Exploring the patient perspective of fatigue in adults with visual impairment: a qualitative study

Usability and feasibility of E-nergEYEze: a blended vision-specific E-health based cognitive behavioral therapy and self-management intervention to reduce fatigue in adults with visual impairment

BACKGROUND

Over 50% of adults with visual impairment experience severe fatigue. Therefore, we developed a guided E-health intervention based on cognitive behavioral therapy and self-management to reduce fatigue in this population. This pilot study evaluated the usability, feasibility, fidelity and potential effectiveness of E-nergEYEze.

METHODS

E-nergEYEze was developed by a design team and customized by conducting a pilot study using an iterative development strategy. The intervention was first tested in a usability study among adults with visual impairment (n = 5). Participants were asked to think-aloud while exploring the intervention features and a semi-structured interview was performed afterwards. Subsequently, the enhanced intervention was tested in a feasibility study. Adults with visual impairment and severe fatigue (n = 10) followed the intervention partially with guidance from a social worker and one-time computer trainer support. Fatigue severity (Checklist Individual Strength), fatigue impact (Modified Fatigue Impact Scale) and cognitive behavioral therapy skills (Competencies of Cognitive Therapy Scale-Self Report) were measured at baseline and at three months follow-up and analyzed with the Wilcoxon signed-rank test. The intervention was evaluated through evaluation forms.

RESULTS

The usability study resulted in adjustments to content and lay-out with regard to optically shortened text sentences, separate pages for information and assignments with one read-aloud audio and an additional descriptive explanation of page content. Digital challenges were overcome with mandatory computer training and e-platform modifications. The feasibility study showed a positive trend in reducing fatigue severity (Z -6.108; P < .001; SD 8.4), impact of fatigue (Z - 4.451; P < .001; SD 11.4) and cognitive behavioral therapy skills (Z -2.278; P = .023; SD 19.3). Participants gave useful feedback regarding accessibility, content and guidance, with an overall positive experience. The intervention was rated with a median score of 8 (range 7-10).

CONCLUSION

We developed, evaluated and optimized E-nergEYEze by applying a user-centered and iterative approach. E-nergEYEze showed a promising trend to reduce fatigue severity and impact of fatigue and to increase cognitive behavioral therapy skills. The study methods were feasible and the fidelity of the intervention protocol was suitable. Performing a randomized controlled trial is warranted to give insight into whether E-nergEYEze is cost-effective in reducing severe fatigue in adults with visual impairment.

TRIAL REGISTRATION

International Clinical Trial Registry Platform: NL7764. Date registered: 28-05-2019.

The Roles of Stress, Sleep, and Fatigue on Depression in People with Visual Impairments

The study aimed to investigate the mediating effect of fatigue and the moderating effect of sleep quality on stress and depressive symptoms among people with visual impairments. A total of 155 participants completed the online survey. The Perceived Stress Scale, the Fatigue Symptom Inventory, the Centre for Epidemiological Studies-Depression Inventory (CES-D), and the Pittsburgh Sleep Quality Index (PSQI) were used. Descriptive analysis, correlations, and moderated mediation modelling were conducted using R software. From the mediator variable (FSI) model (F = 22.427, R2 = 56.5, p < .001) and the dependent variable (CES-D) model (F = 35.912, R2 = 70.5, p < .001), after controlling for age, sex, employment, and education, sleep quality positively predicted fatigue levels (β = 2.422, p = .009), and fatigue positively predicted depressive symptoms (β = .152, p < .001). Sleep quality is an essential component of psychological well-being in people with visual impairments.

Experiences of people with dual sensory loss in various areas of life: A qualitative study

Individuals with dual sensory loss (DSL) appear to have limited ability to compensate for their visual impairment with residual hearing, or for their hearing impairment with residual vision, resulting in challenges in various areas of life. The aim of this qualitative study was to explore the diverse experiences facing individuals with DSL as well as to determine how they experience sensory compensation. Semi-structured interviews were carried out in twenty adults with DSL (13 females and 7 males, mean age 47 years). The causes of DSL severity varied amongst participants. Sensory compensation and experiences in regards to access to information, mobility, communication and fatigue were discussed. Interviews were audio recorded and transcribed verbatim. Framework analysis was used to summarize and interpret the data. In relation to access to information, our results show that, despite various challenges, the use of assistive technology such as voice command functions, enabled participants to operate effectively. Regarding mobility, most participants were capable of finding their way in familiar environments. However, if the setting was unfamiliar, assistance from others or reliance on navigation applications was necessary. Participants experienced little issues with having conversations in quiet settings, however, crowded settings were considered very difficult. The final results showed that most participants suffered from fatigue. Carefully considering which daily activities were feasible and having a daily routine helped to cope with fatigue. This study revealed the experiences of individuals with DSL in important areas of life. The results suggest that, even though many challenges are experienced, individuals with DSL are resourceful in finding compensation strategies. However, capturing participants' sensory compensation experiences was challenging.

E-nergEYEze, a vision-specific eHealth intervention based on cognitive behavioral therapy and self-management to reduce fatigue in adults with visual impairment: study protocol for a randomized controlled trial

Background

More than half of the adults with visual impairment experience severe symptoms of fatigue, with a negative impact on daily life. Since there is no evidence-based treatment to reduce fatigue in adults with visual impairment, we developed E-nergEYEze, an eHealth intervention based on cognitive behavioral therapy and self-management tailored to the needs of visually impaired adults. The aim is to describe the study protocol of a randomized controlled trial testing E-nergEYEze.

Methods

A randomized controlled trial will be conducted to investigate the cost-effectiveness and cost-utility of E-nergEYEze to reduce fatigue severity compared to care as usual from a healthcare and societal perspective. A total of 172 severely fatigued adults with visual impairment will be recruited and randomized to either the E-nergEYEze intervention plus care as usual or to care as usual only (ratio 1:1). Inclusion criteria are having a visual impairment, experiencing severe fatigue (Checklist Individual Strength – subscale Fatigue Severity: CIS-FS > 35), being 18 years or older, understanding the Dutch language, and having access to the internet. The intervention consists of one face-to-face session and a computer training followed by internet-based modules with information and assignments on coping with fatigue. During this 5-month intervention, participants will be digitally supported by a social worker. All measurements will be administered at baseline, after 6 and 12 months, and additionally, those related to cost-effectiveness at 3 and 9 months. The primary outcome is fatigue severity (CIS-FS).

Discussion

Severe fatigue on top of visual impairment compromises quality of life and is associated with incremental societal costs that largely determine the economic burden of low vision or blindness. E-nergEYEze contributes to the evidence base of potentially feasible interventions to reduce the important health-related consequences of vision loss and could fulfill the gap in knowledge, skills and treatment options for low vision services.

Trial registration

Dutch Trial Register NTR7764. Registered on 28 May 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05935-w.

The association between visual impairment and fatigue: a systematic review and meta-analysis of observational studies

PURPOSE

The aim was to compare fatigue levels between patients with visual impairment and controls with normal sight and to examine the association between fatigue and vision loss severity.

METHODS

A systematic literature search was performed using databases of PubMed, Embase, PsycINFO and Cochrane to identify observational studies with outcomes related to fatigue (e.g. vitality subscale of the Short-Form 36, Fatigue Assessment Scale). A meta-analysis was performed using standardised mean differences (SMDs) and odds ratios (OR) to quantitatively summarise the association between visual impairment and fatigue. Sources of heterogeneity were explored by subgroup and sensitivity analyses. Study quality was assessed with the Newcastle-Ottawa scale.

RESULTS

After reviewing 4477 studies, 22 studies with a total of 40 004 participants were included, of which 18 contributed to meta-analysis. Among these, eight were assessed as moderate quality studies and 10 as high quality studies. Pooled analysis involving 2500 patients and 8395 controls showed higher fatigue severity levels (S.M.D. = -0.36, 95% CI -0.50 to -0.22, 14 studies) among visually impaired patients compared to normally sighted controls. This effect size was small and persisted in sensitivity analyses that involved study quality, fatigue assessment tools and visual acuity data. Furthermore, pooled analysis of four studies including 2615 patients and 5438 controls showed a significant association between visual impairment and fatigue (OR = 2.61, 95% CI 1.69 to 4.04). Secondary meta-analysis of four studies showed no significant difference in fatigue severity (S.M.D. = 0.01, 95% CI -0.37 to 0.39) between patients with moderate visual impairment and patients with severe visual impairment or blindness.

CONCLUSIONS

Current moderate to high quality evidence suggest that patients with visual impairment experience more severe fatigue symptoms than persons with normal sight. However, a limited number of available studies indicates that fatigue is not associated with severity of vision loss. Future studies are required to determine which factors and underlying mechanisms may explain the association between visual impairment and fatigue. Discussing fatigue at an early stage and developing intervention options for vision-related fatigue should be considered within the field of low vision rehabilitation.

Understanding fatigue in adults with visual impairment: A path analysis study of sociodemographic, psychological and health-related factors

Background

Fatigue is a disabling problem in patients with visual impairment, but its etiology is still poorly understood. Our objective was to identify the determinants of fatigue in adults with visual impairment compared to adults with normal sight.

Methods

Cross-sectional data on fatigue and sociodemographic, psychological and health-related factors was obtained with validated questionnaires. Structural equational modeling using hypothesized relationships and explorative analyses were used to identify (in)direct pathways contributing to fatigue in 247 adults with visual impairment. The model was then tested in a reference group of 151 adults with normal sight.

Results

The final model explained 64% of fatigue variance in participants with visual impairment and revealed the following factors to be directly associated with fatigue: depressive symptoms (β = 0.723, p<0.001), perceived health (β = -0.158, p = 0.004), accommodative coping (β = 0.116, p = 0.030) and somatic comorbidity (β = 0.311, p = 0.001). Self-efficacy demonstrated a beneficial indirect effect on fatigue (β = -0.228, p<0.001) mediated by depression, accommodative coping and perceived health. Sleep disorder had an indirect effect on fatigue (β = 0.656, p<0.001) mediated by depression and perceived health. After removal of sleep disorder, the model explained 58% of the fatigue variance in normally sighted adults but pathways involving accommodative coping and somatic comorbidity were not confirmed.

Conclusions

These findings suggest that depression and perceived health are important mediating factors that contribute to fatigue in persons with visual impairment and normal sight. In contrast, somatic comorbidity, sleep disorders and accommodative coping seem to have a specific contribution to vision-related fatigue. These factors should be addressed in interventions to assist individuals with visual impairment in dealing with fatigue.

The Eysenck Personality Profile in Selected Groups of Ophthalmological Patients

Personality correlates in patients with eye diseases have bidirectional influence. It is possible that personality variables lead to behaviours that may influence the cause of eye problems, but the opposite is also possible, that eye problems could have a direct effect on personality. The aim of this study was to evaluate personality traits in patients with glaucoma, diabetic retinopathy and cataract using the Eysenck Personality Questionnaire. Obtained results showed similar personality profiles in patients with glaucoma, diabetic retinopathy and cataract. However, extraversion and neuroticism were higher in patients with diabetes, while the psychopathic traits are the highest in the group of cataract. Age and gender of patients do not influence the scores obtained on the questionnaire confirmed with one way ANOVA. Not significant difference in parameters (tested with Student t-test) was obtained between groups. It is proposed psychological evaluation to be included in the assessment of more serious eye diseases for helping patients to adjust and adapt to the condition and treatment.

Subjective and Objective Measures of Daytime Activity and Sleep Disturbance in Retinitis Pigmentosa

SIGNIFICANCE

Objectively measured limitations in daytime activity levels appear to be inextricably linked with sleep disturbances in retinitis pigmentosa (RP) patients, as well as associated with unemployment status and central vision loss. Innovative interventional strategies should be developed to help improve these issues and overall quality of life for RP patients.

PURPOSE

Novel sensor devices are emerging as valuable tools to objectively assess behavior. We used validated measures of wrist accelerometry to determine relationships between sleep, vision, and physical activity in RP subjects.

METHODS

For one week, 33 RP adults wore a wrist Actiwatch to detect movement during the day (average total activity counts) and disturbed sleep at night. They completed Early Treatment Diabetic Retinopathy Study visual acuity testing, Pelli-Robson contrast sensitivity, Goldmann V4e visual fields, and sleep diaries and validated questionnaires to assess their sleep and general health.

RESULTS

Greater wake after sleep onset time measured with actigraphy (i.e., sleep disruption) (P = .01), loss of visual acuity (P = .009), and nonemployment/student status (P = .002) were all significant predictors of reduced daytime average total activity counts in a multiple linear regression model, after adjusting for contrast sensitivity as a cooperative suppressor variable (P = .01) (R = 0.54). Fragmentation measured with actigraphy (i.e., restlessness during sleep) (P = .07) and decreased sleep quality ratings reported upon awakening by the participants in a sleep diary (P = .06) were each marginally associated with reduced daytime average total activity counts, whereas nonemployment/student status, reduced visual acuity, and contrast sensitivity were still significant predictors. Objective and subjective measures of sleep or daytime activity were not statistically significantly correlated (P > .05).

CONCLUSIONS

We find nonemployment/student status and sleep disturbances appear to be related to reduced daytime activity levels in adults with central vision loss due to RP. These findings underscore the importance of developing and evaluating interventions to help RP patients maintain engagement in productive activities and improve their disturbed sleep.

Systematic review and meta-synthesis of coping with retinitis pigmentosa: implications for improving quality of life

BACKGROUND

Retinitis pigmentosa (RP) are a group of incurable and inherited eye conditions, and the leading cause of inherited blindness in people under the age of 60. The aim of this systematic review and meta-synthesis was to present a comprehensive overview of qualitative papers on experiences and coping strategies of adults living with RP, and how these influence quality of life.

METHODS

A pre-registered search strategy was applied in nine databases and 12 articles met eligibility criteria. Studies included were from Australia, Brazil, Ireland, Netherlands, Republic of Korea, United Kingdom, and USA. The overall sample was based on 126 people with RP (ages ranging from 18 to 85; at least 65 female). Principles of meta-ethnography were used to synthesise the articles revealing five higher-level meta-themes.

RESULTS

The five higher-level meta-themes were, 1) managing identity: making sense of RP, managing autonomy and independence; 2) living with RP: practical and emotional issues; 3) experiences with healthcare professionals and other social support; 4) adaptive and maladaptive coping strategies; and 5) impact of RP on work and career. A conceptual model was developed by grouping higher-level meta-themes as intra- and inter-individual factors and how they may be implicated with coping strategies and quality of life.

CONCLUSIONS

This review established factors that can be explored as potential psychosocial influences in the relationship between coping strategies and quality of life in people with RP. Further understanding of these factors and mechanisms can help inform intervention development to support adaptive coping in living with RP and positively impact quality of life.