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Year : 2019  |  Volume : 67  |  Issue : 5  |  Page : 669-676

Coping strategy in persons with low vision or blindness – an exploratory study

Department of Ophthalmology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi - 95, India

Date of Submission01-Oct-2018
Date of Acceptance07-Jan-2019
Date of Web Publication22-Apr-2019

Correspondence Address:
Dr. Upreet Dhaliwal
A-61, Govindpuram, Ghaziabad - 201 002, UP
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1655_18

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Purpose: Coping strategies employed by people with visual disability can influence their quality of life (QoL). We aimed to assess coping in patients with low vision or blindness. Methods: In this descriptive cross sectional study, 60 patients (25–65 years) with <6/18 best-corrected vision (BCVA) in the better eye and vision loss since ≥6 months were recruited after the institutional ethics clearance and written informed consent. Age, gender, presence of other chronic illness, BCVA, coping strategies (Proactive Coping Inventory, Hindi version), and vision-related quality of life (VRQoL; Hindi version of IND-VFQ33) were recorded. Range, mean (standard deviation) for continuous and proportion for categorical variables. Pearson correlation looked at how coping varied with age and with VRQoL. The analysis of variance (ANOVA) and t-test compared coping scores across categorical variables. Statistical significance was taken at P < 0.05. Results: Sixty patients fulfilled inclusion criteria. There were 33 (55%) women; 25 (41.7%) had low vision, 5 (8.3%) had economic blindness, and 30 (50.0%) had social blindness; 27 (45.0%) had a co-morbid chronic illness. Total coping score was 142 ± 26.43 (maximum 217). VRQoL score (maximum 100) was 41.9 ± 15.98 for general functioning; 32.1 ± 12.15 for psychosocial impact, and 41.1 ± 17.30 for visual symptoms. Proactive coping, reflective coping, strategic planning, and preventive coping scores correlated positively with VRQoL in general functioning and psychosocial impact. Conclusion: Positive coping strategies are associated with a better QoL. Ophthalmologists who evaluate visual disability should consider coping mechanisms that their patients employ and should refer them for counseling and training in more positive ways of coping.

Keywords: Blindness, coping strategy, IND-VFQ33, proactive coping inventory, quality of life, vision, low, vision-related quality of life

How to cite this article:
Rai P, Rohatgi J, Dhaliwal U. Coping strategy in persons with low vision or blindness – an exploratory study. Indian J Ophthalmol 2019;67:669-76

How to cite this URL:
Rai P, Rohatgi J, Dhaliwal U. Coping strategy in persons with low vision or blindness – an exploratory study. Indian J Ophthalmol [serial online] 2019 [cited 2020 Jul 5];67:669-76. Available from: http://www.ijo.in/text.asp?2019/67/5/669/256672

People with visual impairment have a poorer quality of life (QoL) since it affects their ability to perform independent activities of daily living, including mobility, reading, earning, and performing personal care.[1],[2] Emotional well-being and social relationships are also affected.[3],[4],[5] Visual disability forces the individual to cope with challenges every day.[6] Coping literally means to face difficulties and to deal with problems in an effort to overcome them. It is known that the ability to function and the approach toward perceived problems varies greatly from disabled to disabled;[7] however, there are no studies on people with low vision and blindness and the coping strategies that they use to manage their daily challenges. As visual disability is a chronic stressor,[8] understanding the coping strategies used by such people may help in the design of interventions targeted to improve their QoL. This study was conducted to assess coping strategies in patients with low vision or blindness and to determine whether particular coping strategies correlated with vision-related QoL.

  Methods Top

This was a descriptive, cross-sectional study conducted at a tertiary level teaching hospital from November 2016 to January 2018. After the institutional ethics committee clearance and written informed consent, adult patients (25–65 years) with a best-corrected visual acuity (BCVA) of <6/18 with current refraction in the better eye and vision loss duration of 6 months or more, who self-presented to the ophthalmology outpatient department were recruited in the study. The cause of visual loss had to be an irreversible one; here, irreversible low vision was defined as current BCVA between <6/18–6/60 in the better eye that could not be treated by any means, irreversible blindness was defined as current BCVA <6/60–3/60 in the better eye (economic blindness), or BCVA <3/60 in the better eye (social blindness) that could not be treated by any means. We excluded patients who were not willing to participate; had cognitive impairment; had congenital onset of visual impairment or onset in the first 5 years of life; had a history of any co-morbid condition (except those related to vision loss); or had a history of psychosocial disorders; or of taking long-term psychiatric medications such that it would impact their ability to respond to the questionnaire.

Proactive coping is a new focus in positive psychology research.[9],[10] During a review of the literature we found that there was no study on the use of the Proactive Coping Inventory (PCI) in patients with irreversible visual loss. In the absence of objective data with respect to the Hindi version of the PCI, we planned an exploratory study that would include consecutive patients who fulfilled the inclusion criteria and who presented to the outpatient department over the period of data collection.

Age, gender, binocular visual function (distant visual acuity using the Snellen's chart and near visual acuity), and presence of chronic systemic disease or other disability were recorded. Coping strategies were assessed using the Hindi version of the PCI. The PCI was chosen as it has shown good construct validity, homogeneity and acceptable reliability, and shows good item correlations.[9] The Hindi adaptation makes it a potentially reliable tool for measuring coping strategies among native Hindi speakers.[10] Vision-related QoL was assessed with the Hindi version of the IND-VFQ33, which is a psychometrically sound measure of the impact of vision impairment on daily activity and emotional well-being.[6],[11] It is designed specifically for the Indian population and has been used in our department before.[12] It is suitable for use in populations of mixed literacy and is short enough to keep respondent burden to a minimum.[6]

Rating of scales

The 55-item PCI has seven scales – proactive coping (14 items), reflective coping (11 items), strategic planning (4 items), preventive coping (10 items), instrumental support seeking (8 items), emotional support seeking (5 items), and avoidance coping (3 items). Each item is rated on a 4-point scale – not at all true (1), barely true (2), somewhat true (3), and completely true (4). Total score for each subscale is calculated by adding the individual scores of the items in that subscale. Three items in the proactive coping subscale (item 2, item 9, and item 14) are rated in reverse since they are negative items. In addition to individual subscale scores, we also calculated the total coping strategy score by adding the seven subscale scores. The higher the score, the better is the coping.

The 33-item IND-VFQ33 has three subscales – general functioning (21 items), psychosocial impact (5 items), and visual symptoms (7 items). General functioning is rated on a 5-point scale (not at all, a little, quite a bit, a lot, and cannot do this because of my sight), while psychosocial impact and visual symptoms are rated on a 4-point scale (not at all, a little, quite a bit, and a lot). The items in each subscale are negative items, so they were rated by scoring in reverse – thus, a higher score meant better functioning in that domain. For each of the three subscales, total score was calculated by adding the individual scores of the items in that subscale. To make them comparable across subscales, the scores were converted into percentage and the converted scores were used in data analysis. Higher scores meant better vision-related QoL.

Data handling were as per the Declaration of Helsinki (1964; revised 2008). Participants were referred to by serial number and data kept confidential. Descriptive statistics were used to calculate range, mean, and standard deviation for all the continuous variables (age and questionnaire scores). For coping scores, the proportion of participants who scored above the mid-point of each subscale was calculated. Proportion percentage was also calculated for gender, presence or absence of chronic disease, and category of BCVA for distance and near. Pearson correlation was used to look for correlation of coping scores with age and vision-related QoL scores. Analysis of variance (ANOVA) and t-test were used to compare coping scores based on gender, on presence or absence of chronic disease, and on category of BCVA distance and near vision. Significance was taken at P < 0.05.

  Results Top

Sixty patients fulfilled the inclusion criteria and consented to participate; of them, 33 were women (55%); age ranged between 25 to 65 years (average 46.1 ± 14.31); and 27 (45.0%) had a co-morbid chronic illness (either diabetes, n = 8; hypertension, n = 6; both conditions, n = 4; treated tuberculosis, n = 6; or others, n = 3) but no other disability other than visual. Posterior segment pathology was common (72 eyes; 60.0%) with degenerative myopia being the leading cause of low vision or blindness (18 eyes; 15%). Twenty-five (41.7%) of all participants had low vision; 5 (8.3%) had economic blindness; and 30 (50.0%) had social blindness – out of the latter, 8 (13.3% of all participants) had no perception of light. When near vision was assessed, 35 (58.3%) participants had ≥N/36 vision; 11 (18.3%) had
[Table 1] details the coping strategies reported by the participants. When all participants were taken together, the highest scores were seen for reflective coping and avoidance coping, while the lowest score was seen in strategic planning.
Table 1: Proactive Coping Inventory scores in 60 participants with low vision or blindness

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Vision-related QoL scores were generally low with the poorest QoL being associated with the psychosocial impact of visual loss [Table 2].
Table 2: Vision-related quality of life scores (IND-VFQ33) in 60 participants with low vision or blindness

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Coping did not correlate with the age of participants [Table 3]. Most strategies of coping did not vary with the gender of participants, either, as shown in [Table 4]; however, emotional support seeking was significantly more likely in women.
Table 3: Correlation between age of participants and coping strategy scores

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Table 4: Comparison of coping strategy scores between men and women participants

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Coping scores did not correlate with the BCVA for distance vision [Table 5] except in the case of proactive coping where it was seen that persons with low vision had higher scores than those with no perception of light (P = 0.042). To further examine this association, the data of participants with no perception of light were merged with that of participants with social and economic blindness. Even then, the score for proactive strategy of participants with low vision (n = 25; mean = 38.7 ± 7.09) was better than that of all other participants (n = 35; mean = 34.1 ± 6.65; P = 0.014). Total coping scores as well as proactive and reflective coping strategy scores were also higher when near vision was better [Table 6]. There was no association of chronic illnesses with coping strategies.
Table 5: Comparison of coping strategy scores in different categories of distance BCVA

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Table 6: Comparison of coping strategy scores in different categories of BCVA for near vision

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Total coping scores correlated positively with visual function scores pertaining to general functioning and psychosocial impact, but negatively with visual symptoms score [Table 7]. The table also shows how the seven individual coping strategies correlated with the three visual function scores.
Table 7: Correlation of coping strategy scores (Proactive Coping Inventory) with visual function domain scores (IND-VFQ33)

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  Discussion Top

Coping strategies in general

From a disability standpoint, coping is the way in which people deal with their particular limitations. Coping can broadly be classified as reactive or proactive.[5],[7],[9],[13] In reactive coping, the individual reacts to a stressor that he has already encountered (disability, in this case) and works to reduce the ensuing stress. Traditional coping models have emphasized the reactive nature of coping while proactive coping is a newer concept. It is a positive coping strategy where the individual anticipates potential stressors that can arise as a result of his disability and seeks proactively to strengthen his ability, develop strategies, and gather resources so that he can manage his life better.[13]

Not all strategies used for coping result in positive outcomes. Thus, a patient may react by avoiding thinking about his disability (avoidance coping) so as to reduce the emotional distress and the negative feelings associated with the disability; however, while this may appear to be a beneficial strategy in the short term, it can delay rehabilitation in the long term.[9]

Coping is thought to be a multidimensional process and the PCI captures this aspect by measuring seven strategies used by individuals when faced with stress.[13] The proactive coping scale, with reference to the PCI, measures a person's ability to set goals autonomously and to self-regulate the attainment of those goals. The reflective coping scale measures the ability to analyze behavioral alternatives and brainstorm about effective plans of action. The strategic planning scale measures the extent to which the individual can break down extensive tasks into manageable components so as to complete an action plan. The preventive coping scale measures how ready the individual is to anticipate potential stressors and prepare himself for them before they develop (threat appraisal). The instrumental support-seeking scale measures how ready the person is to seek advice and help from people in his social network. The emotional support-seeking scale assesses the degree to which the individual regulates emotional distress through disclosing his feelings to significant others and evoking empathy. The avoidance coping scale measures the extent to which the individual uses delaying tactics to avoid taking action in a demanding situation.

Studies show that people may move from one coping strategy to another during the course of the stressful event; many natural factors, individual factors, and situational factors may dictate what coping strategy will be employed.[14]

Proactive coping strategies employed by study participants

In our study, more participants opted for reflective coping and avoidance coping than other strategies. It is encouraging to find that they were using reflective coping strategy since this strategy is known to keep people occupied and optimistic.[9] Avoidance coping, on the other hand, is a passive and distanced approach to stress. While it is considered a negative strategy, it is not always a bad thing. If the problem is too difficult to deal with, as in the case of visual disability, people may put it aside and deal with it whenever they feel they are ready.[9] This allows them a breather during which time they may be able to build up other networks and means of coping. A coping behavior such as avoidance may be positive and helpful in the short run but harmful in the long run if it results in social isolation.[15] Thus, avoidance coping for a short time may be acceptable, provided that it gives way to other, more proactive ways of coping. This was not a longitudinal study so we do not know if avoidance coping in our participants was replaced by other forms of coping over time. Also, we did not measure the time of onset of visual disability. It would have been interesting to see if there was any relationship between type of coping strategy and duration of visual disability. This aspect can be taken up in a future study.

A very few participants employed strategic planning as a coping strategy suggesting that they do not break up their problems into small manageable components. Strategic planning has been shown to improve the ability of people with chronic diseases to function effectively and it can be learned through training.[16] Since their visual disability was irreversible and no recovery was possible, we expected that our participants would demonstrate greater emotion-focused coping; however, this was not the case. Emotion-focused coping results when stressful situations cannot be easily resolved by a person's action and all the person can do is to reduce the resultant emotional distress.[17]

On the surface it may appear that one strategy is better than the other; however, at different times different strategies may work for the same individual.[9],[16] For example, a person with recent visual disability may employ avoidance coping initially if he fears rejection by peers and family, but later may use emotional support-seeking behavior; even if it does not solve the problem, it may provide emotional comfort. Still later, he may seek instrumental support by sharing his difficulties with others and taking advice from them.

Influence of socio-demographic factors on coping

When we examined the factors that might influence coping, we found that there was no association with age. The age groups that were included in our study (25–65 years) represent the working age group. In a developing country like India, other members of the family are dependent on the working age group for sustenance. Studies show that the bread winner is prone to stress.[18] We expected that the presence of visual disability at this age would impact their ability to cope; however, that was not found to be the case. While some studies support this finding,[19] others refute it claiming that age does influence coping and older people are better able to adopt behavioral, cognitive, and emotional strategies to cope with stress.[20]

Most strategies of coping did not vary with the gender of participants in our study [Table 4]; however, women were significantly more likely to try and cope by seeking emotional support. Other studies have also reported this gender variation using other coping instruments;[21] some reveal that males use avoidance coping strategy to much greater extent than females. Possibly, when the problem is difficult to deal with, men might choose to ignore it for a while, getting back to it when they feel they are ready.[9] More research is needed in this area, especially since other studies using different coping instruments have found no association between coping strategy and gender.[22–24] Coping strategies are influenced by chronic illnesses like bipolar disorder, type 2 diabetes mellitus, hemophilia, and chronic obstructive pulmonary disease.[15],[16],[25],[26] People with chronic illness or disability may build up fears of death or permanent disability, they may worry about the medications and possible side effects, and have concerns about disruptions in lifestyle, of being unable to work, and of resultant financial hardship. Thus, chronic illnesses act like a stressor and can make coping difficult.[16] In our study, about 45% of the participants had a chronic illness and we expected that it would impact coping; however, that was not the case. It is possible that we had fewer patients with chronic illnesses; perhaps a larger study could help understand the relationship between chronic illness and coping in persons with visual disability in our set up.

Influence of residual vision on coping

When we looked for associations between coping scores and BCVA for distance, we found none [Table 5] except in the case of the proactive coping strategy where it was seen that participants with some degree of vision (low vision) had higher scores than those with blindness (P = 0.014). Perhaps if people are able to recognize the visual cues of potential stressors, they may be better able to use this coping strategy to reduce or modify the impending stressful event. Participants with no perception of light may have lesser ability to visually detect potential stressors; they may also have less ambitious goals and therefore appear to be less proactive in coping. For the same reason, probably, proactive coping scores were also higher when BCVA for near vision was better. The participants with better near vision also had better reflective coping strategy scores [Table 6]. We can speculate that near visual function, known to be related to the participant's QoL, may enhance self-confidence and, thus, allow reflective coping.[27]

Coping and vision-related QoL

In our study, visual loss seemed to affect QoL adversely in all three domains of IND-VFQ33. The greatest impact of visual disability was seen on psychosocial functioning suggesting that our participants had poor personal, social, or familial well-being. Several studies have proved that people who use strategies that are more proactive have a better QoL.[26] This was seen in our study where we found that participants who were better able to cope with their visual disability also had a better QoL in the general functioning and in the psychosocial domains as assessed by a vision-specific QoL instrument [Table 7]. When individual coping strategies were considered, the positive ways of coping (proactive coping, reflective coping, strategic planning, and preventive coping) were associated with good QoL in these two domains. Good QoL is not just determined by how a person copes with adversity but many other isolated or inter-related factors may contribute;[16],[25],[28] nevertheless, this association encourages one to consider recommending the use of these particular strategies when there is visual disability so as to improve the general and psychosocial health.

When QoL related to visual symptoms was considered, however, QoL was poor even when overall coping was good, and also when preventive strategy and instrumental support-seeking strategy was employed for coping. It is likely that irreversible visual disability and visual symptoms that are associated with it are sufficient to impact QoL and that coping strategies, no matter which is employed, may not be able to compensate for the symptoms of an irreversible visual disability.

Limitations of the study

Our study included a hospital-based sample and the findings may not be representative of the general population. Since many of our patients self-reported to the hospital for visual handicap certificate, the study is likely to have selection bias. These were patients who presented on their own; this suggests that they may already have the propensity to seek support and thus cope proactively unlike what we may find in the general population. We collected data through interviewer administered questionnaires; it is possible that participants became conscious and misinterpreted the questions.[29] Had the questionnaires been self-administered, the responses might have been more accurate, although there is a risk that participants take self-administered questionnaires casually.[30] Being cross-sectional in design, the study is unable to confirm the nature of the association between coping and QoL.

Clinical implications

Despite these limitations, our study shows that determining an individual's coping behavior may be important from the point of view of training them toward positive coping so as to improve QoL. Ophthalmologists have an important role when dealing with patients with visual disability. Where necessary, the treating ophthalmologist or the one certifying the disability can refer to a social worker or a psychologist for help. By modifying maladaptive coping strategies and replacing them with more effective ways of coping, patients may be benefited.

  Conclusion Top

In conclusion, people with low vision and blindness use multiple strategies to cope with their disability. The commonly used strategies in our study were both positive (reflective coping) and negative (avoidance coping); strategic planning was used least often. Positive coping strategies were associated with a better general functioning and better psychosocial QoL. Ophthalmologists who evaluate visual disability should be trained to become aware of the coping mechanisms that their patients employ and should consider directing them for counseling and for training in more positive ways of coping. Longitudinal studies exploring the evolution of coping strategies over time in people with visual disability may be helpful in improving our understanding of the relationship between coping and QoL. Future studies could also be directed to assessing how modification in coping strategies impacts QoL in people with visual disability.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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