Title:

Exploring the potential of occupational therapy for visually impaired adults in Malaysia using the Kawa Model: A qualitative pilot study

Bachelor’s Degree Candidate: Teoh Jou YinMatric. No. : A 118729

Supervisors: Pn Saraswathy VenkataramanDr Michael K. Iwama (Canada – Kawa Model Author)

Introduction: •Occupational therapy is a health profession that endeavours to help people engage and participate in purposeful and meaningful activities of daily living (AOTA 2008)

•In the field of visual rehabilitation however, not much is known of the role and potential of occupational therapy. (Warren 1995; Bachelder & Harkins 1995; Teitelman & Copolillo 2005)

•Occupational therapists use conceptual models to guide and explain their practices. (Kielhofner 2004) However, not much is known of how they influence or determine specific client needs for occupational therapy.

•In this research, a student occupational therapist employs a relatively new model of occupational therapy- the Kawa Model (Iwama 2006) in attempting to comprehend the daily living experiences of people with visual impairment and their subsequent need for occupational therapy.

Abstract

This study aims to illuminate and comprehend the daily lived experiences and occupational needs of Malaysian adults with visual impairments through the collection of potential narratives guided by a contemporary occupational therapy practice framework called the Kawa Model. (Iwama 2006) It also aims to provide insights to the efficacy and potential contribution of occupational therapy in visual rehabilitation as well as how the use of different occupational therapy frameworks can influence the identification of specific client needs. A phenomenological naturalistic inquiry (Depoy & Gitlin 2005) will be conducted by use of semi-structured, open-ended interviews on six Malaysian adults experiencing visual impairments utilizing (1) a questioning tool based on the Kawa Model (Iwama 2006) and the Occupational Therapy Performance Framework (OTPF: AOTA 2008) and (2) the Canadian Occupational Therapy Performance Measure (COPM: Law et al. 1994; Roberts et al. 2008). The results of the interviews will then be transcribed verbatim, coded and transcripts from the Kawa Model / OTPF questioning tool categorized according to themes determined by Kawa Model concepts whereas transcripts from the COPM are categorized according to themes from the Canadian Model of Occupational Performance. (CMOP) The results will then be compared and the effects of the Kawa Model in revealing the occupational needs of visually impaired clients and it’s implications in uncovering potential for the implementation of occupational therapy as well as in guiding practice will be discussed.

Research questions

1) What are the daily lived experiences of Malaysian adults diagnosed with visual impairment from an occupational perspective?

2) How does the use of a specific conceptual model of occupational therapy practice influence the identification of daily living issues and challenges for people with visual impairment?

3) Based on the issues identified through the Kawa Model, what benefits and services can occupational therapy potentially offer to the visually impaired population?

Main Question

What are the lived daily experiences and occupational needs of Malaysian adults diagnosed with visual impairments and what benefits and services might occupational therapists offer to this population?

General Objective:

To illuminate and comprehend the daily lived experiences and occupational needs of Malaysian adults with visual impairments through the collection of potential narratives guided by the Kawa Model.

Specific Objectives:

1. To obtain an occupational perspective of client’s lived experiences through conceptual models of occupational therapy.

2. To explore how the use of a specific OT conceptual model will influence the identification of daily living issues/challenges for people with visual impairment.

Rationale

• The Right To Be Blind Without Being Disabled (Tenberken & Kronenberg 2005) first opened my eyes to the world of the blind and visually impaired.

• Developing awareness of the visually impaired community’s demands and actions for more responsibility in determining the paths of their own lives and future.

Why the Kawa Model? (Iwama 2006)

• The Kawa Model provides the opportunity for clients receiving occupational therapy services to provide the meanings to components of their own lived experiences.

• Clients play a more participatory role in articulating and subsequent decision making about how occupational therapy services should be implemented.

• The Kawa Model provides a more holistic worldview of the dynamic interaction processes between the clients and their environmental contexts. Occupational therapists would be able to see the world from the client’s point of view.

• Not much is known about the implementation of the Kawa Model on persons with visual impairment.

Literature Review

• Current Issues in Visual Rehabilitation

-Number of people worldwide experiencing visual impairment and blindness exceeds those of AIDS. (Chiang et al. 2006) - Blindness and visual impairment is theme of the 59th World Health Assembly (WHO 2006)- Blindness and visual impairment presents high socioeconomic costs at both macro and micro levels (Meade 2003)- Call for multidisciplinary approach in visual rehabilitation (KL Vision 2011) and more meaningful and relevant practice (Frank 2000)- Visually impaired community wants more involvement (Duckett & Pratt 2007; Fourie 2007; Franits 2005) - Impact of social model on visual rehabilitation (Bolt 2005; Warren 1995; Bachelder & Harkins 1995) - Disparities between medical and social models (Brace et al. 2007) and the challenges caused by this issue (Rosenthal 1995; Kielhofner 2005; Franks 2000; Taylor 1990)

• Occupational Therapy in Visual Rehabilitation

-Occupational therapy is a health profession committed to “promoting the health and participation of people, organizations, and populations through engagement in occupation” with the concept of “occupation” being defined as “purposeful and meaningful activities”. (AOTA 2008) - Efforts to engage the involvement of the occupational therapy community in the field of visual rehabilitation since the mid-1990s (Warren 1995, Bachelder & Harkins 1995)- Yet to establish proper presence or have frame of reference specifically for visual impairments (Copollilo & Teitelman 2005; Cleveland 2008)- efforts however, by the American Association of Occupational Therapists (AOTA) to collaborate with American Academy of Ophthalmology, the American Optometric Association, and the Association for Education and Rehabilitation of the Blind and Visually Impaired (Cleveland 2008)

• Conceptual Models in Occupational Therapy

-Occupational therapists employ conceptual models as a way to explain and guide their practices (Kielhofner 2004)- Model of Human Occupation (Kielhofner 2002)- Person-Environment-Occupation Model (Law et al. 1997)- Canadian Model of Occupational Performance- Person-Environment-Occupation-Performance Model (Christiansen & Baum 2005)- Ecology of Human Performance (Dunn et al. 1994)- the Occupational Performance Model (Australia) (Chapparo & Ranka 1997)- Occupational Performance Process Model. (Fearing & Clark 2000) - Kawa Model (Iwama 2006)

• Lived Experiences of People with Visual Impairments

- Many narratives of lived experiences of people with visual impairments (Carey 2001; Maley 2005; Tenberken & Kronenberg 2005; Jones 2006; Pepper 2006; Fourie 2007) - None specifically geared towards an occupational perspective except Rosenthal (1995)- Most about personal experiences growing up with or coping with specific conditions (Maley 2005; Jones 2006; Pepper 2006, Fourie 2007)

Methods

To obtain the data, a phenomenological type study (Depoy & Gitlin 2005) of 6 visually impaired participants will be conducted.

The participants will then be divided into two groups of three, and two seperate half-hour interviews will be conducted to obtain their occupational profiles.

Group A will first be evaluated using the Canadian Occupational Performance Measure (COPM) for 30 minutes and subsequently in the second session for 30 minutes using the questioning tool based on the Kawa Model.

Group B will be evaluated in the same manner, but using the Kawa Model tool first then the COPM.

Instrumentation

• a semi-structured, open-ended questioning tool based on the quantitative version of the Kawa Model (Iwama 2006) and the Occupational Therapy Practice Framework (AOTA 2008)

• the Canadian Occupational Performance Measure (Law et al. 1994, Roberts et al. 2008)

Participant Inclusion Criteria: •Diagnosis of severe low vision [above 20/200] (Colenbrander & Fletcher, 1995)•Adult (age above 18)•Score of at least 24 on MMSE (Folstein, Folstein & McHugh, 1975) indicating satisfactory cognitive status•Fluent and articulate in English language•No evidence of language, auditory or verbal communication deficit.• Willing to participate in study

Participants are sourced from personal contacts and non-government organisations (NGOs) like the Malaysian Association of the Blind.

Analysis

The results of the interviews will then be transcribed verbatim and coded.

Transcripts from the Kawa Model (Iwama 2006)/ OTPF (AOTA 2008) questioning tool categorized according to themes determined by Kawa Model concepts.

Transcripts from the COPM (Law et al. 1994) are categorized according to themes from the Canadian Model of Occupational Performance. (CMOP)

The occupational needs identified using each different model will then be compared.

To enhance the accuracy of representation of data, as recommended by Depoy & Gitlin (2005) the following measures have / will be taken:

1) Triangulation – other than the two interviews, a third session would be arranged to observe the participants within the environmental contexts in which they spend most of their time.

2) Member checking – a fourth session will be arranged after the data has been through initial analysis to verify with the participant whether the intepretations are accurate.

3) Reflexivity – a personal diary will be established during the data collection process chronicling the thoughts, feelings and perspectives of the researcher for self-examination purposes and provide a base from which the researcher is able to reflect upon her personal biases and assumptions and how these might affect what was learned and how it was learned.

4) Audit trail – an audit trail chronicling the unfolding of this project has already been established via personal records, emails, and Facebook notes. The course of logic and decision-making can be easily established through following this trail.

5) Peer debriefing – Before the member checking session and after triangulation, a random set of data from the transcripts will be independently coded by one of the study supervisors and the outcomes will be discussed and areas of agreement and disagreement identified.

Implications and Discussion

Provide insight into the role occupational therapists could potentially play in addressing the current concerns of visual rehabilitation:•Perceptions of irrelevant and meaningless interventions by rehabilitation workers (Frank 2000)• Demands for a more participatory role for visually impaired persons to contribute towards their own enablement and empowerment. (Duckett & Pratt 2007)

Provide knowledge and insight that could potentially contribute towards the construction of a frame of reference for occupational therapists in the field of visual rehabilitation. (Cleveland 2008) Typically frames of reference are constructed using a top-down approach, i.e. based on what is understood and inferred by theory. (Iwama 2006) Incorporating the lived experiences of people with visual impairment would then provide a more holistic perspective in tandem with the principle of client-centred practice in occupational therapy.

Proposed future developments

• A larger scale participatory action research project (Blakeney & Marshal, 2010)which can provide more in-depth information of the lived experiences of visually impaired people

• A quantitative study exploring the application and effectiveness of occupatinal therapy interventions using the information gleaned from the relatively new Kawa Model from individuals with visual impairment.

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