Change-Readiness of the Blind: A Hospital Based Study in a Coastal Town of South India

Abstract

Blindness is a devastating condition with psychosocial and economic effects. The shortcomings result in a burden to the blind person, the family and society. Rehabilitation of the blind can transform their lives. The aim of this study was to assess the "change-readiness" of the blind to undergo a "change-management".
The study was a semi-structured pre-tested questionnaire-based study of 50 blind subjects in a medical college hospital. The blind participants were assessed for depression using the Beck Depression Inventory II, for the perceived effect of blindness on family, social life and occupation. The participants were counseled to undergo psychiatric management, vocational training, use blind aids and learn Braille. The willingness of the participants with reasons was assessed using a verbal analogue scale. Pearson Chi-square test, ANOVA and the t-test were used for statistical analysis.
Over two-thirds of the subjects were depressed. Family life, social life and occupation were perceived to be affected by 44%, 66% and 74%, respectively. Change-readiness scores were low for low vision and blind aids, vocational training, psychiatric management, change of job and learning Braille. The low score was due to the associated taboo, dependence, lack of skills, embarrassment, etc., The most valuable feature was the family cohesiveness.
The results suggest that there is a need to modify health policy to include blind rehabilitation, to improve visibility of blind rehabilitation centers, to include family members and co-professionals while managing the blind so that we treat the "blind person" and not a "pair of blind eyes".

Full text

158 Middle East African Journal of Ophthalmology, Volume 21, Number 2, April - June 2014
Departments of Ophthalmology, and 1Ophthalmology, Yenepoya Medical College, Yenepoya University, Mangalore, Karnataka, India
Corresponding Author: Dr. Uma D. Kulkarni, Lakshmi Keshava, 4th Cross, Shivabagh, Mangalore ‑ 575 002, Karnataka, India.
E‑mail: umasripada@gmail.com, umakulkarni@yenepoya.edu.in
INTRODUCTION
Blindness is a devastating condition and its magnitude
in India is vast (15 million).1 The consequences of
blindness range from depression,2‑4 loss of jobs,5 jeopardized
relationships6,7 to meager economic conditions.8 Faced
by challenges, people with blindness become a burden to
themselves, the family and society.
At present, the National Program for Control of Blindness (NPCB)
policies of the government of India9 focus on prevention and
cure of blindness, but not rehabilitation. It is reported that
without adequate rehabilitation measures, many blind persons
resort to begging.8 The same is true in India, but there is no
literature quoting statistics. On the other hand, there are blind
persons who have been “achievers” in the fields of art, music,
sports, politics, etc., Appropriate rehabilitation can transform
a blind person into a “blind achiever.”
The authors adopt the term “change‑management”10 for the
comprehensive blind rehabilitation strategy, which includes
solutions to psychiatric, vocational, mobility and visual
problems faced by the blind. The aim of the study was to
assess the willingness or “change‑readiness” of the blind to
“change‑management” strategy.
ABSTRACT
Purpose: Blindness is a devastating condition with psychosocial and economic effects. The
shortcomings result in a burden to the blind person, the family and society. Rehabilitation of
the blind can transform their lives. The aim of this study was to assess the “change‑readiness”
of the blind to undergo a “change‑management.”
Materials and Methods: The study was a semi‑structured pre‑tested questionnaire‑based study
of 50 blind subjects in a medical college hospital. The blind participants were assessed for
depression using the Beck Depression Inventory II, for the perceived effect of blindness on
family, social life and occupation. The participants were counseled to undergo psychiatric
management, vocational training, use blind aids and learn Braille. The willingness of the
participants with reasons was assessed using a verbal analogue scale. Pearson Chi‑square
test, ANOVA and the
t
‑test were used for statistical analysis.
Results: Over two‑thirds of the subjects were depressed. Family life, social life and occupation
were perceived to be affected by 44%, 66% and 74%, respectively. Change‑readiness scores
were low for low vision and blind aids, vocational training, psychiatric management, change
of job and learning Braille. The low score was due to the associated taboo, dependence, lack
of skills, embarrassment, etc., The most valuable feature was the family cohesiveness.
Conclusion: The results suggest that there is a need to modify health policy to include blind
rehabilitation, to improve visibility of blind rehabilitation centers, to include family members
and co‑professionals while managing the blind so that we treat the “blind person” and not a
“pair of blind eyes.”
Key words: Blindness, Change‑Management, Change‑Readiness, Depression, Rehabilitation
Change‑Readiness of the Blind: A Hospital Based
Study in a Coastal Town of South India
Ramya Shetty, Uma D. Kulkarni1
Original Article
Access this article online
Website:
www.meajo.org
DOI:
10.4103/0974-9233.129768
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Shetty and Kulkarni: Are we Turning a Blind Eye Toward the Blind?
Middle East African Journal of Ophthalmology, Volume 21, Number 2, April - June 2014 159
The objectives were to assess:
• Depressionandthe “perceived” effect of blindness on
day‑to‑day aspects of life
• “Change‑readiness”tothe“change‑management”protocol
encompassing psychiatric management, vocational and
blind rehabilitation measures
• Factorsaffecting“change‑readiness”.
MATERIALS AND METHODS
The study was a cross‑sectional semi‑structured pre‑tested
questionnaire‑based study of the blind subjects conducted in
the Yenepoya Medical College Hospital, Mangalore from May
to July, 2011. A convenience sample of 50 adult participants
with blindness as defined by Indian modification of World
Health Organization (WHO) classification11 was included.
The blind subjects were selected by purposive sampling from
the patients attending the out‑patient department. Cases of
blindness over 18 years with vision less than 3/60 in the better
eye were included. Unilateral blindness, visual impairment,11
curable blindness (including cataract blindness) and children
with blindness were excluded.
Methodology
The consenting blind participants were enrolled for the study
after a detailed clinical history and ophthalmic evaluation
including visual acuity assessment, anterior and posterior
segment evaluation using slit‑lamp accessories and ultrasound
imaging when required to diagnose blindness and its cause.
• Assessmentoftheeffectofblindness:
a. Assessment of depression was performed with the
BeckDepressionInventoryII(BDI‑II)12 administered
verbally by the investigator. The chosen response
wasmarked and scored for depression. Depression
was classified as no/minimal (0‑13), mild (14‑19),
moderate (20‑28) and severe (29‑63)
b. The “perceived” effect of blindness on the professional
and socio‑economic aspects was assessed using a
verbally administered semi‑structured questionnaire
c. Functional vision was assessed by the ability of the blind
to recognize faces and objects and move about avoiding
obstacles. Such participants were considered suitable for
the optical low vision aid like magnifiers. Participants
without physical disability like hemiparesis, amputated
diabetic limbs were considered as suitable for blind aids
like the walking cane. Since the hospital caters primarily
to the rural and socio‑economically underprivileged
population, the choice of expensive computer aided low
vision devices is not routinely practical. Hence, the study
included “magnifiers” as a form of low vision device,
which could be used for day‑to‑day activities only.
• “Change‑management” strategy was suggested: The
participants were counseled to undergo/use:
a. Psycho‑pharmacotherapy and counseling
b. Vocational training and change of job
c. Blind aids like white cane and low vision devices such
as magnifiers.
• “Change‑readiness”wasassessedusingtheverbalanalogue
scale for the change‑management strategy suggested to
them:
a. The subjects were asked to imagine a scale with markings
0‑10, where “zero” indicated “Not at all willing
for change” and “10” indicated “completely willing
for change or already changing.” The respondents
were asked to quote a number from 0 to 10 which
correspond to their level of agreement for change.
This number was considered as the “change‑readiness
score” for that attribute.
b. The subjects were asked to enumerate reasons for
choosing that particular score for each attribute.
Statistical analysis
Analysis was performed using percentages and proportions.
Significance of differences in responses between different
comparable groups was performed using Pearson Chi‑square
test, ANOVA and the t‑test. P < 0.05 was considered to be
statistically significant.
Ethics
The study was conducted after obtaining clearance from and
in accordance with the regulations of the Institutional Ethics
Committee. An informed written consent was administered to
the subject after verbally discussing the same in the presence of
a bystander. The questionnaire was administered with empathy
and sensitivity for every blind participant.
RESULTS
The 50 blind participants included 29 males and
21 females (M: F 1.38:1). The mean age was 56.64 years
(range: 20‑103; peak: 7th‑8th decade). There was no gender or
age‑wise statistically significant difference in the proportion of
blind cases (Pearson Chi‑square = 0.080, P = 0.961). The
distribution is plotted in Figure 1.
Only 16% had completed higher education and 46% had
schooling up to class 10th; nearly, 38% were illiterate [Figure 2].
Blindness was statistically significantly greater in the lower
educational groups (Chi‑square = 7.149, P = 0.0280). About
54% were unemployed and one, a student. The proportion of
blindness in the various groups of employment was statistically
comparable (Chi‑square = 9.351, P = 0.096).
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Shetty and Kulkarni: Are we Turning a Blind Eye Toward the Blind?
160 Middle East African Journal of Ophthalmology, Volume 21, Number 2, April - June 2014
The etiology of blindness included retinal pathology (38%),
glaucoma (20%), corneal opacity and optic atrophy
(14% each), post‑operative complications (12%) and congenital
anomalies (2%). Sixteen (32%) perceived their eyes to be
disfigured and 36% complained of ocular pain. The average
duration of blindness was 7.75 years with no statistically significant
difference between genders (Chi‑square = 0.643, P = 0.7251).
Most had simultaneous bilateral blindness, whereas
32% had previously experienced unilateral blindness for
2‑48 years (mean = 21.2 years).
The various aspects of life perceived to be affected by the
blind are presented in Figure 3. The majority felt that their
occupation (74%) and income (66%) were affected due
to blindness. This perception was statistically significantly
greater in males (Chi‑square = 6.515, P = 0.038). Family
relations were “perceived” to be affected by 44% with no
statistically significant gender differences (Chi‑square = 2.043,
P = 0.360). Social life was perceived to be affected in
66% with males perceiving it significantly more than
females (Chi‑square = 8.499, P = 0.014).
TheaverageBDIscorewas17.22(male:female16.51:18.19).
The majority had mild and moderate depression [Figure 4].
Proportion of depression was highest in 7th decade and
severity was greatest in the 4‑5th decades. These differences
were statistically comparable in different age groups and
gender (Chi‑square test: P =0.703; Chi‑square = 0.722,
P = 0.868). The severity of depression was not related to the
duration of blindness (Kruskal‑Wallis test = 3.907; P = 0.272).
The change‑readiness scores are shown in Figure 5. There was
no statistically significant gender difference in change‑readiness
for psychiatric counseling and pharmacotherapy. (Levene’s test
for equality variance, t = 0.401, P = 0.690 for psychiatric
counseling, t = 1.13, P = 0.264 for pharmacotherapy). Only
6% had already taken psychiatric counseling and none was
receiving pharmacotherapy. There was no statistically significant
difference in the change‑readiness scores in different severities
of depression (ANOVA; F = 0.815, P = 0.492).
The average change‑readiness score for “change of the job”
was statistically significantly greater in males (Levene’s test
for equality of variance t = 2.723; P = 0.009). There was
no significant gender difference in the scores for vocational
training (Levene’s test for equality of variance t = 2.001;
P = 0.051), for blind aids, learning Braille and for low
vision aids (Levene’s t‑test for equality of variance t = 1.867;
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Shetty and Kulkarni: Are we Turning a Blind Eye Toward the Blind?
Middle East African Journal of Ophthalmology, Volume 21, Number 2, April - June 2014 161
P = 0.068 for blind aids; t = 1.222; P = 0.261 for learning
Braille: t = 0.272; P = 0.790 for low vision aids). Only 48%
were suitable for using magnifiers for day‑to‑day activities.
Only 6% had visited a low vision center and used a low vision
aid, which included spectacle magnifiers by two and hand held
magnifier by one.
A considerable proportion of the blind subjects showed an
absolute lack of change‑readiness for undergoing psychiatric,
vocational and blind rehabilitation [Figure 6]. The reasons
quoted for high and low score are listed in Table 1.
DISCUSSION
Blindness is a major public health problem influencing various aspects
of the life of the blind. Rehabilitation of the blind does not feature in
major health policies in India. Currently, there is no published data
on the proportion of the blind undergoing rehabilitation or regarding
their attitude to “change” in order to improve their quality‑of‑life.
Our study assessed the impact of blindness and the change‑readiness
of the blind to undergo a comprehensive strategy comprising
psychiatric management, blind‑rehabilitation and vocational training,
which the authors termed “change‑management.”
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Figure 3: Aspects of life “perceived” as affected
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Figure 4: Severity of depression
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Shetty and Kulkarni: Are we Turning a Blind Eye Toward the Blind?
162 Middle East African Journal of Ophthalmology, Volume 21, Number 2, April - June 2014
may be attributed to for such variation. This may also reflect the
social, cultural and religious barriers for the females for seeking
hospital services.
The mean age in the current study was less than previous
studies15,16 and this is likely due to the exclusion of cataract,
the most common cause of blindness in the aged. The higher
proportion of blindness was among the groups with lower
educational and was consistent with the WHO data.9 The causes
of blindness were identical to the NPCB9 data when cataract
was excluded.
Impact of blindness
Depressionwas present in 68% of subjects inour study,
comparable to other studies which have reported between
26.4% and 90%.2‑4,8,17TheaverageBDIscorewashigherthanin
other studies2 indicating that depression was more severe. The
BDIscoreswereidenticalinbothgendersasalsoobservedina
study by Hayman.18Depressionwasmorecommonintheolder
individuals, although its severity was greater in the younger age
groups. Visual impairment in working adults is known to lower
levels of mental health.19 The presence and severity of depression
did not correlate with the duration of blindness. “Blindness
reaction” has been likened to “grief,” in which patients “mourn”
the loss of a sighted self.20 An initial denial followed by gradual
acceptance may account for depression in short duration of
blindness whereas the feeling of loss, isolation, dependence,
loneliness and incompetence may account for depression in
long‑term blindness. In our study, factors such as financial stress,
loss of job, strained social and family life may have aggravated
depression. In the current study, approximately a third of the
participants perceived their eyes as “deformed” and had ocular
pain. These factors may have further intensified the depression.
Despitethehighproportionofdepression,thechange‑readiness
scores were low and only one‑third expressed change‑readiness
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Figure 6: 0 and 10 “change‑readiness” scores
Table 1: Reasons quoted for low and high “change‑readiness”
scores
Reasons for low change‑
readiness
Reasons for high change‑
readiness
For psychiatric management
Need to depend for
consultation
Want to get relieved of depression
Need for assistance To improve their relationship with
family members
Need for vehicle To regain confidence
Not aware of depressive
symptoms
To live a better life
Taboo associated Pharmacotherapy is convenient
than counseling
Financial burden
Poor accessibility
Not interested
Poor acceptability
For change of job and vocational
training
Not acceptable To improve financial condition of
family
Presence of tremors due to
old age
To earn respectfully
Don’t have artistic skill To keep occupied
Learning is difficult in old age To overcome the problems posed by
the present job due to poor vision
Not interested in art To become independent financially
For blind aids, low vision aids
and learning Braille
Feel embarrassed using white
cane
Low vision gave hopes of regaining
lost vision
Restricted indoors and hence
don’t need white cane
White cane will enable them to walk
and cross roads without assistance
Braille is new and may be
difficult to learn
White cane will ensure safety while
walking at night and when there is
no assistance
Learning is difficult in old age White cane will protect from street
dogs
Braille learning may be
sophisticated and expensive
Males comprised a greater proportion of the blind in our study
in contrast to other data.13,14 The hospital‑based study design
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Shetty and Kulkarni: Are we Turning a Blind Eye Toward the Blind?
Middle East African Journal of Ophthalmology, Volume 21, Number 2, April - June 2014 163
for psychiatric management. Reasons quoted for low awareness
suggested poor motivation, dependence on family and the taboo
associated with psychiatric problems.
Vision is a major determinant of virtually any profession.
Traditionally, males are the bread earners for the family;
commensurate occupation was perceived to be affected
significantly greater in males. Most of the blind were unemployed,
the findings being similar to a report which stated that 25%
retired or changed to part‑time jobs after the onset of visual
impairment.5 A Nigerian report states that lack of education and
inadequate rehabilitation services turned the blind into street
beggars.8 None of our study participants had resorted to begging
probably due to the support offered by the family, whereas
beggary is indeed a form of profession adopted by many beggars
in India, as seen in temples, railways and public areas, although
no statistical data is available. Factors forcing the blind to resort
to beggary may have a contribution from the socio‑economic
status and the rehabilitation measures provided to them.
Despitethe finding that more than halfof the blind were
unemployed, change‑readiness for vocational rehabilitation
and change of the job was low. Males were more change‑ready
for the same likely due to the increasing financial constraints.
Furthermore, learning handicrafts and art needs some level of
motor skills and patience, which the blind participants perceived
to be lacking in themselves.
Blindness has a negative impact on personal relationships.
Separation from a committed relationship was seen in 50% of
visually impaired.6 In our study, 22% felt that family relations
were strained although none was separated from a committed
relationship. This possibly reflects a strong tendency for family
bonding. However, stress in the family members cannot be ruled
out as reported in a study that 35.4% of caregivers of the blind
were identified to be at risk for depression.7
Two‑thirds indicated that social life was affected. The stigma and
limitations associated with blindness may result in social neglect
of the blind. This is identical to the findings from other studies
that 53% of the visually impaired participants experienced
restrictions in socializing21 and 39.5% stopped participating in
leisure activities.5
Willingness for low vision aids was better than for other
rehabilitation measures. This is understandable because low
vision aid is the only rehabilitation measure, which offers a
chance of regaining vision. Horowitz et al.22 proposed that
optical devices optimize residual vision and thus allow for
greater continuity in the way tasks are accomplished, whereas
blind aids involve learning new methods to compensate for the
lost functions and thus is not as desirable either functionally
or psychologically. Similarly, in our study, willingness to use
blind aids such as a white cane was low and met with barriers
including embarrassment and stigma. Willingness to learn Braille
was the least as many were unaware of Braille and they found
it sophisticated and difficult.
The awareness about blind rehabilitation in Canada was 71%
and 81% had participated in low vision rehabilitation.23 In the
United States, the proportion of employment among the blind
is as high as 90% in Braille literates and is as low as 33% in the
Braille illiterate.24 The inclination of the blind for rehabilitation
in this study is poor as is expected in a developing country
where rehabilitation centers are few, education level low and
socio‑cultural barriers rampant despite the high magnitude of
blindness.
In stark contrast to the Nigerian study,8 where many blind
ended up as street beggars, there have been “blind achievers”
in various fields including sports.25 The blind population should
follow examples of Indian blind achievers like blind chess
players trained by the All India chess federation for the blind,26
blind Indian musicians like Ravindra Jain and the black concert
group, social workers and many others. The success of the blind
achievers indicates that an overall development of the blind is
possible although, only through a planned strategy.
The reasons quoted for high change‑readiness scores indicated
good motivation and enthusiasm to improve their living condition
and the reasons for poor change‑readiness indicate barriers to
effective blind rehabilitation. These factors can be used as a
“guide” in planning and implementing blind rehabilitation
programs. The most valuable factor noted in our study was
the strong family support and bonding. This attribute should
act as a scaffold on which the blind persons can take steps for
rehabilitation.
CONCLUSION
Blindness not only affects visual perception, but is also likely to
cause depression, affect family and social life, occupation and
mobility. The NPCB in India should focus on empowering the
blind by extending blind rehabilitation services to encompass all
the blind in India. Centers offering blind rehabilitation facilities
need increased visibility, funding and promotion so that their
facilities may be extended to all the individuals with irreversible
blindness. There is a need to identify residual functional vision in
ever y blind person and help transform this into their strength using
appropriate low vision devices. Hospitals and ophthalmologists
need to treat the “blind person” and not the “blind eye”
through a multidisciplinary approach. Coordination with other
centers namely, low vision centers, vocational training centers,
motility centers, psychiatry department, psychology department,
medico‑social workers, etc., should become a routine practice in
the management of the blind. A general awareness of blindness,
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Shetty and Kulkarni: Are we Turning a Blind Eye Toward the Blind?
164 Middle East African Journal of Ophthalmology, Volume 21, Number 2, April - June 2014
its impact on the person, family and society and the need for
rehabilitation should be imparted in the general population.
Social issues such as taboos should be addressed. The proactive
involvement of the family members in the rehabilitation of the
blind should be emphasized and internalized so that it becomes
effortless to make a blind individual an independent motivated
achiever. Change‑management is what the blind needs and
change‑readiness is poor. Are we turning a blind eye toward the
blind? The onus of responsibility rests on the shoulders of the
health policy makers, rehabilitation centers, hospitals.
ACKNOWLEDGMENTS
The authors acknowledge the support of ICMR STS program for the
encouragement and financial support and also thank to Ms. Neevan,
Yenepoya University for helping with the statistical analysis.
REFERENCES
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Cite this article as: Shetty R, Kulkarni UD. Change-readiness of the blind:
A hospital based study in a coastal town of South India. Middle East Afr J
Ophthalmol 2014;21:158-64.
Source of Support: ICMR STS program 2011 in the form of stipend to the
student for conducting the research , Conict of Interest: None declared.
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