Occupational priorities and needs of blind and partially sighted people entering the labor market in Slovenia

Abstract

BACKGROUND:

People with vision impairment are a growing group of clients for occupational therapists, particularly those working in vocational rehabilitation.

OBJECTIVE:

To examine the occupational priorities and performance issues of blind and partially sighted people entering vocational rehabilitation in Slovenia. Possible differences between priorities and issues among diagnostic groups and in relation to the rehabilitation outcome were explored.

METHODS:

Records of 42 clients referred to vocational rehabilitation at the University Rehabilitation Institute in Ljubljana between 2007 and 2019 were reviewed. Information on self-perceived occupational priorities and issues was obtained from the Canadian Occupational Performance Measure (COPM).

RESULTS:

Household and other unpaid work was identified the most frequently (20%) as a priority, followed by job-seeking (19%) and community mobility (15%). Job-seeking was the top performance issue (43%), followed by community mobility (21%) and household management (19%). On the 1–10 scale, the average occupational performance and satisfaction scores were 6.7 and 6.5, respectively; no statistically significant differences in relation to the diagnosis or the rehabilitation outcome were observed.

CONCLUSION:

The results highlight the client-identified occupational priorities and issues beside job-seeking that need to be considered in planning occupational therapy and supporting the persons with visual impairments entering the labor market.

Keywords

Vision impairment occupational therapy Canadian occupational performance measure

1 Introduction

Like other groups of persons with disabilities, blind and partially sighted persons are also facing barriers when entering the labor market. Statistical data from various countries confirm a high rate of unemployment and substantially lower representation of blind and partially sighted in the labor force [1, 2]. For example, in the USA, where the general rate of employment is 79%, only 44% of blind and partially sighted persons on the labor market are estimated to be employed [3]. Similarly, in Great Britain only a 45% employment rate was observed among that group between 2012 and 2015 [4]. Official data on the population size or the level of employment of blind and partially sighted persons in Slovenia are not available. Estimates based on international comparisons suggest the prevalence to be 0.051% in children up to 15 years, 0.15% among adults aged 15–50 years, and 1.2% for those above 50 years [5]. The Slovenian Association of Blind and Partially Sighted reported an approximate 20% employment rate among its members in 2012, but that does not include all working-age people with visual impairments [6].

Employment of blind and partially sighted persons is influenced by a variety of factors – those that cannot be modified, such as the level of vision loss, age or gender, and factors that can be influenced, especially skills in using communication technology, behavior, mobility, responsibility, and level of education [7], but also acceptance and optimism [8]. Employment possibilities can also depend on environmental factors, such as specialized education, life context, place of residence, accessibility, and the attitude of the work environment [7]. Accessibility and the contents of the support programs, including vocational rehabilitation, also contribute to the employment [9, 10]. Probability of employment increases with providing support already during the education, primarily learning and development of general skills (punctuality, behavior, communication) and providing the conditions for independent living (including transport). These are followed by support in job seeking and preparation mainly through on-the-job training, which increases the possibilities of job retention [9]. Bell and Mino [10] also emphasize that for blind and partially sighted persons, regular use of the white cane and reading Braille is crucial for successful work integration.

The support for persons with disabilities, including blind and partially sighted, who are entering employment in Slovenia is provided by the vocational rehabilitation program [11, 12]. Within the national network of vocational rehabilitation providers, the University Rehabilitation Institute in Ljubljana supports blind and partially sighted persons entering employment from the whole country [13]. Support is provided by an interdisciplinary team composed of a physician, psychologist, social worker, occupational therapist, technologist, and a specialist teacher for blind and partially sighted [14]. Within this program, the occupational therapist focuses on supporting the clients in developing independent, safe, efficient, and persistent performance of everyday occupations, with the aim of enabling work participation [6]. This includes the assessment of occupational needs, planning of the on-the-job training and making adaptations in the work environment [15]. Occupational therapy follows the process from initial assessment through the intervention to measuring the outcomes. In the first steps of this process, understanding the occupational priorities and issues is crucial [16].

Occupational therapists have been intensely engaged in treatment of blind and partially sighted people for the last twenty years, mostly because of the increasing number of visual impairments among persons referred to occupational therapy, especially older adults [17]. This has presented a new challenge for occupational therapists in relation to specific knowledge about vision impairments and their impact on occupational performance [18]. Because most of the few occupational therapy studies on understanding occupational performance of blind and partially sighted persons have been conducted with older people after the retirement [19, 20], their findings do not reflect the needs of working-age people with visual impairment entering the labor market. Only one study explored the occupational performance challenges of the youth (15–22 years of age) with visual impairment [21] participating in a rehabilitation program. It was a qualitative study that used the Canadian Occupational Performance Measure (COPM) to gather information. The most frequently described challenges were in mobility, domestic life, interpersonal interaction and relationships, major life areas, and leisure activities. The findings of the study emphasized the importance of using an individualized approach, including subjective measures in assessment of participation challenges, for this client group [21].

We could not find other occupational therapy studies on occupational performance of blind and partially sighted persons when entering the labor market. Hence, the aim of our study was to explore how persons who are blind or partially sighted describe their occupational priorities and challenges at the beginning of a vocational rehabilitation program. The following research questions were asked:

Which occupations do the blind and partially sighted persons find most important when starting vocational rehabilitation?

Which occupations do they most often find challenging?

Which occupations are the most challenging and with the performance of which are they least satisfied?

Are the COPM occupational performance and satisfaction scores associated with the diagnosis or the rehabilitation outcome?

2 Methods

The study design was retrospective. We reviewed the records of 42 clients with visual impairments referred to vocational rehabilitation at the University Rehabilitation Institute in Ljubljana between 2007 and 2019 for demographic data and COPM assessments. The inclusion criterion was that the report included complete COPM assessment.

The study was approved by the Research Ethics Board of our institute (motion no. 23/2019). Personal data was anonymized in the process of data collection.

2.1 Data collection and analysis

The demographic and diagnostic information comprised age, gender, education, and the type of visual impairment (blindness or low vision). Vocational rehabilitation outcome was classified as employment, employable but unemployed, or unemployable or retired. Data on priorities, problems and satisfaction with performance in the areas of self-care, productivity and leisure were extracted from the COPM. The COPM is a structured interview and supports people in describing their problems in occupational performance. It also helps them to define the priorities as experienced by themselves. The client rates the importance of daily occupations on the 1–10 scale (10 being extremely important). After defining up to five problems, they rate their current level of performance and satisfaction with their performance on each of them. Ten-point scales are used for performance (1 meaning not able to do it at all, 10 able to do it extremely well) and satisfaction (1 meaning not at all, 10 extremely satisfied). Mean scores are obtained for satisfaction and performance, ranging from 1 to 10 [22]. The COPM is also used for planning and evaluating interdisciplinary programs, including those supporting participation of people with disabilities at work [23].

For the analysis, the occupations that the participants described were classified into performance areas of self-care, productivity and leisure (Table 1) based on the categories and examples proposed in the COPM form and manual [23]. The examples for functional mobility and functioning in the social environment were adapted for blind and partially sighted persons.

Table 1
Areas of occupations

Self -care Productivity Leisure

Personal care (hygiene, dressing etc.) Household management and other unpaid work (cooking, cleaning, taking care of children, voluntary work etc.) Participation in immediate environment (e.g., quiet recreation)

Functional mobility (environmental mobility and independence, using transportation etc.) Job seeking and paid work (on-the-job training, occasional, student work etc.) Participation in community (e.g., active recreation)

Community management (reading, writing, using ICT^* etc.) Education (formal, non-formal) Socialization

Self -care	Productivity	Leisure
Personal care (hygiene, dressing etc.)	Household management and other unpaid work (cooking, cleaning, taking care of children, voluntary work etc.)	Participation in immediate environment (e.g., quiet recreation)
Functional mobility (environmental mobility and independence, using transportation etc.)	Job seeking and paid work (on-the-job training, occasional, student work etc.)	Participation in community (e.g., active recreation)
Community management (reading, writing, using ICT^* etc.)	Education (formal, non-formal)	Socialization

^*Information communication technology (PC, phone, tablet, and other aids).

The data on priority occupations were gathered by extracting five occupations from the COPM forms that received the highest importance rating. When more than five occupations were rated with the same number, the appropriate representation of all the areas was assured.

The data on occupational performance and satisfaction with performance were gathered in two ways – in terms of frequencies of various occupations among up to five identified occupational issues, and in terms of occupations rated with the lowest score for satisfaction with performance. Average scores of performance and satisfaction for up to 5 occupational issues were also extracted from the COPM forms.

Mean ratings were compared using independent-samples t-test between two groups, or one-way analysis of variance (ANOVA) between three groups. Frequency of responses were compared between groups (either two or three) using Fisher-Freeman-Halton exact test (FFHET). Statistical analysis was performed using IBM SPSS statistics 25 (IBM Corp., Armonk, NY, USA); the significance level was set at p≤0.05.

3 Results

Among the 42 records that we reviewed, 26 belonged to female and 16 to male participants. Their average age was 32 years, ranging from 21 to 58 years. Sixteen participants were blind and 26 were partially sighted. They had mainly high-school (45%) or university-level (29%) education.

We collected 205 occupations rated as most important from the participants’ COPM forms. Table 2 shows that household and other unpaid work was the most frequently (20%) described as the most important occupation among the participants, followed by job seeking and paid work (19%). Relevance was also attributed to self-care, especially environment mobility and independence (15%) and personal care (13%).

Table 2
Priority occupations

Area Occupations Number Proportion

(n = 205) (%)

Self-care Personal care 27 13

Environment mobility and independence 31 15

Reading, writing and using ICT 3 1

Productivity Household and other unpaid work 42 20

Job seeking and paid work 38 19

Education 5 2

Leisure Quiet recreation 18 9

Active recreation 22 11

Socialization 19 9

Area	Occupations	Number	Proportion
Self-care	Personal care	27	13
	Environment mobility and independence	31	15
	Reading, writing and using ICT	3	1
Productivity	Household and other unpaid work	42	20
	Job seeking and paid work	38	19
	Education	5	2
Leisure	Quiet recreation	18	9
	Active recreation	22	11
	Socialization	19	9

Job seeking and paid work (22%), household and other unpaid work (19%), and environment mobility and independence (16%) were also among up to five occupations that the participants most frequently described as having issues to perform (Table 3).

Table 3

The most frequent occupational performance issues

Area	Occupations	Number	Proportion
		(n = 153)	(%)
self-care	Personal care	12	8
	Environment mobility and independence	24	16
	Reading, writing, and using ICT	9	6
Productivity	Household and other unpaid work	29	19
	Job seeking and paid work	34	22
	Education	3	2
Leisure	Quiet recreation	13	8
	Active recreation	18	12
	Socialization	11	7

Among all occupations, 43% of participants gave their lowest score on the 1–10 scale for performance to (i.e., found most difficult to perform) job seeking and paid work, 21% to environmental mobility and independence, and 19% to household and other paid work. At the same time, 54% of the participants were least satisfied (i.e., gave the lowest score on the 1–10 scale) with their job seeking and paid work, 21% with household and other unpaid work, and 13% with environmental mobility and independence (Table 4). The total average score of all occupations was 6.7 for performance and 6.5 for satisfaction.

Table 4

Frequency of occupations rated lowest for performance and satisfaction with performance

Area	Occupations	Most difficult performance		Lowest satisfaction with performance
		Number (n = 42)	Proportion (%)	Number (n = 39)	Proportion (%)
self-care	Personal care	0	0	0	0
	Environmental mobility and independence	9	21	5	13
	Reading, writing, and using ICT	1	2	1	3
Productivity	Household and other unpaid work	8	19	8	21
	Job seeking and paid work	18	43	21	54
	Education	1	2	1	3
Leisure	Quiet recreation	1	2	1	3
	Active recreation	2	5	1	3
	Socialization	2	5	1	3

In the COPM process, the participants described a range of occupations and activities that were classified in occupational areas as presented in Table 1. Table 5 lists the most frequent examples of the most important and difficult occupations.

Table 5

Examples of occupations and activities

Job seeking and paid work	Household and other unpaid work	Environmental mobility and independence
Job search	Children care	Shopping
Creativity – designing	Cooking	Finding a way outside home
Helping in the activities of an association	Kitchen work	Mobility outside
On-the -job training	Ironing	Using public transport
	Taking care for the flowers	Errands in the community
	Cooking and baking
	Helping at home
	Cleaning
	Tidying up
	Caring for the animals
	Helping with learning
	Gardening
	Helping parents

There was no statistically significant difference in the analyzed ratings either in relation to diagnosis (p-values 0.212–0.932 from t-test) or in relation to vocational rehabilitation outcome (p-values 0.178–0.951 from ANOVA). There was also no statistically significant difference in the frequencies of occupations with issues (p = 0.618 and p = 0.383 from FFHET in relation to diagnosis and vocational rehabilitation outcome, respectively), or in the frequencies of occupations with the lowest satisfaction with performance issues (p = 0.672 and p = 0.387 from FFHET in relation to diagnosis and vocational rehabilitation outcome, respectively).

4 Discussion

The aim of our study was to understand how blind and partially sighted persons entering the labor market describe their priorities and problems in their everyday occupations at the beginning of vocational rehabilitation. This understanding is important for planning efficient occupational therapy intervention and the entire vocational rehabilitation process. The main findings of the study show that job-seeking and paid work, household and other unpaid work, and environmental mobility and independence are the occupations that the participants described both as the priority and as the most difficult to perform.

In the COPM interview and ratings, the participants described the occupations that were important in their everyday life at the beginning of vocational rehabilitation. The impact of the importance of participation in main life areas has already been explored. Kvam et al. [24] found a positive correlation between importance of participating in work and return to work after rehabilitation for people with complex health problems, but the correlation was negative for the importance of participation in leisure and family activities. From this perspective, the high importance of work for our participants is promising. Because household and other unpaid work involve a lot of family activities (Table 5), these findings may encourage occupational therapists to explore more in-depth the importance of these occupations for their clients and their impact on seeking or participating in work [24].

Like other people with disabilities in Slovenia who are entering the labor market, the participants in our study entered the vocational rehabilitation after a long period of unemployment, usually more than one year and usually after unsuccessful job seeking on their own [14]. In a study on how people with visual impairments perceived their employment possibilities, Donaldson [1] emphasized that negative experience, especially refusals, lead to discouragement and reduce the interest for seeking employment. The importance of household and other unpaid work for the participants in our study can therefore be understood as a way of creating meaning in everyday life. One of the basic beliefs in occupational therapy is namely that people create meaning in their lives through the participation in meaningful occupations and related roles. Occupations are meaningful when they have personal meaning, are relevant and based on experience [25, 26]. When people are excluded from work for a prolonged time or unemployed, other, more accessible occupations may become more important because they enable creating meaning in adverse circumstances [24] and feeling of efficacy and control in life [25, 26].

Job seeking and paid work, household and other unpaid work, and environmental mobility and independence were the most difficult to perform from the participants’ perspective, and they were also least satisfied with their performance in those areas. These results are consistent with the findings of published studies on the impact of problems in performance of daily occupations on the employment possibilities of persons with visual impairments. Problems in job seeking and mobility, including using public transport and white cane, have often been described as barriers and predictive factors in relation to their employment [1 , 27]. For blind and partially sighted persons and for people with other disabilities who are starting to work, published research also emphasizes the importance of participating in other occupations, such as taking care for the home and family [21 , 28]. Muschalla et al. [28] found that unemployed persons described substantially greater barriers to occupational participation in all life areas, not only work, therefore suggesting that return-to-work intervention should address all life domains. In addition, for the group of young adults transitioning from school to work, Elsman et al. [29] found that visual impairment does not only influence participation in work but also independent living, mobility, social skills and relations, and different leisure activities. The findings of our and previous research thus provide insight into occupational areas in which people with visual impairments need to be supported by rehabilitation professionals, including occupational therapists. They especially need support in job-search skills, independent and safe transportation to and from work, learning compensatory strategies of task performance in different contexts, and training in using specialized information and communication technology (ICT) [1 , 27]. Working with employers is also crucial for developing employment possibilities for people with visual impairments [30, 31]. Enabling more efficient and satisfying performance in all life areas also contributes to better occupational balance [32].

The information on occupational priorities and needs of blind and partially sighted persons gathered using the COPM may contribute to understanding the level of their preparedness for employment also from the perspective of the meaning and importance of work [33]. In developing an occupational therapy and vocational rehabilitation plan, the COPM can be used in combination with other measures. Shaw and Gold [34] developed the Tool to Assess Preparedness for Employment (TAPE) for blind and partially sighted based on the factors supporting employment. Several of them are congruent with occupational challenges described by the participants in our study through the COPM process, such as technology, communication, job seeking, job search strategies, access, and support.

Our findings and findings of some other studies suggest that the planning of the support for people with visual impairments who are entering the labor market should be based on understanding of the self-reported priorities and issues in performing daily occupations, not only in occupational therapy [21] but also on the level of interdisciplinary rehabilitation [1, 24]. In occupational therapy, the COPM is most often used for identifying occupational priorities and issues, which also enables a client-centered goal setting and intervention planning [35, 36].

The need to address occupational performance in all life domains, not just work, is one of the implications for occupational therapy when supporting work participation of blind and partially sighted people. In order to be competent and comfortable with providing expertise in activity analysis and restructuring, teaching alternative strategies of occupational performance, environment modification, use of adaptive devices and technology with this population [17], occupational therapists need sufficient entry-level training and opportunities for continuing education on low vision. To assure the quality of their services, it is crucial that occupational therapists work in close collaboration with low-vision specialists [37].

5 Limitations

The study was conducted on a small sample, representing approximately a third of the total number of blind or partially sighted persons participating in the vocational rehabilitation program in Slovenia. Data from a larger group could increase the generalizability of the findings. While the information gathered with the COPM provided insight in the participants’ subjective assessment of their occupational priorities and needs, a qualitative approach to research would enable a more in-depth understanding of the factors and experience influencing them. Nevertheless, the absence of differences either in the ratings or in the identified occupations with issues or lowest satisfaction with performance in relation to diagnosis as well as vocational rehabilitation outcome speaks in favor of validity of our findings.

6 Conclusions

For the blind and partially sighted persons that participated in this study, job seeking and paid work, household and other unpaid work, and community mobility were at the same time their priority occupations and occupations that they found the most difficult to perform. While high relevance of job seeking presents a promising starting point for work participation, specific support should be focused not only on job seeking but also other daily activities, especially community mobility and orientation. To provide this support to the blind and partially sighted persons, occupational therapists need specialist knowledge and have to work in collaboration with low vision specialists. The use of the COPM enables insight into occupational priorities and needs, which is crucial for setting relevant goals and planning not only within occupational therapy but also within entire interdisciplinary rehabilitation, thus supporting the blind and partially sighted persons in entering the labor market.

Conflict of interest

The authors declare no conflict of interest.

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