SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA EXPLORING THE SOCIAL SUPPORT AND PSYCHOLOGICAL IMPLICATIONS OF VISION LOSS AMONG VISUALLY IMPAIRED PERSONS IN LAWRA MUNICIPALITY, A RURAL COMMUNITY OF NORTH-WESTERN GHANA BY ZOBAZIE, CLEMENT BOMWEH (10602099) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF SCIENCE IN APPLIED HEALTH SOCIAL SCIENCE DEGREE MARCH, 2022 University of Ghana http://ugspace.ug.edu.gh i DECLARATION I, Zobazie Clement Bomweh, hereby declare that with exception of specific references made which had been duly acknowledged, this dissertation is my independent research conducted under the supervision of Dr. Adanna Nwameme. I also declare that no part/whole of this study had been submitted for the award of any degree in this or any other institution. SIGNATURE 28/09/2022 ZOBAZIE CLEMENT BOMWEH DATE (CANDIDATE) SIGNATURE 27/09/2022 DR. ADANNA NWAMEME DATE (SUPERVISOR) University of Ghana http://ugspace.ug.edu.gh ii ACKNOWLEDGEMENT First and foremost, glory and honor go to Almighty God for giving me His unending grace, strength, guidance, and direction in my life. My appreciation also goes to the faculty and all staff in the School of Public Health (SPH), especially those in the Department of Social and Behavioural Sciences for their individual and collective mentorship offered me in the course of this program. I offer my sincerest gratitude to my supervisor, Dr. Adanna Nwameme of the above Department, for supporting me with her patience and knowledge. One just could not aspire for a better or friendlier supervisor than her. To all those who supported me during the data collection, may God replenish all your energy. I cannot afford to leave out my wife, Madam Abigail Niyee Ngmenlier, and our lovely sons, Jeffrey Bozie, Nathaniel Tisebr, and Jerome Bielbiel, for the understanding, support, and love shown to me during the program - may God richly bless you. I am also very grateful to my mother, Madam Beyelle-iyel as well as my siblings, Saakum Zobazie, Cecilia Poutierweh, Samuel Zobazie, and Kanyir Zobazie, for their prayers and encouragement. Lastly, to all volunteers who participated in the interviews/discussions, I express my gratitude. God bless you all. University of Ghana http://ugspace.ug.edu.gh iii DEDICATION I dedicate this dissertation to the Zobazie family of Babile Tanchara in the Lawra municipality of Upper West Region. University of Ghana http://ugspace.ug.edu.gh iv TABLE OF CONTENTS DECLARATION............................................................................................................................ i ACKNOWLEDGEMENT ............................................................................................................ ii DEDICATION.............................................................................................................................. iii TABLE OF CONTENTS ............................................................................................................ iv LIST OF TABLES ..................................................................................................................... viii LIST OF FIGURES ..................................................................................................................... ix LIST OF ABBREVIATIONS ...................................................................................................... x ABSTRACT ................................................................................................................................. xii CHAPTER ONE ........................................................................................................................... 1 1.0 INTRODUCTION................................................................................................................... 1 1.1 Introduction ......................................................................................................................... 1 1.2 Background to the study ..................................................................................................... 1 1.3 Problem statement............................................................................................................... 6 1.4 Research questions and objectives ..................................................................................... 8 1.4.1 Research questions ....................................................................................................... 8 1.4.2 Research objectives ....................................................................................................... 9 1.4.2.1 General objective: .................................................................................................. 9 1.4.2.2 Specific objectives: ................................................................................................. 9 1.5 Justification of the study ..................................................................................................... 9 1.6 Conceptual framework ..................................................................................................... 10 1.6.1 Narrative of conceptual framework .......................................................................... 11 1.7 Social support theory and satisfaction with life.............................................................. 12 CHAPTER TWO ........................................................................................................................ 14 2.0 LITERATURE REVIEW .................................................................................................... 14 2.1 Introduction ....................................................................................................................... 14 2.2 The global landscape of visual impairment .................................................................... 14 2.3 Causes of visual impairment ............................................................................................ 17 2.4 Social support, social network, psychological implications of vision loss, and health status of VIPs ........................................................................................................................... 20 2.5 Forms of social support..................................................................................................... 22 2.6 Sources of social support for VIPs ................................................................................... 24 University of Ghana http://ugspace.ug.edu.gh v 2.7 Barriers to social support ................................................................................................. 25 2.8 Facilitators of social support ............................................................................................ 27 CHAPTER THREE .................................................................................................................... 30 3.0 METHODOLOGY ............................................................................................................... 30 3.1 Introduction ....................................................................................................................... 30 3.2 Study design ....................................................................................................................... 30 3.3 Study area .......................................................................................................................... 31 3.4 Study population ............................................................................................................... 31 3.5.0 Sampling strategies ........................................................................................................ 31 3.5.1 Sampling procedure ................................................................................................... 31 3.5.2 Inclusion and exclusion criteria ................................................................................. 32 3.6.0 Data gathering and analysis procedures ...................................................................... 33 3.6.1 Data collection methods ............................................................................................. 33 3.6.2 Data collection instruments ....................................................................................... 34 3.6.3 Pretesting of the discussion/interview guides ........................................................... 35 3.6.4 Data processing and analysis ..................................................................................... 35 3.7 Ensuring Qualitative Rigor .............................................................................................. 37 3.8 Ethical consideration ........................................................................................................ 39 3.9 Privacy and confidentiality ............................................................................................... 39 CHAPTER FOUR ....................................................................................................................... 40 4.0 RESULTS .............................................................................................................................. 40 4.1 Introduction ....................................................................................................................... 40 4.2 Socio-demographic information of the participants ...................................................... 40 4.3 Social support and psychological implications of vision loss ........................................ 42 4.4 Hierarchy chart of coding references .............................................................................. 43 4.5 Psychological implications of vision loss ......................................................................... 44 4.6 Sources of social support among the VIPs ...................................................................... 47 4.6.1 Formal social support services .................................................................................. 48 4.6.1.1 The NHIS implemented by NHIA ...................................................................... 49 4.6.1.2 The Livelihood Empowerment Against Poverty (LEAP) program ................ 50 4.6.1.3 The Disability Common Fund (DCF) ................................................................. 51 4.6.1.4 Non-Governmental Organizations (NGOs) and support services ................... 52 University of Ghana http://ugspace.ug.edu.gh vi 4.6.2 Community support services ..................................................................................... 53 4.6.2.1 Kin-based support systems.................................................................................. 53 4.6.2.2 Social relations outside the family ...................................................................... 56 4.6.2.3 Religious/faith-based network ............................................................................ 57 4.6.2.4 Chiefs and queen mothers support ..................................................................... 59 4.7 Barriers to accessing social support ................................................................................ 60 4.7.1 Barriers to accessing formal support ........................................................................ 60 4.7.2 Barriers to seeking community support ................................................................... 64 4.8 Facilitators to accessing social support ........................................................................... 67 4.9 Health benefits of receiving social support ..................................................................... 69 4.10 Unmet needs of the VIPs ................................................................................................. 71 4.11 Satisfaction with social support ..................................................................................... 75 4.11.1 Satisfaction with the community support systems................................................. 75 4.11.2 Satisfaction with the formal support services ........................................................ 76 4.12 Summary of the major findings ..................................................................................... 77 CHAPTER FIVE ........................................................................................................................ 78 5.0 DISCUSSION ........................................................................................................................ 78 5.1 Introduction ....................................................................................................................... 78 5.2 Socio-demographic characteristics of participants ........................................................ 78 5.3 Psychological implications of vision loss ......................................................................... 79 5.4 Sources and forms of social support ................................................................................ 80 5.4.1 Formal support sources and services ........................................................................ 81 5.4.2 Community support sources and services ................................................................ 83 5.5 Health benefits of social support ...................................................................................... 85 5.6 Barriers to accessing social support ................................................................................ 86 5.7 Facilitators to social support ............................................................................................ 88 5.8 Unmet needs of VIPs ......................................................................................................... 89 5.9 Satisfaction with social support ....................................................................................... 90 CHAPTER SIX ........................................................................................................................... 92 6.0 CONCLUSION AND RECOMMENDATIONS ................................................................ 92 6.1 Introduction ....................................................................................................................... 92 6.2 Conclusion .......................................................................................................................... 92 University of Ghana http://ugspace.ug.edu.gh vii 6.3 Recommendations ............................................................................................................. 93 6.4 Limitations of the study .................................................................................................... 94 REFERENCES ............................................................................................................................ 96 APPENDICES ........................................................................................................................... 102 APPENDIX A: PARTICIPANTS INFORMATION SHEET FOR FGDs ...................... 102 APPENDIX B: PARTICIPANT’S CONSENT FORM FOR FGDs ................................. 104 APPENDIX C: PARTICIPANTS INFORMATION SHEET FOR IDIs ......................... 106 APPENDIX D: PARTICIPANT’S CONSENT FORM FOR IDIs ................................... 108 APPENDIX E: DISCUSSION GUIDE FOR FGDs ........................................................... 110 APPENDIX F: INTERVIEW GUIDE FOR IDIs .............................................................. 112 APPENDIX G: CODEBOOK 1 ........................................................................................... 114 APPENDIX H: CODEBOOK 2 ........................................................................................... 115 APPENDIX I: WORD FREQUENCY QUERY RESULTS ............................................. 116 University of Ghana http://ugspace.ug.edu.gh viii LIST OF TABLES Table 1: Socio-demographic characteristics of participants .................................................. 41 University of Ghana http://ugspace.ug.edu.gh ix LIST OF FIGURES Figure 1: Conceptual framework of social support and wellbeing among VIPs .......................... 10 Figure 2: Word cloud of fifty most dominant words .................................................................... 42 Figure 3: Hierarchy chart of coding references ............................................................................ 43 Figure 4: Items clustered by word similarity ................................................................................ 48 Figure 5: Unmet needs of VIPs ..................................................................................................... 71 University of Ghana http://ugspace.ug.edu.gh x LIST OF ABBREVIATIONS ATR………………….African Traditional Religion BPS…………………..Blind and Partially Sighted CAQDAS…………....Computer Assisted Qualitative Data Analysis Software CSO………………….Civil Society Organization DACF………………..District Assembly Common Fund DALY………………..Disability-Adjusted Life Years DCFs…………………Disability Common Funds FGD………………….Focus Group Discussion GAB………………….Ghana Association of the Blind GAP………………….Global Action Plan GHSERC…………….Ghana Health Service Ethical Review Committee GSS…………………..Ghana Statistical Service IAPB…………………International Agency for the Prevention of Blindness IDI……………………In-Depth Interview LEAP…………………Livelihood Empowerment Against Poverty MDGs………………...Millennium Development Goals NGO………………….Non-Governmental Organization NHIA…………………National Health Insurance Authority NHIF………………….National Health Insurance Funds NHIS………………….National Health Insurance Scheme OPDs………………….Organizations of Persons with Disabilities PHC…………………...Population and Housing Census University of Ghana http://ugspace.ug.edu.gh xi PWD…………………..Person with Disability SDGs…………………..Sustainable Development Goals SPH……………………School of Public Health SSNIT…………………Social Security and National Investment Trust UNCRCPD……………United Nations Convention on the Rights of Children and Persons with Disabilities UNHR…………………United Nations Human Rights VIP…………………….Visually Impaired Person WASH…………………Water, Sanitation, and Hygiene WHA…………………..World Health Assembly WHO…………………..World Health Organization University of Ghana http://ugspace.ug.edu.gh xii ABSTRACT Background: The visually impaired population continues to rise globally with people in rural residence at a greater risk. Since vision loss is mostly irreversible and usually comes as a handicap with psychological implications, affected persons need support to live satisfying lives and also participate in societal development. Methods: A phenomenological approach was employed to study the social supports and psychological implications of vision loss among Visually Impaired Persons (VIPs). From a cross-section of the VIPs in Lawra municipality, 5 Focus Group Discussions and 20 In-depth Interviews were conducted using pretested discussion/interview guides. The interviews and discussions were audio-recorded, transcribed verbatim along with field notes in Microsoft Word document and imported into NVIVO version 2020 where thematic analysis was performed by employing descriptive-focused coding. Results: The study revealed vision loss is associated with anxiety, hopelessness, dependency, depression, loneliness and suicidal ideation. The results suggested that financial and health services are the main formal supports received by the VIPs in the study area. In addition to that, material, emotional, informational, appraisal and spiritual support were provided by the community level support sources such as kin-based network, faith-based associations, traditional authorities and social relations outside their families. However, there are several barriers to seeking available supports such as lack of information, transportation difficulties, illiteracy, political biases, discrimination, family dispute, and the principle of reciprocity. The findings also revealed that having adequate social support helps University of Ghana http://ugspace.ug.edu.gh xiii the VIPs gain self-esteem, feel safe and secure, as well as reduces their stresses. Though the VIPs are pleased with support from the community network especially the family, they were not satisfied with what the formal sector offered them because their needs such as finances, road safety, farm inputs, and housing needs are not met. Conclusion: The study was to explore the social support and psychological effects of vision impairment in a rural setting. Despite the numerous support services available in the communities and formal sector, the VIPs‟ needs are not fully met. Therefore, there is the need to modify and scale up the formal support services such as the LEAP and accessibility of DACF to the VIPs while prevailing community support sources should be reinforced. The VIPs need to be protected against criticism and discrimination to help them access available support services. University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE 1.0 INTRODUCTION 1.1 Introduction This chapter presents important information that is essential to understanding social support and the psychological implications of vision loss among Visually Impaired Persons (VIPs). It highlights the global and local magnitude of visual impairment as well as the causes. The chapter also justifies why the study was necessary, while spelling out the objectives to be met. The conceptual framework and social support theory which set the premise for conducting the study are also described. 1.2 Background to the study Visual impairment is one of the public health crises that are on the rise globally. Flaxman et al. (2017) reported that as of 2015, 36·0 million people were estimated to be blind globally, and 216·6 million more were living with moderate or severe vision impairment. World Health Organization (2007) cautioned that at least 7 million people loss their sight annually, which prompted the drawing of Action Plan 2006 – 2011 to accelerate the implementation of „VISION 2020: the Right to Sight‟. This vision was earlier launched in 1999 with the target of getting rid of avertible blindness by the year 2020 and preventing the projected doubling of avoidable visual impairment between 1990 and 2020. Tetteh et al. (2020) predicted that the population of VIPs worldwide would still correspondingly grow over time as the elderly population is predicted to double by 2050. Hence, the continuous increase in the visually impaired population is driven partly by the increasing proportion of the aged population in developed and developing economies especially for the past three decades (Flaxman et al., 2017). Evidences suggest an upsurge in the number of blindness and vision loss-related Disability-Adjusted Life Years University of Ghana http://ugspace.ug.edu.gh 2 (DALY) in the last two decades (Abbafati et al., 2020; WHO, 2007). Blindness and vision loss- related DALY accounted for 1.2% (0.9 - 1.6) of DALY in 1990 and rose to 1·4% (1·1 - 2·0); representing an 88.8% increase in number of cases for the age range of 50 - 74 years. For persons 75 years and older, the percentage increase in the number of blindness and vision-related DALY was 124.7% within the same period; accounting for 1.4% (1.1 - 1.80) of DALY in 1990 and 1.7% (1.3 - 2.2) in 2019 (Abbafati et al., 2020). Among pensioners in Ghana, for instance, the total prevalence of blindness in 2019 was 3.8%, while the prevalence of moderate to severe visual impairment was 21.7% (Nuertey et al., 2020). Wiafe‟s (2015) study also found that 0.74% of the Ghanaian population were blind and 1.07% more had severe visual impairment while 19.12% of those aged 80 years and above were blind. Since the incidence of diseases that affect the eyes continues to increase based on Global Burden of Disease reports, more and more people are prone to being blind (WHO, 2007). With regards to the causes, visual impairment could be a result of uncorrected refractive errors, glaucoma, age-related macular degeneration, corneal opacities, diabetic retinopathy, trachoma, and onchocerciasis (Wiafe, 2015). Cataract remains the major cause of blindness in middle- and low-income countries where more than 90% of the world‟s visually impaired people live (Nuertey et al., 2020; Flaxman et al., 2017; Wiafe, 2015; WHO, 2007). A study by Wiafe (2015) revealed that a large proportion of those in Ghana with low vision (88.9%) and blindness (67.7%) are due to avoidable causes such as cataract, glaucoma, corneal opacities, trachoma, childhood blindness, and onchocerciasis while global data on visual impairment estimated that 75% of all vision loss globally could have been prevented (WHO, 2007). It has been reported that rural residents carry a greater risk of blindness because they reside in non-intervention areas for eye University of Ghana http://ugspace.ug.edu.gh 3 care and are most likely not to have access to early diagnosis and management (Nuertey et al., 2020; Wiafe, 2015). Luckily enough, the rate at which people develop visual impairment could be reduced if not halted. Several interventions are ongoing, directly and indirectly, to reduce the avoidable causes of blindness in the world. These include surgical interventions, routine Vitamin A distribution, health education, early diagnosis, and antibiotics administrations. The WHO (2007) entreated member states to ensure that societies are made aware of the known, evidence- based, cost-effective interventions for preventing avertible vision loss. Regardless of the time of onset, acceptance of visual impairment as a disability is a lifelong process that goes through phases: shock and denial, mourning and withdrawal, depression, reassessment, and reaffirmation, coping and mobilization, self-acceptance, and self-esteem (Papadopoulos et al., 2013). Aside from the psychological implications on the individual, vision loss creates fundamental human and socioeconomic negative impacts in all societies. Though the economic and social cost of disabilities are difficult to quantify according to the world disability reports (WHO & The World Bank, 2011), the WHO (2007) observed that the costs of lost productivity and rehabilitation and education of the blind person result in a significant economic burden for the individual, the family, and society. With the perception of being a burden to society, visual impairment is mostly associated with social isolation, depression, and diminishing life satisfaction as indicated by Tetteh et al. (2020). But, like other Persons with Disabilities (PWDs), when VIPs get the necessary social support, it can enhance their participation in socio-economic development in diverse ways and improve their quality of life in general (Yoshida et al., 2020). Social support refers to aid relationships, hence it has been connoted with terms such as social networks, social exchange, relationships, and social University of Ghana http://ugspace.ug.edu.gh 4 relations (Zuchowska-Skiba, 2019), and includes giving aid to someone in a time of difficulties. Social networks describe a set of existing relationships and social ties within which an individual functions, including informal, intergroup relationships, and formalized relationships (Zuchowska- Skiba, 2019). The networks of people with disabilities (especially VIPs) were observed to be smaller than those of abled people, according to Vega et al. (2019) and Zuchowska-Skiba (2019), and such persons are less likely to receive health services including vision rehabilitation (Papadopoulos et al., 2014; Yoshida et al., 2020). In a study among persons with multiple disabilities, Vega et al. (2019) observed that those reporting increases in social support reported decreases in depressive symptoms, with the reverse also being the case. Poor social networks and social support are thus associated with a lower level of self-esteem and increased anxiety putting VIPs at risk of psychological disorders. Agoraphobia and social phobia are psychological disorders that are the most prevalent anxiety disorders among visually impaired adults (Tetteh et al., 2020). These adversely affect their ability to engage in a social capacity meaningfully and live a satisfying life. Social support is therapeutic against psychological conditions and a prerequisite for healthy participation in society for persons with visual impairments. Papadopoulos et al. (2014) stated that social support is an „affective buffer‟ against depression due to vision loss. However, like many sub-Saharan African countries, a robust social support system is absent in Ghana (Opoku et al., 2018) especially for vulnerable ones like PWDs. According to Glanz et al. (2014), social support can be rendered by people in one‟s informal network (e.g. family, friends, coworkers, supervisors) and formal assistance networks (e.g. health care professionals, human service workers, social workers). Lack of the necessary formal support services can make persons with visual impairment overly dependent on University of Ghana http://ugspace.ug.edu.gh 5 family members, preventing both them and the family members from becoming economically active and socially participative. Zuchowska-Skiba (2019) and Glanz et al. (2014) grouped social support into four main types: emotional, instrumental, informational, and appraisal social support. Emotional support describes providing empathy, love, trust, and caring support to persons in need. Instrumental support is rendering tangible aids and activities that directly help a person in need. Informational support is providing advice, suggestions, and information that a person can use to solve challenges in life, while appraisal support entails giving information that is needful for self-evaluation purposes. Social support can be available in society but not accessible to all persons. Being visually impaired poses a major limitation for accessing social support (Nuertey et al., 2020), with external factors further deepening the barriers to accessing social support in most cultures and traditions (Ntibea, 2011). Some cultures believe that the cause of visual disability is witchcraft activities or evil machinations against visually impaired individuals and their families (Naami & Mfoafo-M‟Carthy, 2020). This makes visual impairment one of the most stigmatized disabilities in many cultures across the world (Ntibea, 2011). Hence to avoid being stigmatized, persons with visual impairment tend to limit their interaction with society. Other barriers to accessing social support for the visually impaired include lack of formal education, as well as transportation, infrastructural, and institutional barriers. Nevertheless, many factors increase the chances of VIPs receiving social support from informal and formal networks. Facilitators to accessing social support include being educated, affirmative policies, and advocacy by Non-Governmental Organizations (NGOs) and religious bodies. University of Ghana http://ugspace.ug.edu.gh 6 Formal education boosts the confidence and access to information of PWDs (especially VIPs) thereby enabling them to seek social support and interact meaningfully with society. Without formal education, PWDs have limited or no skills to engage in productive economic activities and access social support as well. Unfortunately, social order undermines the education of PWDs with the perception that they need to be supported to live rather than be empowered to be independent (Opoku et al., 2018). A lot needs to be done in studying the needs and ways to integrate VIPs into society rather than treating them as dependent populations because vision loss like any other disability is not an inability. With adequate social support, VIPs can contribute their quota to socio-economic development in diverse ways and improve their quality of life as well (Yoshida et al., 2020). This study, therefore, endeavors to explore the social support available to VIPs as well as the psychological implications of vision loss in the Lawra Municipality of Upper West Region, Ghana. 1.3 Problem statement Vision is one of the fundamental requirements to maintaining one‟s ability to work and live independently in the community (Liu et al., 2020). Inability to see comes with negative psychological impacts such as lower morale, social isolation, depression, reduced feelings of self- esteem, diminished emotional security, and lower levels of social interactions (Papadopoulos et al., 2013). In their studies, Flaxman et al. (2017) and Nuertey et al. (2020) mentioned that visual impairment could result from cataracts, uncorrected refractive error, glaucoma, diabetic retinopathy, corneal opacity, trachoma, congenital abnormalities, and many more. The wide range of causes means many people are exposed to the risks of developing visual impairment. University of Ghana http://ugspace.ug.edu.gh 7 Bourne et al. (2021) & Flaxman et al. (2017) cited that, as of 2015, approximately 36 million people in the world were blind, 216.6 million people more were living with moderate or severe vision problems, and 188.5 million people had mild vision impairment, which accounted for 6% of the world‟s population. Yoshida et al. (2020) also noticed that sensory organ deficits, including vision impairment, ranked second after lower back and neck pain and ahead of depressive disorders among all contributory causes of years lived with disability (DALY) worldwide. Evidence from the Ghana Statistical Service (GSS) indicates that out of the 4.7 % (2,568) of the population living with some form of disabilities in the Lawra municipal, VIPs accounted for 50.9 % (1,308). With regards to the entire municipal, VIPs made up 2.39% of the total population (GSS, 2014c). It is unclear what accounts for the high prevalence of visual impairment in the area against the national value of 1.6%, though the 2010 Population and Housing Census (PHC) revealed that 96.3% of Lawra inhabitants reported using solid fuel for cooking while only 18.1% reported using pipe-borne water for domestic activities. There is evidence to show that the use of solid fuel and source of household water are strongly associated with the development of eye conditions such as cataracts, glaucoma, and trachoma (Wiafe, 2015). In a study among women in Nepal, most reported redness of eyes, burning sensation in eyes, gritting, pains, and tearing when they switched from clean fuel (electricity/liquefied petroleum gas/methane gas) to biomass fuel. About 39% of the women using biomass for cooking reported blindness later in life while those using clean fuel reported none (Patel et al., 2020). In poorer communities, lack of wholesome water also renders people to poor personal hygiene (especially facial cleanliness) and exposure to infections including those of the eyes (WHO, 2007). Trachoma is associated with poor facial cleanliness and is widely tasked as a disease of poverty. It is one of the conditions that had been University of Ghana http://ugspace.ug.edu.gh 8 controlled with the provision of water, sanitation, and hygiene (WASH) programs in poorer communities (WHO, 2020). There is substantial evidence to support that, the VIPs generally exhibit a lower level of self- esteem and increasing anxiety, putting them at risk of psychological disorders (Papadopoulos et al., 2013; Papadopoulos, Papakonstantinou, Koutsoklenis, Koustriava, & Kouderi, 2015; Papadopoulos et al., 2014; Tetteh et al., 2020). These adversely affect their ability to engage in meaningful social participation and healthy living (Ntibea, 2011). All the same, the presence of a strong social support network serves as antidote to these psychological impacts. According to Hapke (2015), the Buffering Model demonstrates that an individual with a strong social support network acts as a buffer to potentially negative outcomes of a stressful event. Papadopoulos et al. (2014) referred to social support as the type of assistance or help individuals receive or expect to receive from those who come into contact with them in any way in their daily life. More often than not, VIPs do not receive adequate social support due to barriers such as misconceptions about the cause of their predicaments, poor health state, lack of access to transport, infrastructural barriers, and lack of knowledge (Asamoah et al., 2018; Ntibea, 2011; Opoku et al., 2018; Tetteh et al., 2020). 1.4 Research questions and objectives 1.4.1 Research questions 1. What are the psychological implications of visual loss among the VIPs in the municipality? 2. What are the sources and forms of social support for VIPs in Lawra municipality? 3. What are the barriers and facilitators to accessing social support for VIPs? 4. How satisfied are VIPs with the social support rendered to them? University of Ghana http://ugspace.ug.edu.gh 9 1.4.2 Research objectives 1.4.2.1 General objective: The study seeks to explore the social support and psychological implications of vision loss among VIPs in Lawra municipality. 1.4.2.2 Specific objectives: 1. To identify the psychological implications of vision loss among the VIPs in the municipality; 2. To ascertain the sources and forms of social support for VIPs in Lawra municipality; 3. To discover the barriers and facilitators to accessing social support among VIPs; and 4. To explore the VIPs‟ satisfaction with social support rendered them. 1.5 Justification of the study Previous studies reveal that people living in rural areas suffer more visual impairment than their urban counterparts (Flaxman et al., 2017; GSS, 2014b; Nuertey et al., 2020; Wiafe, 2015). In the Lawra municipality, a rural community, for instance, VIPs contributes 2.39% of the population (GSS, 2014c), but not much has been done in studying the social support available to them; given that the necessary social support can help suppress the psychological implications of vision loss, enhance their satisfaction with life, and improve their participation in the socio-economic development of the municipality. This makes the study very timely to explore their lived experiences with regards to social support and psychological implications of vision loss. Detailed and evidence-based information this study can help developed policies and interventions that target enhancing the lives of VIPs as well as tapping their potentials towards socio-economic development. Such information on social support systems in Ghana for VIPs is scanty and could result in decision-makings based on assumptions and unjustified recommendations leading to University of Ghana http://ugspace.ug.edu.gh 10 misguided policy choices. Though a lot of studies had been conducted in Ghana on VIPs with regards to prevalence and causes of visual impairment (Adam, 2018; Akuamoah-Boateng, 2013; Asamoah et al., 2018; Komla et al., 2020; Nuertey et al., 2020; Tetteh et al., 2020; Wiafe, 2015), none had attempted to explore the social support given to VIPs and the psychological implications that vision loss comes with especially among rural residents where there is higher prevalence of visual impairment. This study, therefore, strives to bridge that gap in knowledge by exploring the social support and psychological implications of vision loss among VIPs in a rural community of Ghana, the Lawra municipality. 1.6 Conceptual framework A conceptual framework is an organized way of thinking about how and why a phenomenon takes place and about how it is diagrammatically understood. Figure 1: Conceptual framework of social support and wellbeing among VIPs Source: Researcher's concept. Support facilitators - Formal education - Employment - Policies - Advocacy groups - Social cohesion, etc. Support sources - Formal sources - Informal sources Support barriers - Stigma - Structural - Transport - Institutional - Information - Etc. Social support forms - Emotional - Instrumental - Informational - Appraisal support - Coping - Self esteem - Identity Satisfaction with life and psychological wellbeing Stress from - Environmental factors - Psychosocial factors University of Ghana http://ugspace.ug.edu.gh 11 The conceptual framework is a skeletal structure of adopted ideas or concepts which can serve as a guide for data collection in a research study and gives a clue about how the data should be analyzed and explained (Esena, 2017). It illustrates how the interplay of the different factors produces an outcome of interest. 1.6.1 Narrative of conceptual framework The relationship between social support and health is a complex phenomenon. The conceptual framework depicts the complex nature of how social support enhances health and satisfaction with life by suppressing environmental and psychosocial stressors of life. The perspective of social support in the framework explains that support suppresses the effects of stressful life events on health through either the assistive actions of others or the belief that support is available by triggering the individual to develop a strong coping mechanism, identity, and self- esteem. Barriers to accessing social support could be stressors themselves while the support sources could be barriers themselves and can even worsen the severity of stress. The supportive actions approach predicts that social support enhances coping, which buffers the association between stress and satisfaction with life as well as psychological wellbeing. Therefore, social support acts as a key psychosocial “protective” factor that suppresses one‟s vulnerability to the deleterious effects of stress on health. This occurs as social support protects one against the adverse effects of stressors by leading them to interpret stressful situations less negatively and severely. The relationship between social support and wellbeing as well as satisfaction with life is bi-directional. The availability of social support directly leads to wellbeing and satisfaction with life by aiding the individual to engage in healthy practices such as good nutrition, exercise, and personal hygiene, while good health also eases the accessibility of social support. In addition, support such as cash remittances and food can improve the nutritional status of the recipient. University of Ghana http://ugspace.ug.edu.gh 12 Social support leads directly to improved health outcomes by helping the individual to create and sustain identity and self-esteem. 1.7 Social support theory and satisfaction with life The social support theory which sets the premises for the study explains the theoretical perspectives between social support and wellbeing as well as satisfaction with life by exploring the social links of a person and how that improves the health of the individual. The theory is based on three underlining constructs as laid down by Lakey & Cohen (2000). The stress and coping perspective posit that social support contributes to wellbeing and satisfaction with life by protecting people from the adverse effects of stress. During stressing moments, people who have enhanced individual or community resources have the likelihood of handling or coping with the stress in a way that reduces both immediate and long-term adverse health effects, a mechanism called a “buffering effect” of social support. The social constructionist perspective says that social support directly interferes with health by promoting self-esteem and self-regulation, regardless of the presence of stress. Social support boosts the morale and worthiness of an individual by portraying how important a person is to others in society and the need for existence. The relationship perspective predicts that the health effects of social support cannot be separated from relationship processes that often co-occur with support, such as companionship, intimacy, and low social conflict. Human beings are social animals and tend to provide support to one another to show that one is alive because others are alive. University of Ghana http://ugspace.ug.edu.gh 13 Social support network interventions are mainly aimed at enhancing existing social network linkages, developing new social network linkages through the use of indigenous natural helpers, and enhancing networks at the community level through participatory problem-solving processes. Social networks and social support can enhance an individual‟s ability to access new contacts and information and to identify and solve problems leading to self-efficacy and satisfaction with life. Social networks describe the associative relation between people that may or may not provide social support and can serve functions other than providing support (Glanz et al., 2014). Social networks give rise to various social functions such as social influence, social control, social undermining, social comparison, companionship, and social support. University of Ghana http://ugspace.ug.edu.gh 14 CHAPTER TWO 2.0 LITERATURE REVIEW 2.1 Introduction This chapter highlights the several relevant literatures pertaining to the subject under study. In line with the objectives of the study, the review explores the global land scape of visual impairment as well as its magnitude in Ghana. It delineates the causes and risk factors to vision loss. It also explores the social support, social network and psychological implications of vision loss as well as the health status of VIPs. Furthermore, literature is reviewed to shed light on the types of social support and sources where VIPs get them from. Previous evidence on the barriers and facilitators to seeking social support have also been looked at. 2.2 The global landscape of visual impairment The Ghana Statistical Service (2014b) refers to visual impairment as a functional limitation of the visual system due to a disorder or disease that results in a visual disability or a visual handicap. A visual disability is a limitation of the ability of the individual (e.g. the inability to see), while a visual handicap refers to a limitation of personal and socio-economic independence. Persons with visual impairment include those with blindness, and moderate to severe visual impairment. They are often called Blind and Partially Sighted (BPS) persons. A lot of efforts had been made in the last few decades towards the prevention of avertable blindness and visual impairment, particularly caused by infectious diseases (like trachoma and onchocerciasis), and non- communicable diseases such as diabetic retinopathy and glaucoma (WHO, 2007, 2020). University of Ghana http://ugspace.ug.edu.gh 15 Visual impairment remains a major global health issue in many developed and developing countries (Flaxman et al., 2017). Increasing global age is significantly associated with the high prevalence of visual impairment which is projected to increase over time as the older adult population is expected to double by 2050 (Tetteh et al., 2020). Developed countries would particularly experience an epidemic of increasing eye diseases and visual impairments driven by their sustained aging population (Yoshida et al., 2020). The WHO in 2010 as cited by Nuertey et al. (2020) estimated that approximately 285 million people were visually impaired worldwide, of which 39 million of them were blind and 246 million have low vision. In the African region for instance 26.3 million people were estimated to be visually impaired while 5.9 million were blind (Morone, Cuena, Kocur, & Banatvala, 2012). In Ghana, the 2010 PHC reported that about 1.6% of the national population was living with visual impairment, with the prevalence in Upper West estimated as 1.4% (GSS, 2014b). Nuertey et al. (2020) conducted a study among pensioners in Ghana and indicated that 21.7% had moderate to severe visual impairment with 3.8% being blind, while 25.2% of pensioners had moderate to severe visual impairment in the Upper West Region with 8% being blind. In their study, Tetteh et al. (2020) showed a similar prevalence of 9.9% blindness among older adults in the Upper West Region. Globally, Flaxman et al. (2017) reported that avoidable causes of visual impairment made up 80% of the total cases. In Ghana, a large proportion of cases of low vision (88.9%) and blindness (67.7%) could have been prevented if appropriate actions were implemented (Wiafe, 2015). According to Wiafe (2015), rural residents carry a greater risk of blindness because they are more likely to live in a non-interventional area for eye service and rehabilitation. In the 2010 PHC report for Ghana, the proportion of persons with visual impairment residing in rural (1.8%) localities was reported to be higher than those in urban (1.4%) localities (GSS, 2014b). With University of Ghana http://ugspace.ug.edu.gh 16 regards to sex and age, Tetteh et al. (2020) study among older adults in Ghana revealed that the prevalence of visual impairment was 17.1% with a higher prevalence among women compared to men (18.3% vs 15.7%); and increasing age correspondingly leading to higher occurrence of visual disability. Visual impairment is associated with decreased social participation (Yoshida et al., 2020) since vision is a key factor in living an independent and completely functional life. Visual impairment is reported to harm the emotional well-being, physical functioning, and independent living of the affected person (Hong et al., 2013). Many studies have proven that visual impairment is associated with depression, reduced quality of life, premature nursing home placement, and an increased risk of death (Hong et al., 2013; Opoku et al., 2018; Papadopoulos et al., 2013; Tetteh et al., 2020; Yoshida et al., 2020; Zuchowska-Skiba, 2019). As vision is an important factor in the learning process and also serves as a non-verbal communication channel governing social interaction (Lupón et al., 2018), adults who develop visual impairment later in life experience practical limitations with moving about and visual communication, thereby diminishing their opportunities to participate in social activities outside the home. This makes visual impairment to be associated with a decrease in activities of daily living and compromised mobility, and increased risk of falls, depression, and cognitive impairment (Yoshida et al., 2020). Rey-Galindo et al. (2020) observed that using auditory, tactile, or even olfactory signals provides important information for the VIPs when communicating, therefore designing interventions with signals which consider and highlight these senses is paramount since this would facilitate their adaptation and integration into society. University of Ghana http://ugspace.ug.edu.gh 17 2.3 Causes of visual impairment The global population growth and aging have led to more individuals with moderate or worse vision impairment being added annually (Bourne et al., 2021). In 2010, WHO noted that the main causes of blindness worldwide were cataracts (51% of cases), followed by glaucoma with 8%. With regards to visual impairment, 43% of cases result from problems with light refraction, while cataracts, glaucoma, age-related retinopathy, and undetermined causes result in 33%, 2%, 1%, and 18% of cases respectively (Flaxman et al., 2017). Other risk factors for visual impairment include infections, tobacco use, particulate matter, exposure to ultraviolet radiation, vitamin A deficiency, high body mass index, and metabolic disorders. With cataracts (opacification of the lens) reported globally as the leading cause of blindness, cataract surgery is one of the most cost-effective healthcare interventions available (Flaxman et al., 2017). Visually disabling cataracts is prevalent in developing countries compared to industrialized countries, and though women are at greater risk, they are less likely to have access to eye care services than their male counterparts (WHO, 2007). In Ghana, cataract cases account for 54.8% of the causes of blindness with the risk factors including eye injury, eye diseases (e.g. uveitis), diabetes mellitus, ultraviolet irradiation, and smoking (Wiafe, 2015). Factors such as fear of operation, distance to a service provider, cost of treatment, and lack of awareness had been reported to be the main barriers to cataract treatment and rehabilitation (Wiafe, 2015). Glaucoma, another cause of visual impairment, is a group of eye conditions characterized by damage to the optic nerve (mostly a pathological cupping of the optic disc) and loss of the field of vision. Globally, glaucoma accounted for 8.49% (2.99 – 15.66) of the causes of visual impairment in 2015 (Flaxman et al., 2017). Glaucoma is the second leading cause of blindness, University of Ghana http://ugspace.ug.edu.gh 18 and in Ghana, it accounts for 9.2% of the causes of visual impairment (Nuertey et al., 2020). Though glaucoma is less common among persons under 40 years, the prevalence increases with age (WHO, 2007). Diabetic retinopathy is a complicated outcome of poorly managed diabetes mellitus. Effective management of diabetic retinopathy can be provided by ensuring available and accessible medical services for patients with diabetes mellitus. With more than 600 million people projected to develop diabetes by 2040, coupled with diabetes patients living increasingly longer, the number of people with diabetic retinopathy and resulting visual impairment is expected to sharply rise with time (Bourne et al., 2021). Trachoma, caused by Chlamydia trachomatis is the commonest infectious cause of blindness globally. Trachoma is categorized as a condition of poverty, making it a focal disease that mostly affects communities with unsafe water and poor sanitation, and poor health services (Flaxman et al., 2017). Trachoma requires a range of medical, behavioral, and environmental interventions. However, WHO in 2020 reported that the population at risk of trachoma have dropped from 1·5 billion in 2002 to 142 million in 2019 (WHO, 2020). Onchocerciasis, also known as river blindness, is another eye disease caused by the infectious parasitic worm Onchocerca volvulus. Symptoms include severe itching, bumps under the skin, and blindness. The disease is spread by repeated bites from infected black flies. It is more prevalent among those who live in remote African villages. Onchocerciasis, therefore, is the second commonest causes of infection-related blindness in Sub-Sahara Africa, after trachoma. With strategic intervention by WHO's Onchocerciasis Control Programme, this condition has University of Ghana http://ugspace.ug.edu.gh 19 been brought under control in many parts of West Africa with the disease no more a public health concern in many countries (WHO, 2007). In many countries, non-surgical (education and antibiotics) and surgical measures had been the most cost-effective interventions for controlling blindness. According to WHO (2007), socioeconomic studies indicated that prevention and treatment of avertible blindness had promoted and accelerated achievement of broader global development agenda, e.g. the Millennium Development Goals (MDGs). These measures prevented lost education and employment opportunities, lowered productivity, and reduced quality of life that are caused by visual impairment. Voluntary Eye services and rehabilitations should therefore be extended to rural communities such that those at the highest risk (the poor and adults over 50 years of age) can access them since they are more vulnerable and particularly hard hit by the repercussions of visual impairment. In 1999, the global initiative called „VISION 2020: the Right to Sight‟ was launched by WHO and International Agency for the Prevention of Blindness (IAPB), with the target of eliminating the main causes of avoidable blindness by the year 2020 (Komla et al., 2020). The initiative works by the planning, development, and implementation of sustainable national eye-care programs in low and middle-income countries. The core strategies were disease control, developing the human resource, and improving infrastructure and technology with primary health care serving as the guiding principles (WHO, 2007). After a decade of implementing „VISION 2020‟, visual impairment continues to add more people to the dependent populations of most economies. In 2013, the World Health Assembly (WHA) University of Ghana http://ugspace.ug.edu.gh 20 launched a new plan, towards universal eye health: a Global Action Plan 2014–2019 (GAP) to achieve by 2019 a 25% reduction from the baseline of 2010 in the prevalence of “avoidable” visual impairment (Bourne et al., 2021). 2.4 Social support, social network, psychological implications of vision loss, and health status of VIPs Vision is a key sensory modality for individual interpersonal interactions and social communication, hence people with vision loss have fewer opportunities to learn and modify social skills (Tetteh et al., 2020) which could be enhanced by persons in their social network. Heppe et al. (2020) observed that small social networks, peer rejection, and low friendship quality in adolescence correlate with feeling lonely. Facing the significant challenges instigated by small social networks often leads VIPs to seek social welfare support to maintain their basic living needs (Liu et al., 2020). Zuchowska-Skiba (2019) described social support as the degree to which an individual‟s basic social needs are met in their interactions with others. Social support is proven to act as a buffer and facilitates positive and proactive reactions to stress, hence individuals with strong social support systems report fewer psychological, physical, and social problems than those without it (Hapke, 2015). Among adults with visual impairment, higher levels of perceived and received social support are associated with better psychological well-being (Heppe et al., 2020). With lack of social support, vision loss had consistently been found to be associated with depression, reduced quality of life, premature nursing home placement, and an increased risk of death (Hong et al., 2013). University of Ghana http://ugspace.ug.edu.gh 21 Haegele et al. (2018) established that adults with visual impairments tend not to engage in health- enhancing levels of physical activity, which can have health-related and quality of life consequences. Adam (2018) stated that financial constraints, lack of social support, and an unfriendly physical environment are some barriers that prevent persons with a visual impairment from engaging in desired leisure activities including health-enhancing physical activity. Enhancing quality of life involves activities that promote a person‟s general feelings or perception of well-being, opportunities to fulfill potentials, and positive social involvement (Ntibea, 2011). Positive social involvement includes social participation and interaction with the social environment. Yoshida et al. (2020) noted that social participation is a key determinant of active aging, which is defined by the WHO in 2000 as “the process of optimizing opportunities for health, participation, and security to enhance the quality of life as people age”. Failure to optimize social participation results in social isolation leading to a higher prevalence of depression among persons with visual impairment (Tetteh et al., 2020). Heppe et al. (2020) suggested that low levels of social support lead to higher levels of depression for adults with visual impairment due to stress. Peer relationships, a crucial part of social support networks had also been reported to provide resilience against stress (Lee & Goldstein, 2016). Persons with visual impairment face numerous stresses in society including gender-based violence. Without adequate social support, this puts them at risk of sexually transmitted infection and psychological distress (Azumah, Samuel, Nachinaab, & Serwaa, 2019). A cross-sectional study in Norway reported that the prevalence of sexual assaults (rape, attempted rape, and forced into sexual acts) in the visually impaired population was 17.4% (95% CI = 14.0 - 21.4) among women and 2.4% (95% CI = 1.2 - 4.7) among men which were higher than 10.1% (95% CI = 8.3 University of Ghana http://ugspace.ug.edu.gh 22 - 12.1) among females and 1.7% (95% CI = 1.0 - 2.8) among males in the general population (Brunes & Heir, 2018). 2.5 Forms of social support The provision of adequate social support benefits persons with visual impairment in several ways including improving physical health, greater resilience to stress, improving self-esteem, feeling of security, improving mental well-being, and greater life satisfaction (Barr, Hodge, Leeven, Bowen, & Knox, 2012; Barrow, Ting, & Patel, 2018; Elsman et al., 2019; Manitsa & Doikou, 2020; Papadopoulos et al., 2015, 2014; Pinquart & Pfeiffer, 2013; Sim, 2020; Stevelink, Malcolm, & Fear, 2015; Tetteh et al., 2020; Vega et al., 2019; WHO, 2011). Many forms of social support had been identified and can be grouped into emotional support (provision of trust, sympathy, and encouragement), instrumental support (practical assistance), informational support (provision of advice), and appraisal support (Barrow et al., 2018; Cutrona & Russell, 1990; Papadopoulos et al., 2015, 2014; Pinquart & Pfeiffer, 2013). Emotional support is defined as affective support and includes expressions of concern resulting in feelings of being accepted, respected, included, and having one‟s emotions acknowledged (De Almeida Holanda et al., 2015; Papadopoulos et al., 2014) mostly expressed by support agents in the form of provision of empathy, affection, love, trust, and care (García-Martín, Hombrados- Mendieta, & Gómez-Jacinto, 2016). Vision loss has been likened to the grieving process and as such, the person may experience a range of similar emotions such as anger, denial, hopelessness, fear, depression, and guilt (Papadopoulos et al., 2013). Provision of adequate emotional support would serve as a buffer against the psychological trauma during and after the grieving process University of Ghana http://ugspace.ug.edu.gh 23 (Papadopoulos et al., 2014). Emotional support thus helps with managing emotions such as stress, anger, or depression (Barrow et al., 2018). Instrumental support means giving tangible help such as material support and help that directly support a person in need (García-Martín et al., 2016). These include food, clothing, and cash remittances, and in-kind assistance. Notably, PWDs often receive food and clothing from family members, friends, and donations from other benevolent agencies such as churches and governmental and non-governmental organizations (Opoku et al., 2018). In Ghana, PWDs are cushioned financially from the Disability Common Funds (DCFs) where three percent (3%) from the District Assembly Common Fund (DACF) is apportioned into (NCPD/GFD, 2010). Aside from the DACF, another instrumental social support at the national level is the Livelihood Empowerment Against Poverty (LEAP) program which mandatorily enrolls PWDs in Ghana (Dako-Gyeke, 2013; Handa et al., 2014; Ministry of Gender Children and Social Protection, 2015). The LEAP program is a social cash transfer program under which cash and health insurance are provided to the extremely poor households across Ghana with the target of alleviating short-term impoverishment and promote long-term human capital development (Handa et al., 2014). Informational support is the provision of suggestions, advice, and information that a person can use to solve problems (Agyire-tettey & Naami, 2019; García-Martín et al., 2016; Glanz et al., 2014; Opoku et al., 2018). The provision of informational support such as suggestions, advice, or guidance is crucial for persons with impairment to deal with personal or circumstantial challenges (Barrow et al., 2018). The provision of informational support by trusted friends and love ones would help persons with a visual impairment feels less anxious and stressed out in coping with University of Ghana http://ugspace.ug.edu.gh 24 challenges involved in the condition. Giving visually impaired people direction to navigate their environment could also be termed as informational support. This form of support is often rendered by families and other people in VIPs informal social network. Appraisal support involves the provision of information that is useful for self-evaluation and adaptation (Glanz et al., 2014; Moore & Barnett, 2015). Appraisal support entails the provision of information in the form of social comparison or evaluative feedback to the receiver of support (García-Martín et al., 2016). Appraisal support includes the provision of feedback regarding the performance or personal qualities. This helps persons with visual impairment to evaluate themselves and readjust to fit into society. Appraisal support usually comes from the community support network of VIPs. 2.6 Sources of social support for VIPs Social support can be provided by people in the formal and informal network of persons with visual impairment. The formal support sources are institutional systems that facilitated the support for PWDs (Agyire-tettey et al., 2019). These include the various groups that aim at drawing stakeholders‟ awareness about the capabilities of persons with visual impairment and also engage in through advocacy, lobbying, and collaborating with other relevant agencies to improve VIPs wellbeing. The DACF assists PWDs with cash (through DCF) and training to improve their wellbeing (NCPD/GFD, 2010). The DACF was created under Article 252 of the 1992 Constitution of Ghana, agreeing that a minimum of 5.0% of the national revenue should be set aside to be shared among all District Assemblies in Ghana which should be used to support PWDs (NCPD/GFD, 2010). In addition, the department renders counseling services and operates rehabilitation centers. University of Ghana http://ugspace.ug.edu.gh 25 Another formal support source is the Ghana Association of the Blind (GAB) established in 1963. It is the mouthpiece of the BPS persons in Ghana and has consistently advocated for their rights to be recognized in society (GAB, 2006) as well as the need to be cushion financially. However, the Ghanaian economy generally lacks a robust social safety net, making it difficult for the marginalized in society (e.g. VIPs) to be inclusively supported (Naami & Mfoafo-M‟Carthy, 2020). Informal support sources include support from the family and other outside family social relations, through which persons living with visual impairment receive support (Barrow et al., 2018). Thus family and friends are usually the first points of call for help of PWDs. The family is often referred to as the backbone for PWDs since they are the closest contacts with regard to assistance in everyday challenges (Opoku et al., 2018). Other sources of informal support include that offered by peers, teachers, and other professional networks (Pinquart & Pfeiffer, 2013). Evidence on social support suggested that people with strong social support networks tend to report fewer psychological, physical, and social problems than those without such support (Hapke, 2015). 2.7 Barriers to social support The role of social support in ensuring that VIPs live a productive and satisfying life cannot be underestimated. However, VIPs do not get access to adequate social support due to human and environmental barriers. To help tackle these problems, there is the need to understand more about the barriers that VIPs face, which could be taken into consideration in policy development and the provision of social incentives. A range of barriers contribute to the inability of VIPs to access desired assistance, including the burden of appointments, travel to access services, stigma and University of Ghana http://ugspace.ug.edu.gh 26 negative staff/community attitudes, personal ill-health, lack of material/informational resources, and anxieties about accessing support (Agyire-tettey et al., 2019). Transportation is a notable barrier to seeking formal support for VIPs. Transportation systems in Ghana are not favorable to be used by PWDs and this leads to them missing out on support opportunities that may be available to them (Agyire-tettey et al., 2019). To travel from their homes to the various offices to seek formal support services, they have to get assistance from others which in most cases come with cost. Bad roads and lack of means of transport accounted for much of challenges faced by VIPs in seeking formal support services. Insufficient information exchange between service providers and disability groups has also been identified as a challenge that PWDs face in seeking formal support services (Badu, Agyei- Baffour, & Opoku, 2016). The rampant use of posters, billboards, clipart, etc. disadvantaged those with visual impairment in the community. Radio announcement of most available support services are irregular and even do not get to VIPs in remote villages. Infrastructural barriers include confusing roads, inaccessible structures, open gutters, and poor drainage systems. Where PWDs have access to information and had travelled to government and Civil Society Organization (CSO) offices, yet independent access to the buildings could still be a challenge. Regarding feelings of safety during their travels, most VIPs expressed feeling unsafe while traveling, in a study carried out by Rey-Galindo et al. (2020). One of the major barriers to seeking formal support is institutional barrier. This involves procedures VIPs need to go through to receive formal support. The protocols in accessing social support are so cumbersome compelling some VIPs to give up on seeking support. With the introduction of digital processes University of Ghana http://ugspace.ug.edu.gh 27 in many registration centers in Ghana, visually impaired individuals may not be able to independently take advantage of visual aid benefits (Naami & Mfoafo-M‟Carthy, 2020). Misconceptions regarding the causes of visual impairment, like the erroneous assumption that it is caused by non-biological or genetic processes can lead to stigmatization of VIPs. The VIPs are socialized to internalize the negative view of visual impairment collectively held by society (Adam, 2018). To tackle discrimination and stigmatization, some governments had passed legislation against disability discrimination (USA 1990; Zimbabwe 1992; Australia 1993; India 1995; Bangladesh 2001) which is often the first step towards fairness and equality (Isaac et al., 2010). A study conducted in Israel indicated that perceptions of visual impairment as a form of punishment for “wrongdoing” lead to stigma by some cultures, with Israeli Arab-Palestinians reporting higher occurrence of punitive attributions to visual impairment, consequently resulting in elevated incidence of stigma (Soffer, 2019). In seeking available support services from formal and informal information sectors, PWDs were constrained by the negative perceptions people had about their disabilities and capabilities in any endeavor or work. This stigma also leads to individuals with a visual impairment being substantially discriminated against even in renting accommodation (Verhaeghe, Van Der Bracht, & Van De Putte, 2016). 2.8 Facilitators of social support The availability of social support is not enough for VIPs to access. Several social factors encourage visually impaired persons to solicit available social support within their catchment area. University of Ghana http://ugspace.ug.edu.gh 28 Formal education enhances one‟s networks and social status and in addition enlightens an individual of opportunities (Adam, 2018). Formal education tends to enlighten individuals with visual impairment causing them to rely on their abilities and focus less on the impairment. Additionally, being formally educated empowers the PWDs to resist some of the negative socio- cultural inclinations of disability making it unlikely for educated PWDs to cite their impairment as an impediment to their freedom. However, PWDs, on average, have lower levels of education than those without disabilities (Shandra, 2017). Evidence suggest that, relatively high-income earning VIPs are less likely to cite lack of social support as a reason for their inability to undertake normal activities (Adam, 2018). Legislative policies such as Disability Act (Act 75) ensure that persons with visual impairment are entitled to some basic services (Ghana Disability Act, 2006). Providing healthcare (general and specialist care) is guaranteed free for all PWDs in Ghana. The National Social Protection Policy serves as a guideline for providing social protection coherently, effectively and efficiently in Ghana. Per the policy, social protection in Ghana defined as “a range of actions carried out by the state and other parties in response to vulnerability and poverty, which seek to guarantee relief for those sections of the population who for any reason are not able to provide for themselves” (Ministry of Gender, Children and Social Protection, 2015). Ghana is also a signatory to and has ratified most of the relevant Conventions, Treaties and Protocols of the United Nations and the African Union for social protection. These are the Universal Declaration of Human Rights, the United Nations Conventions on the Rights of the Child and Persons with Disabilities (UNCRPD), the Millennium Development Goals (MDGs) and the post-2015 Sustainable Development Goals (SDGs). University of Ghana http://ugspace.ug.edu.gh 29 The employment status of persons with visual impairment appears to play a significant role in accessing social support, as employed visually impaired individuals had been found to have larger and more supportive networks than their unemployed counterparts (Papadopoulos et al., 2015). This makes accessing formal social support less stressful. Also, persons with disabilities are less likely to be employed, but more likely to lose their jobs. It is reported that majority of persons with disabilities work in vulnerable employment, characterized by low income, lack of job security, and poor job-related benefits (Naami & Mfoafo-M‟Carthy, 2020). Having strong social cohesion is also key for persons with visual impairment to access social support. Visually impaired persons with large and active networks of people find it easier to access social support (Papadopoulos et al., 2015). Social cohesion involves creating shared values that enable people to have a sense that they are engaged in a common enterprise, facing shared challenges, and that they are members of the same community. This gives confidence and hopes to VIPs to seek assistance with the belief that they are recognized and appreciated as members of the community. Ghanaians for instance, cherish the collective family system, a form of social cohesion, where the family oversees the overall wellbeing of its members, regardless of disability status though this had been threatened by modernization and urbanization (Dako-Gyeke, 2013). University of Ghana http://ugspace.ug.edu.gh 30 CHAPTER THREE 3.0 METHODOLOGY 3.1 Introduction This chapter gives an outline of the methods that were employed to explore the social support and psychological implications of vision loss among the VIPs in the Lawra Municipality. It gives a description of the study design, study area, study population, sampling procedure, tools, and techniques that had been used in collecting the data, and how the data was analyzed as well. 3.2 Study design A non-analytic study design using phenomenology was employed to achieve the objectives of the study. Phenomenology, according to Bryman (2012) is a philosophy that is concerned with the question of how individuals make sense of the world around them and how in particular the philosopher should bracket out preconceptions about a phenomenon of interest in his or her grasp of the world. Phenomenology is selected as appropriate because the primary aim of the research is to explore the lived experiences of VIPs and their satisfaction with the available social support rendered to them (Patton, 2014). Satisfaction with social support can be better explored using qualitative research (e.g. phenomenology) instead of a quantitative approach. With the qualitative study, the researcher focused on learning the meanings the participants alluded to their experiences, and not the meaning that the researcher brings to the study or writers express in the literature (Creswell, 2009). The phenomenology approach, therefore, provided a rich textured description of lived experience as supported by Lune & Berg (2017). University of Ghana http://ugspace.ug.edu.gh 31 3.3 Study area The study was undertaken in the Lawra municipality of Upper West Region, Ghana. The overall population of the study area, according to the 2010 PHC, is 54,889 (GSS, 2014c). Lawra municipal is located within Latitude 100 30 & 100 10 58 N and Longitude 20 30 & 20 45 W of North-Western Ghana. It is bordered by Nandom municipal to the North, the Black Volta and Burkina Faso to the West, Lambussie district to the East, and Jirapa municipal to the South. The municipality is decentralized into five (5) sub-municipals for health care delivery which are Babile, Domwine, Eremon, Lawra, and Zambo. Though mainly populated by Dagaabas (the indigenes), other minor tribes are present such as Akans, Hausa, Mossi, and Fulani. Agriculture is the predominant economic activity with others working in commerce and government employment. According to GSS (2014c), most of the inhabitants depend on solid fuel and open water sources for their domestic activities 3.4 Study population The study population includes individuals with visual impairment who reside in the municipality. According to GSS (2014c), a total of 1,123 persons with visual disabilities living in the municipality are fifteen years and above. Persons with visual impairment age 18 years and above qualified to be recruited as participants. Those who are ready to participate were asked to give informed consent after giving them enough information about the study. . 3.5.0 Sampling strategies 3.5.1 Sampling procedure The study recruited 50 participants, including twenty (20) participants for In-depth Interviews (IDIs) and thirty (30) participants for five Focus Group Discussions (FGDs) comprising of six (6) University of Ghana http://ugspace.ug.edu.gh 32 participants per group. According to Francis et al. (2009), a qualitative study would reach saturation within 17 IDIs conducted. Hanscock et al. (2016) also reported that qualitative research employing an inductive approach reaches saturation by the completion of five (5) FGDs. In recruiting the participants, a cross-section of the blind and partially sight persons in the municipality were given information about the study in the presence of a witness, and those who agreed to participate were required to thump print a consent form. In this research, each of the five sub-municipalities in the Lawra Municipal was deemed a stratum. Four (4) IDIs and one (1) FGD comprising of six (6) VIPs were done in each stratum and all the participants were purposively sampled using the maximum variation strategy. In qualitative research, stratified purposive sampling is used to give details about a research problem and the phenomenon under study by recruiting persons who fit the criteria (Bryman, 2012; Creswell, 2009). Maximum variation is an approach used in selecting the sites and socio- demographic differences of respondents to ensure that varied locations or individuals are chosen to reflect any dissimilarity in opinions expressed (Creswell, 2009). The maximum variation strategy aims at capturing and describing the ideal lived experiences that cut across various groups of VIPs with respect to localities, age differences, sex, education, occupation, and religious backgrounds such that the information gathered is not biased. 3.5.2 Inclusion and exclusion criteria Blind and partially sighted persons of above 18 years who have difficulty moving about on their own due to the vision loss and are permanent residents of the area formed the target group. However, those with any other disabilities were excluded from the study. Those that took part in the FGDs were exempted from the IDIs and vice versa. In addition, qualified participants who demonstrate signs and symptoms of ill health were exempted from the study. University of Ghana http://ugspace.ug.edu.gh 33 3.6.0 Data gathering and analysis procedures 3.6.1 Data collection methods Information from the discussions and interviews was elicited using FGD and IDI guides. Data collection took place in a natural setting, thus the researcher and the assistants had a face-to-face interaction with participants in real-time. Two research assistants were recruited and trained during the pre-testing in Nandom on 4 th and 5 th of October, 2021 on all aspects of the study and were same used in the actual data collection. While the researcher was keenly listening to the interactions, probing into emerging issues and jotting notes, one assistant was moderating the sessions and the other engaged in audio-recording and timing the sessions. Considering the nature of the study, an open-ended questionnaire was appropriate since it provided flexibility (Lune & Berg, 2017) by allowing the researchers to probe into emerging insights and also giving opportunities to participants to elaborate more on their responses. Moreover, the flexible nature of the discussions/interviews generated multiple and divergent responses from the participants that enhanced the understanding of the topic under study (Bryman, 2012; Creswell, 2009). The FGDs were conducted to discover group opinions of issues that affect the VIPs as well as describing the varied perspectives that surround their scenarios. It offers the opportunity of allowing participants to probe each other‟s reasons for holding a certain view. As participant listens to others‟ answers, he or she may want to qualify or modify a view; or alternatively may want to voice agreement to something that he or she probably would not have thought of without the opportunity of hearing the views of others (Bryman, 2012). University of Ghana http://ugspace.ug.edu.gh 34 Fear of stigma, discrimination, and cultural norms could intimidate some participants to feel uncomfortable expressing their opinions on all issues and sharing their experiences within the group context. Hence IDIs were conducted to gain any private information from participants concerning the objectives of the study (Bryman, 2012). All discussions were done in the local dialect (Dagaare) because literacy, in general, is low in the Lawra municipality (GSS, 2014c), thereby reducing the chances of the VIPs being formally educated. Each IDI took about 45 minutes while the FGDs lasted an average of 80 minutes. The audio recordings were accompanied by field notes. For the IDIs, data saturation was achieved by the fourteenth interview, while that of the FGDs reached saturation at the fourth group discussion; nonetheless, six additional IDIs and one more FGD were conducted to ensure that new relevant issues were not missed. 3.6.2 Data collection instruments The qualitative data was collected using IDI and FGD guides as well as field notes. Both guides consisted of the same open-ended questions posed to participants on their socio-demographic characteristics, sources and forms of social support, psychological implication of visual loss, barriers and facilitators to accessing social support as well as the their satisfaction with the support they received from the community and formal systems. They were also asked of the benefits of social support and the unmet needs of VIPs in the municipality. Open-ended questions allowed the researcher to gather more detailed and in-depth information about a research subject (Bryman, 2012). The IDIs and FGDs were audio-recorded. The audio- recording gives ample time for the researcher to focus on the interaction rather than handwritten recordings (Macdonald & Headlam, 2016). University of Ghana http://ugspace.ug.edu.gh 35 A back-to-back translation by the researcher and a peer (who are both proficient in English Language and Dagaare) was done as all discussions and interviews were conducted in the local language, Dagaare. By employing this, the FGD and IDI guides which were formulated in the English language were translated and transcribed by the researcher and his peer into Dagaare language then an agreement was reached before the guide was deployed. The audiotape interviews and discussions were again transcribed back to the English language. A third person was involved to intensify the clarity of the transcription wherever the need arose. 3.6.3 Pretesting of the discussion/interview guides To ensure credibility, the guides for the FGDs and IDIs were pre-tested on the 4 th and 5 th of October, 2021 in Nandom municipality which shares a border with the northern part of Lawra municipal. The pre-testing assesses the guides for participants' understanding of the questions. It was also an opportunity to assess the data collection assistants of their ability to moderate and audio-record the interviews and discussions as well as train them on ethical issues in the study. Amendments were made on unclear and sensitive questions in the guide before being deployed for use in the main study. Nandom municipal, recently carved out from the Lawra municipal, was chosen because it shares common geographical and cultural characteristics with the study area than the other neighboring districts hence experiences of VIPs in Nandom municipal might not differ much from those in the study area. 3.6.4 Data processing and analysis The qualitative data from audio-recorded FGDs and IDIs were transcribed into the English Language in the form of a word document. The field notes that accompanied the IDIs and FGDs captured socio-demographic characteristics of participants and their non-verbal communications University of Ghana http://ugspace.ug.edu.gh 36 such as gestures, facial expressions, and emotions. These were interpreted as part of data collected. The transcripts were cleaned, formatted, and uploaded into a Computer Assisted Qualitative Data Analysis Software (CAQDAS) called NVIVO statistical software (latest version 2020) as recommended by Bryman (2012). The data were further reorganized suitably for exploratory purposes in the software where searches or queries of coded passages identified particular codes that co-occurred, overlapped, or appeared in a sequence. A „word cloud‟ was run to give a clear idea of the frequently used words in the transcripts (Saldaña, 2013). The analysis employed thematic and inductive strategies (Clarke & Braun, 2013; Braun & Clarke, 2017). A thematic analysis demands first reading and rereading the transcribed data to get familiar with it, then initial codes that emerge were collated into themes which were refined to ensure that the themes represent a coherent pattern as well as resonate with the research objectives (Braun & Clarke, 2017; Bryman, 2012; Clarke & Braun, 2013; Creswell, 2009). The coding method used descriptive-focused coding by assigning words or short phrases to summarize the most frequent or significant patterns of ideas expressed by the participants (Saldaña, 2013). The codes were eventually categorized into eight major themes which are “sources of social support”, “psychological impacts of visual loss”, “satisfaction with social support”, “barriers to accessing community support services”, “barriers to accessing formal support services”, “unmet needs of VIPs”, “facilitators to accessing social support; or “health benefits of received social support”, then, several sub-themes were placed under each major theme. The NVIVO software reorganized all of the sub-themes relating to the texts replicating them into “References” as count levels that helped in formulating and determining the magnitude of the major and sub-themes in the thematic analysis. After developing themes, codes, word University of Ghana http://ugspace.ug.edu.gh 37 frequency, word-cloud, tree-map, or clustered-tree were generated to visualize the correlation among various codes and some themes. For the inductive data analysis; patterns, categories, and themes were derived from the bottom- up, by organizing the data into increasingly similar themes. The inductive process means working back and forth between the themes and the database until a comprehensive set of themes was established (Creswell, 2009). Where names of persons were mentioned in the interviews/discussions, pseudonyms were used to ensure that no information is linked to any participant. In presenting the findings, percentages were used to improve the transparency of the data analysis, give precision to statements, enable patterns in the data to emerge with greater clarity and increase the meaning of key findings in their lived experiences. According to Neale, Miller, & West (2014) a qualitative study can use percentages in presenting the findings if the sample size is 50 or thereabouts. By doing so the researcher ensured that every participant gives their opinion or scenario on each question asked in order to form a solid denominator. However, no inferences can be drawn about the prevalence or magnitude of their shared experiences or scenarios beyond the sample. Some explanatory citations were used to buttress important patterns that emerged from their narrated experiences. 3.7 Ensuring Qualitative Rigor To produce credible and valid findings, several strategies such as credibility, confirmability, dependability, reflexibility, reflexity, peer debriefing, member checking, and using the participants‟ words in the final report were employed (Creswell, 2009). Credibility was obtained by piloting the interview/discussion guides among VIPs in Nandom municipal before being University of Ghana http://ugspace.ug.edu.gh 38 launched in the study area. Confirmability was ensured by two independent reviewers (the study supervisor and a peer) reviewing the proposal and the data collection instruments for appropriateness. With regards to dependability, the methodological processes had been fairly illustrated to enhance future replication of this study. In ensuring reflexibility, two assistants were involved in audiotaping and moderating the interactions while the researcher paid attention to the issues raised in the discussion in order to examine their feelings, reactions and motives behind their scenarios. Aside from that, during the FGDs, enough time was given to each participant to make their contributions before the next question was asked. Reflexity means a qualitative researcher stating personal assumptions/biases and beliefs that may affect the participants scenarios or the research in general. Reflexity was employed by suspending all personal understanding of their lived experiences to encourage probing into emerging issues. For the member checking, four transcripts were returned to the corresponding participants to check for accuracy and resonance with their scenarios/experiences to ensure that obvious mistakes were not made during translation or transcription. The four research participants were asked to confirm the responses from the interviews to ensure that the findings were consistent with their expressions to avert possible biases and inconsistencies in participants‟ narratives. Verbatim transcription was also employed to reduce the chances of losing the respondents‟ submissions due to interpretation or summary in the course of transcribing. Peer debriefing was ensured by two reviewers (the study supervisor and a peer) to review and assess verbatim transcriptions, emerging and final categories codes from the transcriptions, and the final themes or findings in the study. Where necessary, the participants‟ own words were used in explaining contexts during presenting and discussing the results. University of Ghana http://ugspace.ug.edu.gh 39 3.8 Ethical consideration The qualitative data was collected from October to December 2021 per the Declaration of Helsinki following approval from the Ghana Health Service Ethical Review Committee (Protocol ID NO: GHS-ERC 038/08/21), while permission to access the participants was sought from the Lawra Municipal Coordinating Directorate. Informed consent was obtained from the VIPs in the presence of a witness after reading the research purpose and its objectives to them in Dagaare language, then having their questions addressed. It was made known to participants that they could decline to answer any question or withdraw at any stage of the study without repercussion. Aside the risk of contracting COVID-19, the study carries no known physical and mental harm, but participants were informed to decline to answer any question that may pose psychological stress to them or their families. Participating in the study had no direct benefit, but a package of detergents (a bar of key soap and washing powder) was presented to each participant in appreciation of their participation. 3.9 Privacy and confidentiality All data collected for the study were kept private and protected by a password known to the investigator only. All participants/groups interviewed were assigned a unique identification number only for data sorting, and no names or traceable identity was attached to any study data by ensuring that pseudonyms are used where names of persons are mentioned in the transcripts. Before that, confidentiality was ensured as names and identifiable information were not even included in the demographic information section of the data collection tools. As much as possible, discussions/interviews were conducted in places that reduce the chances of public viewing. University of Ghana http://ugspace.ug.edu.gh 40 CHAPTER FOUR 4.0 RESULTS 4.1 Introduction This chapter deals with the analysis and presentation of the findings from the qualitative data collected for this study. The results are arranged in themes and sub-themes in line with the research questions of this study. Diagrams and tables are used to display a basic visual representation of the coded information while their lived experiences are presented verbatim. The chapter summarily presents results on the socio-demographic information, sources and kinds of social support, facilitators and barriers to social support, the participants' satisfaction with social support, the psychological implication of vision loss, etc. 4.2 Socio-demographic information of the participants The personal information of the participants revealed that majority of the participants is within the age range of 60-79 years (40%) with 30% being above 80 years while 20% were between 40 and 59 years. With regards to sex, most of the participants were females (68%) with the remaining being males. In terms of marital status, 50% participants were widowed with 36% currently married while 12% were single. Most of them (74%) acquired vision loss between the ages of 18 and 79 years while 14% and 12% of the cases occurred before the age of 18, and after 80 years old, respectively. Among them, 88% had no formal education with only 8%, 2%, and 2% obtaining primary, secondary, and tertiary education respectively. The predominant occupation among those productive was farming (32%) but 30% of the participants were aged and thus were not working. In terms of religion, 50% participants were Christians while 46% are African Traditiona