In this study we examined factors associated with discussing depression and anxiety in visually impaired and blind adults by LVS workers. All participants believed detection of mental health is part of their job and often recognized symptoms of depression and anxiety. Many LVS workers discussed client’s feelings, but information was less often provided and only a few used a screening instrument. LVS workers that were male, had lower levels of education, did not intend to discuss mental health, experienced lower self-efficacy and lower social influence within their organization were less likely to discuss mental health.
Findings suggest that LVS workers are aware of symptoms of mental health problems. Almost all symptoms were recognized by LVS workers as part of depression or anxiety. However, symptoms were also linked to being visually impaired and similar findings are found in eye health professionals . This seems a reasonable response, since some mental health symptoms, such as fatigue or decrease of social activities , are also specifically associated with being visually impaired [26, 27]. However, this might complicate attribution of symptoms and could result in overlooking them. Training and standardized use of a screening instrument could help LVS workers to accurately identify depression and anxiety in their clients. While different screening instruments can be used for this purpose, the Patient Health Questionnaire (PHQ)-4 would be a good choice, since it is a short questionnaire to screen for depression and anxiety , can be used by healthcare providers without training in psychiatry , and is feasible for use in LVS organizations .
LVS workers often addressed mental health problems by reporting or discussing concerns or client’s feelings. Discussing client’s feelings seems an important first step in management of depression and anxiety, since clients get the opportunity to open up about possible mental health problems. Still, one in five LVS workers often did not discuss suspected mental health problems, and might not meet the needs of visually impaired and blind adults to receive information about mental health problems and support options from their healthcare providers . Only a quarter of the LVS workers often provided verbal information about mental health problems, and almost none of them often provided written information, which can be adapted for their clients by using e.g. Braille, large print. Providing information about depression or anxiety can improve the mental health literacy of clients, resulting in a well-informed client who can make health decisions , such as following-up on referrals to general practitioners and psychologists. Encouraging LVS workers to address client’s mental health could be strengthened by teaching additional depression and anxiety management strategies to improve quality of their mental health support.
Increasing LVS workers’ intention to discuss mental health, their self-efficacy and social support in their workspace seems to increase their likelihood of discussing mental health with clients. This might be the result of mental health not being the main focus of care in LVS organizations, and healthcare providers experiencing barriers in managing mental health problems, such as lack of knowledge, clients’ reluctance to discuss mental health and clients not expecting healthcare providers to discuss mental health problems [13,14,15]. Higher levels of self-efficacy might overcome these barriers, since LVS workers may then feel more competent to discuss their concerns, even in reluctant or denying clients. Low self-efficacy may be caused by lack of experience in depression and anxiety management. LVS workers might fear their incompetence resulting in discomfort in clients or even deteriorating client’s mental health; barriers previously reported by eye care practitioners . Healthcare providers might report a need of proper training in managing mental health [14, 15, 25], while they do not encounter such situations on a daily basis, and self-efficacy can be enhanced by experiencing successful outcomes in discussing mental health .
Results also suggest that LVS workers are encouraged to provide non-vision related care by perceived social influence within their organization. Knowing that colleagues are discussing mental health as well, might reduce feelings of inappropriateness , and might encourage LVS workers to ask their colleagues for help. The effect of social influence on healthcare providers’ behavior is illustrated in social norm interventions. Within these interventions healthcare providers are exposed to values, beliefs, attitudes or behaviors of other healthcare providers and it demonstrates improvement in their clinical behavior . According to the I-Change model, LVS workers’ intention to discuss mental health problems is affected by their perceived social influence and self-efficacy . LVS workers that intend to discuss their concerns about symptoms of depression or anxiety might discuss client’s feelings and invite clients to discuss mental health problems as an opportunity to subsequently express their own concerns. Altogether, an organization where discussing mental health is part of their care, and training in depression and anxiety management is provided, seems to create a work environment where LVS workers can overcome perceived barriers and address mental health problems more often.
Implications for clinical practice
LVS organizations could facilitate LVS workers to discuss mental health by creating a working environment that also focusses on client’s mental health. They should incorporate detection and support for mental health problems into their care policy and regulations, introduce screening as a standard procedure, employ psychologists, and implement evidence-based treatment for depression and anxiety, such as stepped-care . Especially in health care systems where referrals or access to specialists are not feasible.
Moreover, a training in discussing mental health problems could be introduced. Previous depression training in Wales and Australia showed positive results [32, 34]. Existing educational programs could be further developed by including recent insights in the client’s perspective , and by addressing LVS workers’ self-efficacy, perceived social influence and intention to discuss mental health. Training LVS workers in discussing mental health with clients and them experiencing successful outcomes in their own behavior enhances self-efficacy . Furthermore, principles of social norm interventions could be used, including professional supervision, in which perceived social influence can be increased by improving the working environment with better teamwork and more support from within the organization [33, 35]. Improving LVS workers’ self-efficacy and perceived social influence might result in a higher intention to discuss mental health . Trainers might include goal setting, a common feature of behavior change interventions , to help LVS workers to set goals and develop an action plan to discuss mental health. Moreover, LVS workers should be stimulated to think about specific moments when they want to discuss mental health with their clients, also called "if–then plans" to promote their intention to reach their goals . Altogether, a training could consist of an e-learning to share knowledge about depression and anxiety and support options, a meeting to practice discussing mental health problems, and a session to share and discuss experiences in practice.
Strengths and limitations
Our study has uncovered predictors in depression and anxiety management in LVS workers, while previous studies mainly focused on eye care practitioners and depression management. Findings suggest that anxiety and depression management are comparable, and previous studies on depression might be transferable to anxiety. Use of the I-Change model as a theoretical framework helped to delineate potential predictors. While we were unable to perform IRT-analyses (Additional file 2), we could rely on classical test theory and additional measures to ensure psychometric properties of the questionnaire. However, results should be interpreted with caution since these are based on cross-sectional data, and therefore it is impossible to deduce the causality between the predictors and outcome. Moreover, participants might have had more interest in mental health than non-responders, which seems to be reflected in all participants experiencing detection of mental health as part of their job. This indicates a possible risk of selection bias.
This study lacked external validation of the model, but future studies could examine generalizability of the model in other healthcare providers working with adults with VI. In-depth studies could further explore potential mechanisms between found predictors and discussion of mental health by LVS workers. For example, knowing the impact of specific client characteristics in LVS workers’ approaches, contributes to the development of specific guidelines. Moreover, it is still unclear how often mental health problems are recognized and discussed in adults with VI, what external factors (e.g. information resources and referral options) affect discussion of mental health problems, and how LVS workers can be encouraged to use other depression and anxiety management strategies, such as providing information about mental health. Other beneficial future work lies in investigating how discussions about mental health are managed by LVS workers, and subsequently client’s experiences. Future research into these subjects could help us to better understand and improve current practice.