Patient preferences for portable versus table-mounted visual field devices in rural Alabama: a mixed methods study within a telemedicine setting

In a mixed-methods study of rural Alabama patients, portable visual field devices, particularly virtual reality-based systems, were significantly preferred over traditional table-mounted equipment due to superior comfort, ease of use, and immersive visual experiences, suggesting their potential to enhance patient-centered glaucoma monitoring in telemedicine settings.

The Gist

Imagine you have to take a very specific test to check if your eyes are working correctly. For decades, the "gold standard" for this test has been a giant, stationary machine that looks like a white bowl. You have to sit perfectly still, rest your chin on a hard bar, cover one eye with a patch, and stare into the darkness while tiny lights flash. It's like trying to take a photo while sitting in a vice grip; it's accurate, but it's stiff, uncomfortable, and a bit intimidating.

Now, imagine two new ways to take that same test:

1. The Tablet: Like holding an iPad and tapping the screen when you see a light.
2. The VR Headset: Like putting on a virtual reality gaming headset where you just look around and click a button.

This study asked a simple question: If you could choose, which one would you rather use? And more importantly, why?

The researchers went to rural Alabama, specifically to areas where people often struggle to get to big city hospitals. They tested 271 people using all three methods (the old bowl, the tablet, and the VR headset) and then asked them what they thought.

Here is the breakdown of what they found, using some everyday analogies:

1. The "Gym vs. The Living Room" Analogy

The old machine (the Humphrey Field Analyzer) is like a gym machine. It's heavy, fixed in one spot, and forces your body into a specific, often awkward position. If you have a bad neck or back, it feels like a torture session.

The new portable devices (Tablet and VR) are like working out in your living room. You can sit in your favorite chair, lean back, and move your head slightly without the machine breaking.

• The Result: The vast majority of people (over 50%) picked the VR headset as their favorite. They said it felt the most comfortable because they weren't "trapped" in a chair. It was like the difference between being strapped into a rollercoaster seat versus sitting on a couch.

2. The "Noise-Canceling Headphones" Analogy

When you take the old test, you can still see the edges of the room, the technician, and the lights around you. It's like trying to focus on a movie while someone is talking to you in the next room.

The VR headset is like putting on noise-canceling headphones. It blocks out the outside world.

• The Result: Patients loved this. They felt "wrapped up" in the test. It felt private and focused. One patient said it felt like a video game, which made the scary medical test feel fun and less stressful.

3. The "Driving a Manual vs. Automatic Car" Analogy

The old machine requires a lot of setup: adjusting the chin rest, putting on a patch, making sure your eyes are aligned perfectly. It's like driving a stick-shift car where you have to constantly worry about the clutch and gears.

The new devices are like automatic cars. You put them on, and the instructions are simple.

• The Result: People found the VR and tablet much easier to use. They didn't need to be "tech wizards" to figure it out. The instructions were clear, and the process felt intuitive.

4. The "Familiarity vs. Novelty" Twist

Interestingly, not everyone loved the new tech. A small group of people actually preferred the old "bowl" machine. Why?

• The "Old Reliable" Factor: Some people had used the old machine for years. They trusted it. It was like preferring a familiar, old pair of shoes over a brand-new, high-tech pair. They felt the old machine was "more real" or "more accurate" just because they knew it.
• The "Gamer" Factor: For the younger or tech-savvy, the VR headset felt cool and modern, like playing a game.

The Big Takeaway

The study concluded that people in rural areas strongly prefer the new, portable devices, especially the VR headset.

Why does this matter?
Think of glaucoma (an eye disease) like a slow leak in a tire. You need to check the tire pressure regularly to make sure you don't get a flat.

• The Problem: In rural areas, people often skip these checks because the drive to the specialist is long, the clinic is hard to get to, and the test itself is uncomfortable.
• The Solution: If doctors can use these portable devices in local community clinics (or even send them home), the test becomes less scary, more comfortable, and easier to fit into a busy life.

In a nutshell:
The study found that when given a choice, patients would rather wear a cool VR headset and sit comfortably than get stuck in a rigid, old-fashioned machine. By making the test more like a game and less like a medical ordeal, doctors can help more people stay on top of their eye health, especially those who live far away from big hospitals.

Technical Summary

1. Problem Statement

Glaucoma is a leading cause of irreversible blindness, requiring regular Visual Field (VF) testing for diagnosis and monitoring. However, the clinical gold standard, the table-mounted Humphrey Field Analyzer (HFA), presents significant barriers to access, particularly in rural and underserved communities. These barriers include:

• Logistical Constraints: The HFA is expensive, stationary, requires a dedicated dark room, and needs specialized technician supervision.
• Patient Burden: The testing process is often described as physically uncomfortable (requiring rigid chin/forehead rests, eye patching, and fixed posture), time-consuming, and tiring.
• Adherence Issues: In rural settings, travel distances and prolonged clinic visits associated with HFA testing contribute to poor adherence to follow-up care.

While portable alternatives (tablet-based and Virtual Reality-based perimeters) have been developed to address these issues, there is a lack of data regarding how patients in medically underserved rural populations perceive these technologies compared to the clinical standard.

2. Methodology

The study employed a sequential explanatory mixed methods design embedded within the Alabama Screening and Intervention for Glaucoma and eye Health through Telemedicine (AL-SIGHT) study.

• Setting & Participants:

  • Location: Three Federally Qualified Health Centers (FQHCs) in rural Alabama (Centreville, Maplesville, Marion), serving the historically underserved "Black Belt" region.
  • Sample: 271 adult patients (mean age 60.4 years; 62.4% female; 30.6% African American) completed the quantitative phase.
  • Sub-sample: 12 participants were selected for qualitative interviews using stratified purposive sampling to ensure representation across device preferences.

• Devices Tested:

  1. Table-mounted: Humphrey Field Analyzer (HFA3) – The clinical standard.
  2. Tablet-based: Melbourne Rapid Fields (MRF).
  3. VR-based: VisuALL (head-mounted virtual reality perimeter).

• Data Collection:

  • Quantitative: Participants underwent VF testing with all three devices. They then completed a structured questionnaire rating satisfaction, comfort, ease of use, and future preference on a 4-point Likert scale. Statistical analysis included Chi-square tests and Benjamini-Hochberg correction for multiple comparisons.
  • Qualitative: Semi-structured interviews were conducted via Zoom. Participants viewed images of the devices and discussed their experiences. Data was analyzed using reflexive thematic analysis (Braun & Clarke) in NVivo 14, with inter-rater reliability (Cohen's $\kappa$ = 0.90).

3. Key Contributions

• Contextual Relevance: This is one of the first studies to evaluate patient preferences for portable perimetry specifically within rural, underserved FQHC settings, rather than tertiary academic centers.
• Mixed Methods Integration: It combines quantitative preference data with deep qualitative insights into the why behind those preferences, offering a holistic view of patient experience.
• Patient-Centered Metrics: The study shifts the focus from purely diagnostic accuracy (which previous studies have addressed) to usability, ergonomics, and psychological engagement as critical drivers of technology adoption in glaucoma care.
• Framework Development: It proposes a conceptual framework linking physical comfort, visual experience, ease of use, and psychological factors to device preference.

4. Key Results

Quantitative Findings (N=271)

• Preference: There was a statistically significant preference for portable devices.
  • VR-based (VisuALL): 50.6% preferred for future testing.
  • Tablet-based (MRF): 35.1%.
  • Table-mounted (HFA): 14.4%.
  • Statistical Significance: $\chi^2(2) = 53.52, p < 0.001$.
• Satisfaction: VR had the highest "very satisfied" rating (56.9%), followed by Tablet (49.4%) and HFA (38.0%).
• Comfort & Ease: VR was rated as the most comfortable (55.7%) and easiest to use (54.6%).
• Demographics: Preferences did not vary significantly by age, sex, race, or education level.

Qualitative Findings (N=12)

Four primary themes emerged explaining the preference for portable devices:

1. Comfort and Physical Experience:
   • Patients found the HFA "confined," "claustrophobic," and physically straining (neck/back pain).
   • Portable devices allowed for natural posture, freedom of movement, and the ability to wear habitual glasses without eye patches.
2. Visual Experience:
   • Immersion: The VR headset was praised for "sealing off" ambient light and peripheral distractions, enhancing focus.
   • Clarity: Participants found stimuli on portable devices clear and sharp.
   • Binocularity: The ability to keep both eyes open (vs. patching one eye) was perceived as more natural and less disorienting.
3. Ease of Use and Interaction:
   • Portable devices were described as intuitive, requiring minimal setup (no chin rests or trial lenses).
   • Instructions were perceived as simpler, reducing cognitive load.
4. Psychological and Motivational Factors:
   • Novelty: The VR experience was described as "fun" and "game-like," reducing anxiety and increasing engagement.
   • Trust: While some preferred the HFA due to familiarity, the majority felt the portable devices were less intimidating and more aligned with modern digital experiences.

5. Significance and Implications

• Enhancing Access: Portable perimetry (especially VR) can be deployed in primary care and community settings without the need for dark rooms or expensive infrastructure, directly addressing the "structural barriers" to glaucoma monitoring in rural areas.
• Improving Adherence: By reducing physical discomfort and test duration, portable devices may increase patient willingness to return for follow-up testing, a critical factor in preventing vision loss.
• Telemedicine Integration: The study supports the feasibility of integrating portable perimetry into telemedicine workflows. However, it notes that while patients appreciate the convenience, they still value human support and guidance, suggesting a hybrid model (portable device + remote coaching) is optimal.
• Theoretical Alignment: The findings align with the Technology Acceptance Model (TAM) and Self-Determination Theory (SDT), indicating that perceived ease of use, comfort, and intrinsic enjoyment are decisive factors in adopting medical technologies.

Conclusion: Rural, underserved patients strongly prefer portable, VR-based visual field testing over the traditional table-mounted HFA. The shift toward portable perimetry is driven by superior ergonomics, reduced physical burden, immersive visual environments, and psychological engagement, offering a viable pathway to expand equitable glaucoma care.