Strengths and limitations
Implications for further research
Background: Visual impairments are wide spread around the globe. It is estimated that around 2,2 billion people are visually impaired. Such impairments often negatively impact the well-being and quality of life of those affected. To better face the many challenges imposed upon them by their impairments, many individuals with visual impairments employ selfmanagement. To support this self-management, individuals with visual impairments can make use of their strengths and more specifically the strength-based approach. Here, the focus is laid upon strengths instead of limitations, enabling individuals suffering from visual impairments to grow and realize their full potential. Given its importance there is not enough research available about the strengths that individuals with visual impairments use to selfmanage their lives. Therefore, the current study aims to identify which strengths are used by individuals with visual impairments to self-manage their lives.
Methods: A convenience sample was used to recruit 10 visually impaired participants that were needed for the current study. Semi-structured interviews were conducted to investigate the experiences these individuals have made with regards to their visual impairments and which strengths they thought helped them to self-manage their lives, Interviews were executed and audio-recorded via Skype, transcribed by the researcher, and finally coded following an inductive approach.
Results: After conducting the interviews, a total of 10 codes were found which were integrated into the main themes ‘internal strengths’, ‘external strengths’, and ‘selfmanagement strategies’. The internal strengths of having self-confidence and humour were found to directly contribute to the self-management strategies ‘seeking help’ and ‘acceptance of the visual impairment’ respectively.
Conclusion: The current study investigated the role that strengths play in self-management and offered an in-depth insight into which strengths supported individuals with visual impairments in their self-management. While some strengths aided the participants in their self-management strategies, others were beneficial to the participants independent of these strategies they employed.
Imagine your vision was permanently low. For many people around the globe, this is reality. In fact, it is estimated that worldwide at least 2.2 billion people are affected by some form of visual impairment (World Health Organization, 2019).
These individuals often report lower levels of psychosocial well-being than the sighted population on measures including mental health, social functioning, and quality of life (Nyman, Gosney, & Victor, 2009). Additionally, being affected by visual impairment has often been linked with higher levels of anxiety (Bolat, Dogangün, Yavuz, Demir, & Kayaalp, 2011), higher risks of experiencing loneliness (Brunes, Hansen, & Heir, 2019) and even higher risks to commit suicide (Lam, Christ, Lee, Zheng, & Arheart, 2008). People who suffer from visual impairments further frequently report not being able to do things like reading, cooking, or driving (Thetford, Robinson, Knox, Mehta, & Wong, 2009). As a result of this, people with visual impairments are often unable to live independently (Langelaan et al., 2007; Thetford et al., 2009). Given that these individuals at least to some degree experience unpleasant consequences as a result of their visual impairments, it is important to support them to better live with their impairments. Therefore, the target group of the current study are individuals with visual impairments.
To be able to encounter these unpleasant consequences, many individuals with visual impairments are urged to engage in what is called self-management. Self-management is “the ability of the individual, in conjunction with family, community, and healthcare professionals, to manage symptoms, treatments, lifestyle changes, and psychosocial, cultural, and spiritual consequences of health conditions” (Richard & Shea, 2011, p. 261). As such, effective selfmanagement enables individuals with visual impairments to mitigate the extent to which their visual impairments affect both their daily lives and mental health (Gallant, 2003; Barlow, Wright, Sheasby, Turner & Hainsworth, 2002).
However, while the value of self-management for individuals with visual impairments is clear, the exact strategies such individuals use to self-manage require research. Although the forms that successful self-management can take for persons with chronic illnesses in general have been well-researched (Grady & Gough, 2014; Lorig & Holman, 2003), there is a significant gap in the literature when it comes to the self-management of individuals with visual impairments. Such research often largely focuses on the same chronic illnesses which typically include diabetes, arthritis, and asthma (Barlow et al., 2002; Gallant, 2003; Newman, Steed, & Mulligan, 2004; Kralik, Koch, & Price, 2004). This is problematic, shown by the study of Lorig and Holman (2003) that points out that there are many differences between patient populations amongst other things including their self-management. Consequently, it cannot be assumed that individuals with visual impairments use the same self-management strategies as other populations with different chronic illnesses do.
The fact that research often focuses on largely the same chronic illnesses is further problematic as it results in an imbalance in the distribution of self-management programs. Again diabetes, arthritis, and asthma are often the focus of such programs and interventions (Barlow et al., 2002). These programs often successfully reach their goals of teaching populations with different chronic illnesses approaches as well as strategies for effective selfmanagement (Grady & Gough, 2014). However, only a few of such programs are tailored to individuals with visual impairments (Rees, Keeffe, Hassell, Larizza, & Lamoureux, 2010). In addition to this, individuals with visual impairments are often unable to attend the latter due to practical barriers such as problems with transport or ill health (Rees, Saw, Lamourex, & Keeffe, 2007). This shows that there are several obstacles that individuals with visual impairment must overcome to learn how to self-manage their lives compared to other populations with different chronic illnesses (Barlow et al., 2002). As a result, individuals with visual impairments have fewer opportunities to better understand their conditions and will eventually miss out on at least some of the positive impacts on the quality of life and the benefits that self-management can bring about for well-being, mood, and self-efficacy (Grady & Gough, 2014; Barlow et al., 2002). Consequently, it is particularly important to find a better way of aiding individuals with visual impairments to self-manage their lives adequately.
One such way that can support individuals with visual impairments in self-managing their lives is posed by positive psychology where the focus is laid on strengths instead of deficits and shortcomings (Sheldon & King, 2001). Strengths can thereby be defined as "any internal or external element that may improve the person’s quality of life or well-being" (Bellier-Teichmann & Pomini, 2015, p. 101). Following the strength-based approach, individuals with visual impairment could benefit from using strengths not only to change their perspective but also to overcome challenges (Rashid, 2015). The use of strengths has further shown to aid individuals to grow, realize their full potential (Staudt, Howardw, & Drake, 2001) and improve their well-being (Wood, Linley, Maltby, Kashdan, & Hurling, 2011). It thereby nurtures resilience and supports a successful adaptation to adversity (Lee et al., 2013; Zautra, Hall, & Murray, 2010), to name a few ways in which the use of strengths could be beneficial for the self-management of individuals with visual impairments.
Given this importance, there are not enough studies that have researched strengths used by individuals with visual impairments. However, the one study that is available about the topic confirms a significant association between strengths use, subjective happiness, and positive emotions of individuals with visual impairments. Matsuguma et al. (2018) found that the use of personal strengths can act as a shield for protecting visually impaired people from emotional distress and unhappiness.
However, it is unknown which strengths are used by individuals with visual impairments. Such knowledge is important as it could support individuals with visual impairments to better self-manage their lives in light of their impairments. The current study, therefore, fills this gap by interviewing individuals who are visually impaired about their selfmanagement strategies as well as which strengths they use for their self-management. The following research question emerges: Which strengths do individuals suffering from visual impairment use to self-manage their lives?
The current study was conducted in Germany in 2020. A qualitative research design was chosen to get insight into the experiences individuals with visual impairments have made as a result of their visual impairments as well as their thoughts and opinions about which strengths they used to self-manage their lives in the light of their impairments. To enable this, semistructured interviews were used.
The current study included 10 participants with visual impairments whose ages ranged from 22 to 26 (M= 23.8, SD= 1.17). Moreover, out of these participants, 8 were male and 2 were female. All participants were German. The inclusion criteria for participation in the interviews were a minimum age of 18 years as well as the presence of visual impairment according to the WHO (2018). This means participants had to have a visual acuity of worse than 0,3 or a visual field fewer than 10 degrees. This was determined by self-reports of the participants.
Before starting the interviews ethical approval was sought and granted by the ethical commission of the University of Twente (request number: 200323). Participants for the current study were recruited via a convenience sample. The researcher knew the participants who all went to the same school for the blind and visually impaired as he had worked with them before. The researcher created a group chat in which he invited the potential participants and informed them about the interview study with a short introductory message (See Appendix A). In this group, participants were also asked by the researcher to voluntary participate in the interview. After a few participants did not show interest in the study, new participants were added into the group chat until a total of ten participants who were willing to take place in the current study were found. Those participants were then asked to send the researcher their Skype names privately. From this moment on all communication happened privately between each participant and the researcher via Skype. The group chat was deleted at this point.
The participants were then supplied with an information sheet (See Appendix B) containing detailed information about the interview. Additionally, a list of possible strengths (See Appendix C) was sent to the participants to help them further understand what was meant with the term strengths in the context of the current study. Lastly, the participants were provided with an informed consent to teach them about their rights (See Appendix D). After this, they were given time to read through the documents and ask questions that were then answered by the researcher. In some cases, the researcher read the documents to the participants due to their visual impairments. Moreover, participants were asked to sign the informed consent and send it back to the researcher. While most participants signed the printed form of the informed consent, some signed it digitally and sent it back to the researcher. When the informed consents were obtained, the researcher introduced himself and explained the purpose of the interview. Afterwards, the participants were read the definitions for the terms 'self-management' and 'strengths', to make sure they understood what was meant with them. If there were no remaining questions the interviews were conducted.
The first interview that was conducted was intended to function as a pilot test. The procedure for this interview did not differ from the procedure used for the interviews of the other participants. The pilot test was conducted to see whether there was a need to adapt interview questions and whether the quality of the audio-recordings would be suitable. Also, it was assessed whether the exchange of documents would run smoothly via Skype. Given that questions did not need further adaptation, the audio-recording was of sufficient quality, and exchanging and downloading of documents was possible, the data from the pilot test was eligible to be used as the first interview of the current study.
The remaining interviews were also executed and recorded via Skype. All interviews were conducted in German. The length of the interviews ranged between 14 and 51 minutes. At the end of each interview, the researcher thanked the participants for taking part in the interview and gave them the opportunity to add remarks and ask questions. After all remaining questions were answered, the researcher offered the participants to leave their email addresses and send them the results of the study once the study was completed, in case they showed interest in the outcomes of the study.
An extensive interview scheme containing 16 open-ended questions (See Appendix E) was used to gain insight into the experiences the participants have made as a result of their visual impairments and which strengths they used to self-manage their lives. Interviews were semistructured, and several probes were used to allow for a more flexible interview where the researcher could pick up on the things participants mentioned during the interview. The questions of the interviews can be structured in three parts. The first questions were concerned with a short introduction of the participants where demographics such as age and employment status were acquired. The next set of questions addressed general information concerning the participants’ visual impairments. To give a few examples, questions included ‘What kind of visual impairment are you affected by?’ and ‘For how long have you been visually impairment?’. Furthermore, the interview contained questions regarding the experiences participants had made as a result of their visual impairments. Also, at this point, the ways participants cope with their impairments were addressed. Questions included ‘What is it like for you to live with a visual impairment?’, ‘What is going well?’, and ‘What do you find difficult?’. The following questions were aiming to explore the strengths that participants used to manage their lives in the light of their visual impairments. To give a few examples, questions such as 'What helps you in coping with your visual impairment?', 'Are there certain things that you are good at / strengths that you use to cope with your visual impairment?' and 'How do these strengths help you?' were used.
After all interviews were conducted, they were transcribed verbatim by the researcher using Microsoft Word. Only relevant parts of the interviews were translated into English. While transcribing, the interviews were anonymized so that participants were not identifiable from this moment on. Also, at this point, the audio files were deleted. The anonymized transcripts were then imported into Atlas.TI (Version 8.4.4) where they were read multiple times by the researcher to get familiar with the content of the interviews. After this, the interviews were analysed undertaking iterative and systematic steps. This means that the researcher, utilising content analysis of the interviews, created codes and at a later point in time adjusted and supplemented them by further codes. The reason for this is that new codes emerged frequently in the process of working through the transcripts of the interviews. Further, coding was an inductive approach which means that codes were created not by using predefined themes but by looking at the data and analysing which themes had emerged.
To create the first version of the coding scheme, the first two interviews were coded and checked by two supervisors to verify its completeness. After some suggestions for improvement, codes were adapted and combined. Consensus between the researcher and supervisors was reached and the definite coding scheme (See Appendix F) consisted of a total of 10 codes. These were integrated into the main themes ‘self-management strategies’, ‘internal strengths’, and ‘external ‘strengths’.
After analysing the interviews, a total of 10 codes were found in order to answer the research question, 'which strengths do individuals suffering from visual impairment use to self-manage their lives'.
The first main theme that reoccurred throughout the interviews was named ‘internal strengths’ (Table 1). It includes qualities of the participants that they held and made use of with regards to their visual impairments. These were (1) ‘resilience’, (2) ‘independence’, (3) ‘humour’, and (4) ‘self-confidence’.
Having resilience in the domains that are concerned by their visual impairments was the most frequently reported internal strength, referred to by 8 participants. Amongst other things, participants mentioned that they needed resilience in order to successfully tackle tasks and challenges. As an example, one participant talked about his ambition to integrate into his workplace and how he needed resilience to not quit and persist throughout the many burdens imposed on him by this novel chapter in his life. These included, for instance, having to use computer programs that were not suitable for the blind or visually impaired. Many participants also made references to when they went to school. They experienced this time as stressful and reported needing resilience in order to not give up. One participant reported how he frequently had to have talks with his teachers, explaining to them his necessities related to his visual impairment. Another participant reported how he was getting bullied at school and used resilience to bear through it and not get pulled down by it. Other participants described how resilience was useful in their university life. As an example, one participant explained that before lectures he regularly had to ask the lecturer to print out the slides for him as the participant otherwise would not be able to read them properly: “if the lecturers do not put the slides online on time, I have to go and ask them to and they always discuss with me because they sometimes do not want me to have the slides beforehand but otherwise I cannot see them [...] and it helps that I am so consistent and do not leave unless I have the slides.“ (P8) When asked how the participants have obtained this resilience, one of them stated that he did so by chasing and finally reaching a goal that he had in mind, which was going to university. He further explained that through this he understood that he needed time and had to put in a lot of work to reach such goals. Other participants reasoned that they became resilient by learning from their mistakes and reflecting upon their developments. An example of this is provided by one participant who described how failures taught him to try again. He further stated that this process took very long and that he is happy to have put in the work for it.
With a total of 7 participants mentioning ‘independence’, it is the second most reported theme. This code involves the participants’ ability to independently manage their lives. According to the participants, being independent was essential to them as they needed it to be able to do as much as possible by themselves. One participant said: “I am quite independent, meaning that I try to take care of things on my own and I also try to wait with asking people for help [...] because I think even blind people can do a lot on their own, it is just more work [...].” (P3) Participants explained how they had an urge to tackle things on their own even if they would be confronted with difficulties. These difficulties were often a direct consequence of the participants’ visual impairments. One participant gave an example of this by stating how she wanted to file documents at work by herself even though she had a hard time reading them. She further explained that she was very proud of herself after successfully finishing tasks like these on her own and as a result had a sense of accomplishment and independence. Similarly, other participants emphasized how, instead of just letting others do the work for them, they rather wanted to try it themselves. They wanted to take initiative and try out things even if these would possibly fail. Other examples that were mentioned included going to work or university by themselves or being able to find friends at an arranged venue.
The next code, ‘self-confidence’, which was mentioned by 7 participants, was amongst other things crucial for the participants’ ability to seek help. Participants explained how self-confidence enabled them to approach strangers and ask for help as many of the participants indicated being afraid of that. According to the participants, self-confidence was needed to dare approaching strangers and asking them for help regardless of this fear: “[...] a certain amount of self-confidence. I think to some extent you have to have that [...] if you have to ask people on the streets, or if you really have to ask for help [...].” (P3) Selfconfidence also proved to be useful as it enabled the participants to talk more openly about their visual impairments and reveal to others that they could not see certain things. Participants reported how this also supported them in seeking help. They explained that approaching strangers often required the participants to engage in such an exposition of their visual impairments. An example was provided by one participant who described how he feared the judgement of the bus driver when asking him which bus line the bus was. Some participants explained how they developed confidence from trying to approach strangers and seeing that it worked and that they were getting the help they asked for when dared to ask for it. Others referred to the courses of their lives and that they have gotten more confident simply from growing up. Besides supporting the participants when it comes to approaching strangers, some participants explained how they used self-confidence to dare doing other things ranging from assembling furniture to being able to graduate from school. These examples had in common that the participants at first glance thought them to be difficult, if not even impossible for them to accomplish. Participants explained how having the confidence to dare such, for them, difficult tasks, over time made them understand how capable they were and what they were able to accomplish. Participants thereby mentioned the important role of having a sense of achievement and the positive effects this had on their selfconfidence and willingness to try other things as well.