1. Introduction
Young people with visual impairment face challenges in many areas of their lives. Disabled young people may often remain children longer than their peers due to, for example, overprotective parents and helpers, a lack of assistive devices or the nature of their disability [
1]. The self-esteem of young persons with visual impairment is shown to not differ from that of their sighted peers, but relationships with friends contribute to enhancing the self-esteem of adolescents with visual impairments [
2]. Young persons with special needs have fewer friends and consider themselves lonely more often than those without disabilities [
3,
4,
5,
6]. Also, romantic relationships are more difficult to form [
6]. Some young persons with visual impairment, especially girls, need support in their psychosocial development [
4]. In addition, visually impaired young people seem to have fewer activities than their sighted peers and they seem to rely on their parents for transportation [
7]. Children and young people with chronic physical conditions are 51% more likely to develop a chronic mental health condition than other children and youth [
8]. Conversely, adolescents with visual impairment have reported higher rates of overall computer usage than sighted peers, due to higher usage for school work and searching for information [
9]. These everyday challenges need to be tackled in their normal daily support regimen, in their education and in their rehabilitation.
These difficulties may hamper visually impaired young people’s transition to adulthood, and lead to potential difficulties in full participation as adults. Participation contributes to health and well-being, and in rehabilitation, participation is considered as the most relevant outcome [
10]. The International Classification of Functioning, Disability and Health (ICF) [
11]—a framework for rehabilitation practice—defines participation as personal involvement in life situations. The ICF constitutes a unified and consistent language of human functioning suitable as a reference for comparing health information [
12]. The ICF brings together three perspectives—bodily, individual, and societal—and contains the following broad components: Body Function and Structures, Activities and Participation, and Environmental Factors, as well as personal factors not yet coded in the ICF. Leeuwen et al. [
13] identified the most prevalent rehabilitation needs of visually impaired young adults on the Activities and Participation Component of the ICF. These needs were related to major life areas such as finding a job, mobility-related needs such as self-reliance in travelling, and needs related to communication, e.g., using communication devices and techniques. Also in this pilot study, we noticed that young persons with visual impairment faced challenges in Activities and Participation [
14]. The most frequently identified challenges were related to mobility (e.g., using transportation), domestic life (e.g., doing housework), interpersonal interaction and relationships (e.g., informal social relationships such as making friends), major life areas (e.g., basic economic transactions such as using cash machine), and leisure activities. We also identified some environmental factors that can be either facilitators or barriers to participation. For example, assistive devices facilitated mobility and schoolwork but they could also be experienced as a barrier to social participation. Similarly, parental attitudes can either support or hinder a visually impaired child’s participation.
Rehabilitation is an integral component of health services, ensuring that people can realize their full functional potential in their own living and working environments [
15]. In relation to the ICF, the role of rehabilitation has been described in enhancing participation [
16]. Rehabilitation can address impairments, activity limitations and participation restrictions, as well as personal and environmental factors (including assistive technology) that impact on functioning [
15]. However, the way in which rehabilitation is implemented and understood in real life varies and the focus is often on the impairment itself [
16]. In the rehabilitation of visually impaired young people, there may be too much focus on underlying capacities instead of the different kinds of skills needed in participation [
14].
In Finland, the rehabilitation of people with visual impairments is funded either by municipalities or by the Social Insurance Institution (Kela). Kela organizes medical rehabilitation services for people who have severe limitations in activity and severe restrictions in participation and pays them rehabilitation allowances. The total number of young people aged 15 to 24 in Finland in 2016 was 633,704, of whom 761 were visually impaired: 450 male, 311 female [
17]. Finland is a geographically large country and even with the majority of the population concentrated in the southern region, distances between visually impaired peers may be long. This is one reason, why young visually impaired people have only few friends and often consider themselves lonely and lacking support from their visually impaired peers [
14].
Kela developed and arranged (2011–2012) a new one-year group-based outpatient rehabilitation program for young people with visual impairment to support them in their everyday lives. The general aims of the program were to support young people in becoming more independent and to promote their participation. The program was developed and arranged together with the Finnish Federation of the Visually Impaired (FFVI), an advocacy organization for the blind and the partially sighted, which also provides a special rehabilitation service with social element.
The aims of this pilot study were to describe clinical outcomes and the acceptability of the piloted program.
2. Materials and Methods
2.1. Piloted Rehabilitation Programme
A one-year, multiform, group-based rehabilitation program for visually impaired young people was arranged in two regional groups, one in the Helsinki capital area (7 participants) and one in western Finland (8 participants).
The rehabilitation consisted of both inpatient group meetings in institutional settings and online, and individually tailored one-on-one guidance in individually selected settings (e.g., home, school or cafeteria).
Group meetings in an institutional setting were arranged in four modules. The first module (five days) dealt with themes of interpersonal skills and life management. At this phase, a great deal of effort was put into building group cohesion among participants. The themes of the second period (two days) were social and psychological well-being, sexuality and self-determination, leisure time, and hobbies. The third module (two days) dealt with education, work and the role of the employer (in Finland disabled people employ their assistants). During the last module (five days) the participants were given practical guidance and tips for everyday life. They also received support in planning their lives and looking forward to the future. Each day included six hours of rehabilitation and three hours of other supporting activities. In addition to professional supervisors, two young persons with visual impairment acted as a part-time support team for the participants.
One-on-one guidance in individually selected settings included interviews before and after the program and three to five meetings based on the individual needs and wishes of the young people. The focus was on the performance of practical tasks in conjunction with personal goals. Participants learned, for example, the use of public transport, made college visits and learned to use ATM machines or their assistive devices. Participants were asked to arrange one-on-one meetings with supervisors independently without their parents’ support. In addition, supervisors encouraged participants to travel independently to the meetings.
Both real time and asynchronous tele-rehabilitation were used in the online interventions. Real time monthly group meetings (chat rooms) were built around primary themes of the rehabilitation. Some group meetings did not have a predefined theme. Supervisors provided information on an as-needed basis during chat room meetings. Participants completed tasks related to the rehabilitation themes, and in the Moodle learning platform, participants had opportunities to read more information about the themes. Supervisors supported participants with personal e-mails. Tools for this section were financed by the Finnish Ministry of Education and Culture.
Parents had one-day group meetings twice, once in the beginning of the rehabilitation and once at the end of it. The parents program included also individual meetings in the beginning and at the end of the rehabilitation. Parents had the opportunity to reflect the strengths of their children and their own parenthood as well as to suggest their wishes for the program. The rehabilitation professionals’ peaceful presence was considered highly important. The parents’ sessions supported the agenda of the children’s rehabilitation. They had group conversations about being a parent to a growing up young person with visual impairment, and about supporting their children becoming independent. They also discussed the different roles of parenthood. Contents of their children’s rehabilitation and plans for the future were presented to the parents. Parents were provided information about the FFVI. Counsellors presented their role and services to the children and youth with visual impairments and their families. At the end of the rehabilitation parents were given advice on how to support their children’s independent living and travelling.
2.2. Participants and Methods
Ethical approval for the study (following the tenets of the World Medical Association Declaration of Helsinki) was obtained from the Ethical Review Board of the Social Insurance Institution of Finland in Helsinki. All participants gave their written informed consent for participation in the study.
Inclusion criteria were age (16–22 years), visual impairment (blind, severe visual impairment or mild visual impairment), motivation for rehabilitation, lack of other severe illnesses (such as severe mental illness), lack of difficult cognitive problems and independence in daily activities (i.e., dressing, personal hygiene, eating).
Fourteen young people with visual impairment participated in the program from the beginning to the end. They were 16–22 years of age, nine of them were male and five were female. Six were blind or had severe visual impairment and eight had mild visual impairment. All attended school—either in primary, vocational, or higher education—and took part in the rehabilitation program during their leisure time. One participant discontinued during its course.
This study utilized a mixed methods triangulation design [
18]. In this type of design qualitative and quantitative data are collected concurrently. The data were analyzed separately and then compared to corroborate the findings. Qualitative data from focus group interviews were used to assess whether the program was appropriate to the participants, and qualitative data from individual interviews were used to expand quantitative data in outcome evaluation.
Clinical outcome measures were the rehabilitees’ occupational performance and rehabilitation goal attainment. The measurements were carried out within the rehabilitation program by the rehabilitation professionals in the beginning and the end of the program.
The Canadian Occupational Performance Measure (COPM) was used to capture self-perceived problems in everyday activities and participation. COPM is a semi-structured interview designed to identify the activities that a person wants, needs or is expected to perform [
19]. An occupational therapist trained to use the COPM interviewed the participants at the beginning of the rehabilitation program. In the first phase of the interview, participants reported the activities they found difficult to perform. Then they rated the importance of each activity on a ten-point scale, with one being not important at all and ten being extremely important. Then the participants scored their own performance and satisfaction levels on a ten-point scale with five of the most important activities and the total scores were then calculated. At the end of the rehabilitation they scored the same activities again. The new scores and the change in scores were calculated. The validity and reliability of the COPM has been widely established [
20].
Goal Attainment Scaling (GAS) was used to set and score the participants’ individual goals. GAS is a method of scoring the extent to which individual goals are achieved in the course of an intervention. Participants have their own outcome measures, but standardized scoring allows for statistical analysis. At the beginning of the intervention, each participant established two to five individual goals for rehabilitation with support from professionals. Each goal was rated on a five-point scale so that the “expected outcome” fell in the middle of the scale at a score of zero. Also the levels for “somewhat less” and “much less”, “somewhat more” and “much more” were defined. At the end of the rehabilitation program, the participants evaluated their goal achievement and scored the achieved performance [
21,
22].
Individual interviews were used to obtain in-depth information pertaining to the experiences young persons and their parents had in terms of outcomes of the program. The young persons (
n = 14) and their parents (
n = 22) were interviewed by the first author of this article at the end of the rehabilitation program. The young persons were interviewed individually and their parents as couples when two parents took part in the study. Using open-ended questions modified according to the circumstances, the interviews focused on the impact of the rehabilitation program on social and independent living skills of the visually impaired participants. Additional discussions were held to describe the challenges young people experience in participation. This topic has been reported in another article about this pilot study [
14]. Most of the interviews took place in the participants’ homes, while two were held in cafes and two by phone for practical reasons. The interviews were audiotaped and transcribed verbatim. Some of the young persons were quite short-spoken, so the interviews took 23 min on average (11–40 min). Interviews with parents took on average 34 minutes (15–50 min).
Acceptability of the rehabilitation program was evaluated in focus-group interviews with the young persons (in two groups) and their parents (in two groups). The interviews focused on functionality and the importance of different modes of interventions included in the program: inpatient rehabilitation, groups, one-on-one guidance, online interventions, parents’ program and adverse effects of the program. The focus groups were run by two researchers (A-LS and TH), and each group gathered for about an hour each. Interviews were audio-recorded and transcribed verbatim.
2.3. Data Analysis
The ICF was used as a conceptual framework in the data-analysis to enable the comparability between the results and health information [
12]. The problems identified by the program participants by using the COPM (3–6 problems per participant) were linked with the ICF linking rules (e.g., [
12]) to the corresponding ICF second-level categories chosen by the first author of this study and then checked by another researcher. The individual COPM scores from the beginning and the end of the rehabilitation were compared by use of the Wilcoxon Signed Rank test.
The goals identified by the young people with GAS (2–5 goals per participant) were linked to the corresponding ICF second-level categories chosen by the first author of this study and then checked by another researcher. The GAS goals were incorporated into the single overall GAS T-score by applying the GAS formula, and interpreted as follows: 50, expected level of achievement; <50, performance below the expected level; >50, performance above the expected level. Means and range for the group were calculated from individual T-scores.
The analysis of the individual interview data was carried out by the first author by means of conventional content analysis [
23] with the help of the AtlasTi analysis program. By combining data from individual interviews with COPM- and GAS-measurements, it was possible to expand the understanding of outcomes of the program.
The analysis of the focus group data was carried out by the second author of this manuscript by the use of qualitative inductive content analysis. The analysis focused on the manifest and explicit level where the codes were identified within the explicit or obvious components of the data [
24,
25]. The codes show something important about the data in relation to the research question and they were generated from the data itself over the course of the study [
24]. One sentence or meaningful data set could include one or more codes.
The results from different data sets were combined to describe clinical outcomes, using the ICF as a conceptual framework, and the acceptability of the piloted program.
4. Discussion
Results of this study show that a multiform, group-based rehabilitation program for young people with visual impairment is beneficial in promoting activities and participation. Due to, for example, parental overprotection and a lack of activities, it is beneficial to provide them extra support on their path towards independence. Some of the participants in this study will never be fully independent, but will live with interdependence instead, in which a person does some things with assistance and others without [
26]. In these cases, activity with assistance may be a realistic goal for many visually impaired youths, and it is important to explain this to them instead of focusing only on independence [
26].
Group-based rehabilitation proved to be especially important for the young participants. Like the participants in this study, young persons with disabilities consider themselves lonely more often than those without disability [
4,
5]. Social support, especially the support of peers, is important to adolescents with visual impairments [
27] and may contribute positively to their self-esteem [
2]. Group meetings, both face-to-face and online, provided participants the opportunity to meet their peers, which is important especially in sparsely populated countries or areas. Indeed, some of the participants’ experiences identified in this study relate to the therapeutic factors of group therapy as described by Yalom [
28]. Peers and acceptance relate to Yalom’s universality: The realization that one’s concerns or problems are not unique but experienced by others as well. Furthermore, acceptance relates to Yalom’s concept of group cohesiveness: a trustworthy, warm, empathetic, understanding and accepting atmosphere is therapeutic. Advice and encouragement relate to Yalom’s altruism because giving advice and encouraging each other give an opportunity to be of help to others.
Furthermore, peer support from more experienced young persons with visual impairment is important, as this way young people can better understand their potential and their parents can understand that having expectations for their children is both realistic and a critical part of their child’s development [
29]. Peer support from more experienced young persons may, for example, improve participants’ negative attitudes towards assistive devices, which often have a crucial role in enabling activity and preventing underachievement.
Interestingly, participants were divided on the online components of the intervention and criticized them widely. Young people tend to spend their social lives on the Internet—according to a Finnish study, 16% of youths aged 13–16 spend more time with their friends on the Internet than face-to-face and 41% have good friends with Internet contact only [
30]. Young people participate in online activities and social media most commonly for friendship or interest-driven purposes. Interest-driven means that the time spent online is focused on a certain interest, activity or hobby [
31]. Criticism about the online segment of rehabilitation might be due to young people finding other social media or Internet forums more motivational than tasks and information presented in the learning platform. A potential explanation concerning the criticism of the online activities might be the lack of parental involvement or technical problems with the learning platform. According to Yu et al. [
32] and Raghavendra et al. [
33], young people with health-related problems value the social and emotional support from families and close friends and technical support on the use of the Internet as a venue for social networking and sharing feelings and experiences with others.
After the completion of this program, the use of tele-rehabilitation has increased widely. As of yet, there seems to be only little evidence about tele-rehabilitation among visually impaired people [
34]. However, low vision tele-rehabilitation has proved to be feasible and acceptable [
35]. A recently published study provides evidence of the effectiveness of a home rehabilitation intervention for visually impaired adults by showing an improvement of visual functions [
36]. The focus of the intervention was on underlying capacities, whereas in this program it was on activity and participation. It may be that a broad content area brings an extra challenge into online interventions.
The results of this study show that the program succeeded to focus not on underlying capacities but instead on the different kinds of skills needed in participation. Concrete action and being engaged in something that is meaningful and important for the individual concerned is a way for people to become what they want and have the potential to become [
37]. Through the execution of tasks and activities, a person gets involved in life situations, which means that they participate [
11]. How young persons with a visual impairment negotiate socially within their life contexts is a determining factor in the ultimate level of independence in their lives [
38]. For young people with visual impairment, concrete and independent action supported by the supervisors improves their potential to participate. On the one hand, it gives them real-life feedback regarding their abilities that they tend to estimate better than their parents [
14,
39], and on the one hand, they may show their potential to their parents who tend to underestimate their capabilities. Still, for many, transferring the potential, for example newly learned skills, into real life requires long-term support from both supervisors and parents.
The program for parents was too limited in this program. Parents play a crucial role in the socialization process of young people with visual impairment [
29]. There are individual differences among parents with respect to their acceptance, involvement, and understanding of the social development process, and parents may have feelings of isolation due to their visually impaired child and a need for practical information sharing. Therefore, they need, in addition to professional support, peer support from other parents.
Overall, the program is appropriate for young people with visual impairments. The program still requires some structural modifications. Possibly two or three 3–4-day inpatient rehabilitation modules would produce a similar outcome and disturb studying less. Online intervention components could be limited to informal discussions. Parents need a more intense program that could partly take place online.
The strength of the study lies in its mixed methods triangulation design describing how visually impaired young people and their parent report the outcomes and acceptability of the piloted program. Subjective COPM and GAS measures were used in addition to the interviews as the method of data collection. The use of a mixed-method design has both theoretical and practical strengths by involving stakeholders in the research process and by enhancing context sensitivity in line with models such as the ICF, that leads to the potential ecological and external validity of research [
40].Thus the research approach is philosophically and methodologically congruent with the study [
41]. The primary limitation of the study is the small sample size, which is limited in its statistical power. However, significant improvements after intervention for total performance self-ratings on both the COPM and GAS T-scores and interview data support the positive outcome. Involving visually impaired young people in the evaluation of outcomes and acceptability of the program helps represent their interests and ensures that young people’s voices have been heard. The use of the ICF as the conceptual framework in the data analysis and the results of the study increases the comparability of information, and makes the results available in a consistent manner to clinicians and decision makers [
12].
The group exceeded a mean normalized T-score of 50 on GAS, indicating that, on average, goals were above the expected level. On the other hand, this—as well as the broad range of the T-scores—may show difficulties in the goal-setting process, leading participants to set goals that were either too easy or too difficult to achieve.
Originally, the COPM and GAS were intended to be used in a combination in this intervention. The COPM was first used by an external occupational therapist to identify the problems of young persons after which GAS was used by the group supervisors to define the goals for implementation. However, the ICF linking of the COPM problems and GAS goals showed that the setting of GAS goals was not based on the COPM assessment. The main reason for this was lack of cooperation between professionals. On the one hand, the group supervisors had thorough information on the participants from their medical background data and personal interviews that may have had impact on setting of GAS goals. Previous research [
42] has shown that a combined use of the COPM and GAS—although time-consuming—results in goals that are perceived almost unanimously as client centered. Furthermore, the combined use has been shown [
42] to enable the subjective and objective demonstration of goal achievement, thereby supporting the clinical utility and treatment validity of the combined use of these tools. On the other hand, there is evidence that the use of the COPM did not grasp the challenges related to body functions or environmental factors with visually impaired young people, which highlights how critical it is, to complete the use of the COPM with an evaluation of factors that may have an impact on participation [
15].