Date of Award


Degree Name

Doctor of Philosophy


Interdisciplinary Health Sciences

First Advisor

Dr. Linda Shuster

Second Advisor

Dr. Anne Riddering

Third Advisor

Dr. Cassie Lopez-Jeng


Health literacy, age-related macular degeneration, visual impairment, patient education, low vision, readability


This three-paper dissertation explores functional health literacy (i.e., the ability to access, process and understand health information) in older adults with vision loss caused by age-related macular degeneration (AMD). This research builds scholarship that explores the unique patient education needs of older adults with AMD. The specific aims of this research are to: (1) explore associations between functional health literacy and severity of visual impairment; (2) determine the general readability, suitability and comprehensibility of online patient education materials (PEMs) designed for older adults with AMD; and, (3) assess the overall quality of one PEM that has been simplified based on recommended guidelines for patients with low health literacy and low vision. Lack of existing research evidence on these topics creates a great need for additional studies to explore the unique health information needs of this population.

This research aims to inform clinical practice about factors that may influence functional health literacy in older adults with AMD. Low health literacy is a significant problem in the United States. In general, there is a disconnect between the readability (i.e., grade level) of PEMs and the average reading ability of American adults. The gap is even wider for older adults and people with visual impairment. Evidence-based guidelines and strategies are readily available to assist with modifying PEMs for patients with low health literacy and low vision (NIH, 2014; NIH 2018; Kitchel, 2011). Health care providers can apply these guidelines to develop appropriate PEMs for specific patient populations. Providing PEMs patients can access, process and understand is essential for promoting health literacy in older adults with AMD.

The findings gleaned from these studies have important implications for clinical practice. In general, visual impairment may be an under-recognized barrier to both health literacy and the self-management of chronic health conditions. Learning to self-manage AMD is essential for achieving health outcomes, including slowing the progression of vision loss. Older adults with AMD have unique educational needs. In general, readily available PEMs designed for older adults with AMD have suboptimal readability and suitability. Health care providers should apply the evidence-based guidelines for developing PEMs. Providing PEMs that are easy to access, process and understand is essential for patients with low health literacy and low vision may promote health literacy and improve patient outcomes. Additional research is needed to ensure health condition-specific PEMs become the standard of care in the future. Several audiences including researchers, policymakers and health care providers (i.e., occupational therapists, optometrists and ophthalmologists) will benefit from the information gleaned from these studies. Most importantly, older adults with AMD will benefit from health care providers who understand their challenges and educational needs.

Access Setting

Dissertation-Open Access