performance) to
Participants with complete loss of vision ability 10 (8.0) 5 (inability to perform activity). The higher the score, the less
Participants with poor vision ability 111 (92.0) the participant’s daily functional independence (a = 0.91).
1232 L. RAFAELY ET AL.
Social
Social support
Kim, Hisata, Kai, and Lee (2000) scale comprises statements
regarding two types of support: emotional and instrumental.
In this study, a statement addressing informative support was
added to the index as well. The scale examines the extent of
two-way social support in the severe vision-impaired older
adult’s life in terms of frequency of its receipt/provision from/
to three support sources spouse, children, friends, or commu-
nity agents (social workers, nurses). The participant is asked to
rank the 24 statements on a 3-item scale in which 0 = never, 1
= sometimes, and 2 = frequently. The higher the summation
score, the greater the social support. It should be noted that
the addition of the informative support item to the scale did
not affect its internal reliability (a = 0.88).
Social involvement
Kravetz’s (1973) scale comprises 10 statements, one of which,
for example, lists 10 social organizations and asks participants
to indicate the one(s) in which they are active. Answers are
ranked on a 5-point Likert scale ranging from 1 (none) to 5
(seven or more). The higher the average score, the greater the
participant’s social involvement in his living environment (a =
0.75).
Psychological
Mastery
Pearlin and Schooler’s (1978) scale examines the participant’s
perceived mastery of his life. The scale comprises seven state-
ments, such as ‘I have little control over the things that hap-
pen to me,’ with a 5-point Likert scale ranging from 1
(strongly disagree) to 5 (strongly agree) (a = 0.74).
Meaning and purpose in life
Crumbaugh and Maholick’s (1964) purpose in life (PIL) test
comprises 20 statements ranked on a 7-point Likert scale (e.g.
‘In achieving life goals, I’ve: (1) progressed to complete fulfill-
ment… (7) made no progress whatsoever’). The higher the
score, the greater the participant’s sense of meaning and pur-
pose in life (a = 0.85).
Optimism
Scheier and Carver’s (1985) life orientation test (LOT) meas-
ures optimism as defined in terms of likelihood that pleasant
expectations will indeed be fulfilled. It comprises 12 state-
ments: four worded positively (e.g. ‘In uncertain times, I usu-
ally expect the best’), four negatively, and four included for
purposes of diversion. Participants are asked to indicate the
extent to which they agree/disagree with each statement on
a 5-point Likert scale ranging from 1 (disagree a lot) to 5
(agree a lot). The higher the score, the greater the optimism
(a = 0.74).
Environmental
Physical home environment
Sheffield Care Environment Assessment Matrix (SCEAM) scale
(Parker et al., 2004) evaluates the physical home features of
older adults’ living conditions. It comprises 11 statements in
four major domains: (1) universal living needs for the elderly
population (for example: privacy; choice and control); (2)
physical/structural needs (support of physical disabilities;
comfort of rooms’ conditions); (3) cognitive needs (support of
cognitive impairments; awareness of the outside world), and
(4) caregiving needs (means for the daily caregiver: separate
dressing/dining room, etc.). For each feature, participants
were asked to assign a score of 0 (unavailable at my place of
residence), 1 (partly available), or 2 (fully available). The higher
the total score, the greater the compatibility of the partici-
pant’s physical home environment to the needs of older
adults (a = 0.68).
Statistical analysis
The correlations among the different variables were assessed
using Pearson, Spearman or x2 tests according to the varia-
bles’ scale structures. Differences among groups were evalu-
ated using t-test, one-way ANOVA and the Mann–Whitney U
test. The unique relative contribution of the independent vari-
ables to the explanation of SWB was examined by multiple
linear regression analysis. The significance of all tests was
determined to be p < 0.05. All tests were conducted using
SPSS v. 23.
Results
Descriptive statistics of all study variables and the correlations
between the dependent variable of SWB and the indepen-
dent ones are presented in Table 2.
A moderately high level of SWB was found among partici-
pants. No statistically significant differences were found in
SWB between men and women, between married and unmar-
ried (single/divorced/widowed), between non-religious and
religious/traditional, between participants with complete loss
of vision and those with severe vision impairment, and
between participants born in Asia/Africa, Europe/America or
Israel. Furthermore, no significant correlation was found
between years with vision impairment, education level, and
SWB. A strong and positive correlation was found between
self-rated health and SWB. Other significant correlations were
found between SWB and number of diseases the participant
had, age (negative correlation) and economic status (positive
correlation).
All independent variables from the four dimensions of life
were significantly correlated with SWB: extent of functional
independence (functional/physical) correlated negatively
with SWB, while social support and social involvement corre-
lated positively. SWB correlated more strongly with giving
support to others than with receiving support from others.
Among the three sources of support (spouses, children,
friends), friends were most strongly correlated with SWB. This
finding emerged for both, giving and receiving support (r =
0.46, p < 0.01; r = 0.33, p < 0.01, respectively).
All three variables of the psychological dimension (control,
meaning in life and optimism) were also found to correlate
significantly and positively with SWB, wherein meaning in life
was the most strongly correlated. Finally, compatibility
between physical home environment and needs (environ-
mental sphere) was also found to be positively correlated
with SWB.
A correlation matrix of all the independent variables that
were found to be significantly correlated with SWB was exam-
ined. The associations among the different variables were low
to moderate, in a range between r = 0.03 and r = 0.62 (opti-
mism with economic status and number of diseases with self-
rated health, respectively) in absolute value. It should be
 AGING & MENTAL HEALTH 1233

Table 2. Descriptive statistics of all studies variables and the associations Table 3. Model’s variables and sociodemographic characteristics as predictors
between independent variables and the subjective well-being (n = 121). of subjective well-being among visually impaired older adults (n = 121).
Association with B SE b t
No. of subjective Functional Independence # ¡0.30 0.97 ¡0.23 ¡3.12 **
Variables Items Range M SD well-being Social support 0.01 0.07 0.01 0.03
Subjective well-being 5 0–5 3.01 1.18 – Mastery 0.42 0.15 0.18 2.70 *
Sociodemographic and medical variables Optimism 0.16 0.23 0.05 0.72
Age 1 60–95 77.41 7.60 r = ¡0.26** Meaning in life 0.55 0.17 0.24 3.22 **
Gender 1 Physical home environment 0.02 0.04 0.05 0.65
Female 2.90 1.22 t = ¡1.03 Self-rated health 0.37 0.11 0.26 3.27 **
Male 3.12 1.14 Age ¡0.02 0.01 ¡0.16 ¡2.51 *
Country of birth 1 Economic status 0.10 0.09 0.08 1.20
Israel 3.10 0.99 F = 0.53 *p < 0.05 **p < 0.01 R2 = 0.610.
Asia–Africa 3.08 1.05 # Functional independence was measured by the level of participant’s dis-
Europe–America 2.93 0.97 ability in daily activities.
Marital status 1 That is to say that high score indicates high disability, namely low level of
Married 3.16 1.13 t = ¡1.66 functional independence.
Single/divorced/ 2.80 1.23
widowed
Number of children 1 1–3 rho = ¡0.07
Religiosity 1 Discussion
Secular 3.06 1.13 t = 0.69
Traditionalist- 2.91 1.25 Severe vision impairment poses a complex coping challenge
orthodox that covers all aspects of life and demands extensive changes
Education level 1
Elementary school 3.46 1.03 F = 3.01 in one’s personal world and living environment, in which nor-
High school 3.28 1.07 mative social behavior is determined by normally sighted
Academic 3.09 1.14 people. This difficulty is likely to intensify in old age – a period
Economic status 1 1–6 3.78 0.92 r = 0.37**
Self-rated health 2 1–6 3.64 0.85 r = 0.62** characterized by losses in key spheres of life. This study exam-
Years with vision 1 1–3 rho = ¡0.08 ined the correlations between SWB and four dimensions of
impairment life among older adults with severe vision impairment. The
Number of diseases 1 0–8 2.03 1.69 r = ¡0.42**
Vision ability 1 moderately high level of overall SWB found in this study is
Complete loss of 3.85 0.51 Z# = 1.15 similar to an earlier study conducted among the general
vision ability elderly population in Israel (Zeltzer-Zubida & Salpeter, 2008).
Poor vision ability 3.48 1.09
Variables of the four dimensions of life This finding can be discussed in the context of the ‘stability
Functional 8 1–5 2.41 0.95 r = ¡0.59** despite loss paradox’, which refers to the relative stability of
Independence # SWB (mainly in the domain of negative effects, but may also
Social support 24 0–48 20.49 9.61 r = 0.23*
Giving support 12 0–24 10.99 5.48 r = 0.28** comprise positive effects and life satisfaction) despite health-
Receiving support 12 0–24 10.42 5.31 r = 0.17* related loss among older adults (Kunzmann, Little, & Smith,
Social involvement 10 1–5 2.69 0.58 r = 0.25** 2000 ). Moreover, this high level of SWB may be related to the
Mastery 7 1–5 3.10 0.50 r = 0.40**
Meaning in life 20 1–7 4.52 0.52 r = 0.54** lack of differences in regards to SWB-related indicators found
Optimism 12 1–5 3.23 0.36 r = 0.22* between sensory-impaired and sensory-unimpaired older
Physical home 11 0–22 19.42 2.25 r = 0.33** adults (Wahl et al., 2013). Yet, this moderately high level of
environment
SWB found in our study is encouraging, as one might still
*p < 0.05; **p < 0.01; #Mann–Whitney U test.
# Functional independence was measured by the level of participant’s dis- have expected rather low SWB among severely vision-
ability in daily activities. That is to say that high score indicates high dis- impaired older adults whose complex lives pose extended
ability, namely low level of functional independence. coping challenges, similar to old people with other chronic ill-
nesses (Ben-Yaakov & Amir, 2001; Williams et al., 1998). There-
noted that most of the correlations were found to be lower fore, this finding might suggest that vision-impaired older
than r = 0.30. These results imply that the variables are rela- adults do benefit from a sound overall perception of well-
tively independent and represent different constructs. being despite their daily need to cope with complex chal-
To determine the unique relative contribution of the inde- lenges and difficulties originating in impaired vision and
pendent variables in explaining participants’ variability in advancing age.
SWB, we conducted a multivariate linear regression analysis. No significant differences in SWB level were found among
To the regression equations were added only those variables the four key sociodemographic characteristics (gender, religi-
that were found to be significant in the bivariate analyses. osity, marital status, and country of origin). These findings
The variable ‘number of diseases’ that was found to be signifi- contrast with those of studies examining the elderly popula-
cantly correlated with SWB was not included in this final anal- tion as a whole with regard to marital status (Larson, 1978)
ysis because of its strong correlation with self-rated health (r and religiosity (Levin & Chatters, 1998), apparently hinting at
= 0.62, p < 0.01). Table 3. structural variance in the components of this feeling among
Table 3 indicates that the model variables and sociodemo- people who experience loss of vision during their advanced
graphic characteristics account for much of the explained var- years. The lack of difference in SWB level with respect to the
iance (61%) of SWB. The following five variables, listed in marital status (married vs. single/divorced/widowed) is sur-
descending order, were found to be significant in explaining prising, as people who lose their sight in old age – in parallel
variability in SWB: self-rated health, meaning in life, functional to depletion of other physical, functional and at times even
independence, mastery, and age. That is, a positive estimation social resources – tend to display a marked increase in depen-
of one’s health status, a strong sense of meaning in life, ability dence on the external support of a significant other. One pos-
to function independently, perceived control of one’s life, and sible explanation is apprehension over increasing
a relatively younger age all explained high level of SWB. dependence and loss of autonomy, which tends to intensify
1234 L. RAFAELY ET AL.
in old age as physical systems experience a natural decline in
biological functioning (Baltes, 1995), threatening functional
autonomy, and even mental independence. Older adults who
are losing their vision may thus seek to preserve whatever
autonomy and control they still possess and avoid constant
dependence on others. This personal psychological effort, to
the extent that it is manifested, may weaken the positive
effect of couplehood on the older adult’s SWB. An additional
explanation is that of social support (which has positive corre-
lation with SWB) that may also be provided by people other
than partners, such as neighbors, friends or relatives, and
especially for unmarried visually impaired older adults.
Indeed, in our study social support given/received by/to
friends had the strongest correlation with SWB among all
three sources of support.
The functional–physical and psychological dimensions
were found to be more strongly correlated with SWB com-
pared to the social and environmental spheres. These findings
are also reflected in the summative regression analysis, in
which four of the five variables (self-rated health, meaning in
life, functional independence, and mastery) contributing to
the explained variation of SWB belong to these two key
dimensions of life. Age was the fifth contributing variable,
and it contributed least to the explained variation of SWB
among all five variables. The weak association of sociodemo-
graphic variables with SWB among older adults is in line with
prior findings in the Western world (Diener, 2009; Smith,
2001). Previous studies note that a positive subjective assess-
ment of one’s self-rated health is a strong predictor of high
survivability (Carmel, Baron-Epel, & Shemy, 2007; Schnittker &
Bacak, 2014) and of reinforced positive feelings about vitality
and well-being during the latter stages of the life cycle (Burns,
Sargent-Cox, Mitchell, & Anstey, 2014). Its status as the leading
explanatory variable for SWB in this study may also result
from the ‘healthy’ population’s overall control and leadership
of society (Deshen, 1996). In this context, a ‘healthy’ popula-
tion is one that is not stricken by severe physical disability
such as vision impairment, deafness, and the like and is con-
sequently considered healthy according to objective indica-
tors in a limited conceptual world. The personality-conceptual
characteristic of the functional/psychological variable group
in explaining SWB may well reflect the supreme importance
of inner resources available to older adults for positive coping
with and adjustment to the harsh reality of major loss, such as
severe vision impairment. This feature is also discussed in
other studies that consider such components significant in
the development of constructive coping strategies among
people who experience loss, such as the death of a life partner
during old age ( Malikson & Witztum, 2003). A positive con-
ceptual ethos of overall good health, as well as a sense of con-
trol and significance in life, apparently attest to an
accommodative means of coping, expressed in the institution
of inner changes regarding objectives, priorities and self-con-
ceptions so that they conform with the disabilities and func-
tional setbacks experienced in their environment
(Brandtst€adter & Renner, 1990). Apparently, such adaptation
is feasible for severe vision-impaired older adults who possess
mature defense mechanisms that help them improve given
situations in their everyday lives instead of expanding prob-
lems out of proportion to the realities in which they occur
(Vaillant, 2002). Unique and valued mechanisms of this nature
may keep people with objective disabilities – such as severe
vision impairment – from feeling subjectively disabled. This
phenomenon of objectively disabled people who do not nec-
essarily feel disabled or ill can be explained in the context of
the ‘disability paradox’ (Albrecht & Devlieger, 1999). The mod-
erately high level of SWB found in our study joins the findings
of previous studies that report good or excellent QOL among
physically disabled people (see Ubel, Loewenstein, Schwarz, &
Smith, 2005). Because coping strategies and defense mecha-
nism were not among the constructs examined in this study,
all of the explanations above need to be assessed in future
studies preferably with longitudinal data and representative
samples. Also of note, the associations of the four dimensions
with SWB may be more complex, with some dimensions
mediating or moderating the associations of others. Future
studies in this direction are also recommended.
Study limitations
This study has several possible limitations that should be
acknowledged when assessing its findings and deriving gen-
eralizations from them. First, although the sample comprises
a relatively large number of participants (121), it is still rela-
tively small – especially with respect to the large number of
variables examined – and may thus engender some distor-
tion. Second, the study is cross-sectional in nature, delineating
correlations among research variables without necessarily
determining causality. For example, we cannot determine
whether study participants who reported high SWB felt that
way because of their high positive self-rated health or
because ranking their health high improves their general
sense of well-being. Also of note, research questions dealing
with socially and emotionally delicate/sensitive issues may
lead participants to respond in a manner they believe is
expected of them according to conventional social norms.
Such social placation may even be intensified by the personal
interviews conducted with each participant. Finally, we used a
unidimensional measure of overall SWB. However, there are a
range of validated measures which operationalized SWB in
various ways (Diener, 2009; Ryff & Keyes, 1995). Future
research should replicate our findings using other or prefera-
bly multiple measures of well-being.
Practical implications
All five variables found to explain SWB may assist locate older
adults most likely to experience low levels of SWB. Visual
therapists, social, and healthcare professionals should con-
sider these variables when evaluating coping skills, adjust-
ment, and rehabilitation as well as the extent of mental and
physical vulnerability to the realities of life among the severe
visually impaired older adults. Programs and intervention
strategies should be tailored specifically for this population,
aimed at reinforcing their SWB. These programs should focus
on strengthening the sense of mastery (control) and expand
the older adults’ variety to provide social support and assis-
tance to others thus providing them with significant activity
and reinforcement. Finally, it is also important to develop
informative programs for the public, focusing on the realities
of life and everyday needs of severe visually impaired older
adults living in the community. All of these implications
should be considered as tentative due to the cross-sectional
design of this study.

Disclosure statement
No potential conflict of interest was reported by the authors.
Funding
This work was supported by a grant from Mayers-JDS-Brookdale institute
of Gerontology and Human Development, and ESHEL - The Association
for the planning and development of services for the Aged in Israel.
References
Ainlay, S. C. (1989). Day brought back my night: Aging and new vision loss.
London: Routledge.
Albrecht, G. L., & Devlieger, P. J. (1999). The disability paradox: High qual-
ity of life against all odds. Social Science & Medicine, 48(8), 977–988.
Allison, P. G., Guichard, C., & Gilain, L. (2000). A prospective investigation
of dispositional Optimism as a predictor of health-related quality of
life in head and neck cancer patients. Springer Netherlands, Quality of
Life Research, 9(8), 951–960.
American Foundation for the Blind. (2013). Special report on aging and
vision loss. Retrieved May 8, 2014 from http://www.afb.org/
Ardelt, M. (2003). Effects of religion and purpose in life on Elders’ subjec-
tive well-being and attitudes towards death. Journal of Religious Ger-
ontology, 14(4), 55–77.
Baltes, M. M. (1995). Dependency in old age: Gains and losses. Current
Directions in Psychological Science, 4(1), 14–19.
Bazargan, M., Baker, R. S., & Bazargan, S. H. (2001). Sensory impairments
and subjective well- being among aged African American persons.
The Journals of Gerontology Series B: Psychological Sciences and Social
Sciences, 56(5), P268–P278.
Ben-Yaakov, Y., & Amir, M. (2001). Subjective quality of life: Conceptualiza-
tion and measurement by the World Health Organization. Gerontolo-
gia (Journal of the Israel Gerontological Society), 28(3–4), 169–185.
[Hebrew]
Bonsignore, M., Barkow, K., Jessen, F., & Heun, R. (2001). Validity of the
five-item WHO Well-Being Index (WHO-5) in an elderly population.
European Archives of Psychiatry and Clinical Neuroscience, 251(2), 27–
31.
Bowling, A., Banister, D., Sutton, S., Evans, O., & Windsor, J. (2002). A multi-
dimensional model of the quality of life in older age. Aging & Mental
Health, 6, 355–371.
Brandtst€adter, J., & Renner, G. (1990). Tenacious goal pursuit and flexible
goal adjustment: Explication and age-related analysis of assimilative
and accommodative strategies of coping. Psychology and Aging, 5, 58–
67.
Brawley, E. C. (2001). Environmental design for Alzheimer’s disease: A
quality of life issue. Aging & Mental Health, 5(Suppl. 1), 79–83.
Brown, R. L., & Barrett, A. E. (2011). Visual impairment and quality of life
among older adults: An examination of explanations for the relation-
ship. The Journals of Gerontology Series B: Psychological Sciences and
Social Sciences, 66B(3), 364–373,
Burns, R. A., Sargent-Cox, K., Mitchell, P., & Anstey, K. J. (2014). An examina-
tion of the effects of intra and inter-individual changes in well-being
and mental health on self-related health in a population study of mid-
dle and older-aged adults. Social Psychiatry and Psychiatric Epidemiol-
ogy, 49(11), 1849–1858.
Carmel, S., Baron-Epel, O., & Shemy, G. (2007). The will-to-live and survival
at old age: Gender differences. Social Science & Medicine, 65(3), 518–
523.
Cimarolli, V. R., Boerner, K., Brennan-ing, M., Reinhardt, J. P., & Horowitz, A.
(2012). Challenges faced by older adults with vision loss: A qualitative
study with implications for rehabilitation.Clinica Rehabilitation, 26(8),
748–757.
Cohen, N., & Carmel, S. (2003). Fear of death among the elderly in Israel. In
A. Rosin (Ed.), Aging and old age in Israel (pp. 531–554). Jerusalem:
Eshel. [Hebrew]
Crumbaugh, J. C., & Maholick, L. T. (1964). An experimental study in exis-
tentialism: The Psychometric approach to concept of noogenic neuro-
sis. Journal of clinical Psychology, 20, 200–207.
Deshen, S. (1996). With a Folding Cane: The Anthropology of Disability. Jeru-
salem: Schocken. [Hebrew]
Diener, E. D., & Diener, R. B. (2002). Findings on subjective well-being and
their implications for empowerment. Paper presented at the workshop
AGING & MENTAL HEALTH 1235
on "measuring inpowerment: cross-disciplinary perspectives" held at
the world bank in Washington, DC on February 4-5 2003.
Diener, E. (2009). The science of well-being: The collected works of Ed Diener
(Vol .37). Springer Science & Business Media.
Diener, E., Suh, E. M., Lucas, R. E., & Smith, H. L. (1999). Subjective well-
being: Three decades of progress. Psychological Bulletin, 125(2), 276–
302.
George, L. K. (2006). Perceived quality of life. In R. H. Binstock & L. K.
George (Eds.), Handbook of aging and the social sciences (6th ed., pp.
320–336). San Diego, CA: Academic Press.
Heo, J., & Lee, Y. (2010). Serious leisure, health perception, dispositional
optimism, and life satisfaction among senior games participants. Edu-
cational Gerontology, 36, 112–126.
Heyl, V., & Wahl, H. W. (2012). Managing daily life with age-related sensory
loss: Cognitive resources gain in importance. Psychology and Aging, 27
(2), 510–521.
Heyl, V., & Wahl, H. W. (2014). Experiencing age-related vision and hearing
impairment: The psychosocial dimension. Journals of Clinical Outcomes
Managements, 21(7), 323–335.
Hilleras, P. K., Jorm, A. F., Herlitz, A., & Winblad, B. (2001). Life satisfaction
among the very old: A survey of a cognitively intact sample aged
90 years or above. The International Journal of Aging and Human Devel-
opment, 52, 71–90.
Kempen, G. I. J. M., Ballemans, J., Ranchor, A. V., Van Rens, G. H. M. B., & Zijl-
stra, G. A. R. (2012). The impact of low vision on activities of daily liv-
ing, symptoms of depression, feelings of anxiety and social support in
community living older adults seeking vision rehabilitation services.
Quality of Life Research, 21, 1405–1411.
Kim, H. K., Hisata, M., Kai, L., & Lee, S. K. (2000). Social support exchange
and quality of life among the Korean elderly. Journal of Cross-Cultural
Gerontology, 15(4), 331–347.
Krause, N. (2009). Meaning in life and mortality. The Journals of Gerontol-
ogy Series B: Psychological Sciences and Social Sciences, 64B(4), 517–527.
Kravetz, S. (1973). Rehabilitation, need and status: Substance, structure and
process (Unpublished Doctorate Dissertation). University of Wisconsin.
Kunzmann, U., Little, T. D., & Smith, J. (2000). Is age-related stability of sub-
jective well-being a paradox? Cross-sectional and longitudinal evi-
dence from the Berlin aging study. Psychology and Aging, 15(3), 511–
526.
Larson, R. (1978). Thirty years of research on the subjective well-being of
older Americans. Journal of Gerontology, 33(1), 109–125.
Lawton, M. P. (1982). Competence, environmental press, and the adapta-
tion of older people. In M. Powell Lawton, P. G. Windley, & T. O. Byerts
(Eds.), Aging and the environment: Theoretical approaches (pp. 33–59).
New York, NY: Springer.
Lawton, M. P., & Nahemow, L. (1973). Ecology and the aging process. In C.
Eisdorfer & M. P. Lawton (Eds.), The psychology of adult development
and aging (pp. 619–674). Washington, DC: American Psychological
Association.
Levin, J. S., & Chatters, L. S. (1998). Religion, health, and psychological well-
being in older adults – findings from three national surveys. Journal of
Aging and Health, 10, 504–531.
Lowenstein, A. (2003). Social concepts and theories of aging. In A. Rosin
(Ed.), Aging and old age in Israel (pp. 617–628). Jerusalem: Eshel.
[Hebrew]
Malikson, R., & Witztum, E. (2003). Death, mourning and widowhood: Liv-
ing with loss in old age. In A. Rosin (Ed.), Aging and old age in Israel
(pp. 555–571). Jerusalem: Eshel. [Hebrew]
Or, A. (2002). Vision impairment and its implications for the old person’s
lifestyle. In S. Kutner (Ed.), Sensory correlation – sensory cessation (pp.
115–122). Jerusalem: Eshel. [Hebrew]
Parker, C., Barnes, S., Mckee, K., Morgan, K., Torrington, J., & Tregenza, P.
(2004). Quality of life and building design in residential and nursing
homes for older people. Ageing and Society, 24, 941–962.
Pearlin, L. I., & Schooler, C. (1978). The structure of coping. Journal of
Health and Social Behavior, 19, 2–21.
Piferi, R. L., & Lawler, K. A. (2006). Social support and ambulatory blood
pressure: An examination of both receiving and giving. International
Journal of Psychophysiology, 62, 328–336.
Pinquart, M., & Sorensen, S. (2000). Influences of socioeconomic status,
social network, and competence on subjective well-being in later life:
A meta-analysis. Psychology and Aging, 15(2), 187–224.
Ramrattan, R. S., Wolfs, R. C. W., Panda-Jonas, S., Jonas, G. B., Baker, D., Pols,
H. A., … De Jong, P. T. V. M. (2001). Prevalence and causes of visual
field loss in the elderly and associations with impairment in daily
1236 L. RAFAELY ET AL.
functioning – the Rotterdam study. Archives of Ophthalmology, 119,
1788–1794.
Reyes-Ortiz, C. A., Kuo, Y.-F., DiNuzzo, A. R., Ray, L. A., Raji, M. A., & Markides,
K. S. (2005). Near vision impairment predicts cognitive decline: Data
from the Hispanic established populations for epidemiologic studies of
the elderly. Journal of the American Geriatrics Society, 53(4), 681–686.
Ryff, C. D., & Keyes, C. L. M. (1995). The structure of psychological well-
being revisited. Journal of Personality and Social Psychology, 69(4), 719.
Ryff, C. D., Singer, B. H., & Love, G. D. (2004). Positive health: Connecting
well-being with biology. Philosophical Transactions of the Royal Society
B: Biological Sciences, 359, 1383–1394.
Sarvimaki, A., & Stenbok-Halt, B. (2000). Quality of life in old age described
as a sense of well-being, meaning and value. Journal of Advanced
Nursing, 32(4), 1025–1033.
Scheier, M. F., & Carver, C. S. (1985). Optimism, coping, and health: Assess-
ment and implications of generalized outcome expectancies. Health
Psychology, 4(3), 219–247.
Schnittker, J., & Bacak, V. (2014). The increasing predictive validity of self-
rated health. PLOS One, 9(1), E84933.
Smith, A., Young, A., & Lee, C. (2004). Optimism, health-related hardiness
and well-being among older Australian women. Journal of Health Psy-
chology, 9, 741–752.
Smith, J. (2001). Well-being and health from age 70–100: Findings from
the Berlin aging study. European Review, 9(4), 461–477. doi:10.1017/
S1062798701000424
The WHOQOL Group. (1998). Development of the World Health Organiza-
tion WHOQOL-BREF quality of life assessment. Psychological Medicine,
28, 551–558.
Thomas, P.A. (2010). Is it better to give or to receive? Social support and
the well-being of older adults. The Journals of Gerontology Series B: Psy-
chological Sciences and Social Sciences, 65B(3), 351–357.
Ubel, P. A., Loewenstein, G., Schwarz, N., & Smith, D. (2005). Misimagining
the unimaginable: The disability paradox and health care decision
making. Health Psychology, 24(Suppl. 4), S57–S62.
Vaillant, G. E. (2002). Aging well. New York, NY: Little, Brown and Company.
Valentijn, S. A. M., Van Boxtel, M. P. J., Van Hooren, S. A. H., Bosma, H.,
Beckers, H. J. M., Ponds, R. W. H. M., & Jolles, J. (2005). Change in sen-
sory functioning predicts change in cognitive functioning: Results
from a 6-Year Follow-Up in the Maastricht aging study. Journal of the
American Geriatrics Society, 53(3), 374–380.
Verdugo, M. A., Prieto, G., Caballo, C., & Pel
aez, A. (2005). Factorial struc-
ture of the quality of life questionnaire in a Spanish sample of visually
disabled adult. European Journal of Psychological Assessment, 21(1),
44–55.
Verstraten, P. F. J., Brinkmann, W. L. J. H., Stevens, N. L., & Schouten, J. S. A.
G. (2005, September). Loneliness, adaptation to vision impairment,
social support and depression among visually impaired elderly. In
International congress series (Vol. 1282, pp. 317–321). Elsevier.
Wahl, H. W. (2013). The psychological challenge of late-life vision
impairment: Concepts, findings, and practical implic ations. Journal of
Ophthalmology, 2013, 1–11.
Wahl, H. W., Heyl, V., Drapaniotis, P. M., Hormann, K., Jonas, J. B., Plinkert, P.
K., & Rohrschneider, K. (2013). Severe vision and hearing impairment
and successful aging: A multidimensional view. The Gerontologist, 53
(6), 950–962.
Williams, R. A., Brody, B. L., Thomas, R. G., Kaplan, R. M., & Brown, S. I.
(1998). The psychosocial impact of macular degeneration. Archives of
Ophthalmology, 116, 514–520.
Zeltzer-Zubida, A., & Salpeter, T. (2008). Subjective well-being among peo-
ple aged 50 and up in Israel. Bitahon Sociali (Social Security), 76, 269–
290. [Hebrew]
Zhang, X. L., Du, S. L., Ge, J., Chen, W. R., Fan, Q., Peng, S. X., … Liu, X.
(2009). Quality of life in patients with primary congenital glaucoma fol-
lowing antiglaucoma surgical management. Chinese Journal of Oph-
thalmology, 45(6), 514–521.
Zilberman, N. (2002). Psychological aspects and rehabilitation processes
for visually impaired elderly persons. In S. Kutner (Ed.), Sensory correla-
tion – sensory cessation (pp. 127–134). Jerusalem: Eshel. [Hebrew]