The Mental Health of People With Visual Impairments and Related Interventions: A Scoping Review From 2016 to 2023

Abstract

Introduction

The purpose of this scoping review was to understand the extent and nature of recent literature on the mental health of people with visual impairments and their experiences with related nonpharmaceutical interventions.

Methods

Two separate literature searches were conducted. The first, covering January 2016–August 2021, identified 1,130 potentially relevant papers; following deduplication, title and abstract checks, and full-text screening, 41 papers remained that met the inclusion criteria. The second search involved literature published from September 2021 to November 2023 and highlighted 718 papers, with this number reduced to nine following the deduplication, title and abstract checks, and full-text screening process.

Results

Although there appears to be some movement toward increased incorporation of lived experience accounts in related research, such efforts remain overshadowed by more traditional approaches.

Discussion

The presence of lived experience accounts being relevant to the holistic integrity of the literature has not been asserted by the included papers.

Implications for Practitioners

Conscientious approaches to inclusiveness in research concerning the mental health of people with visual impairments, particularly co-production and participatory research methods, are encouraged.

Keywords

counseling emotional support mental health psychotherapy scoping review visual impairment

However caused, visual impairment can have a negative effect on mental health (Boagey et al., 2022). Manifestations of associated problems include anxiety (Binder et al., 2020; Knight et al., 2021; Sims et al., 2021; Zhang et al., 2023), depression (Holloway et al., 2018; Nollet et al. 2016a; Parravano et al., 2021), stress (Naylor & Labbé, 2017; Sabel et al., 2018), and suicidal ideation (Cosh et al., 2019). The effectiveness of nonpharmaceutical interventions utilized to address related concerns has not been properly assessed (Van der Aa et al., 2016). Also, the many and varied relationships between the factors at play require the attention of powers of discernment (Boagey et al., 2022). Although there are at least 2.2 billion people affected by visual impairment (World Health Organization, 2019), the mental health needs of this population have been largely overlooked (Demmin & Silverstein, 2020). People with visual impairments are increasingly considered central to research efforts toward greater understanding and to widened and improved ameliorative action (Dean et al., 2017).

Considerations around the place of individuals intimately linked with studies can be approached via the principles of pluralistic research (Smith et al., 2021). Urgings for methodological inclusiveness, epistemic justice, social justice, and dialogical testing (Smith et al., 2021), although originally put forward as pertaining to research within counseling and psychotherapy, can be extended in their application. Emerging from the pluralistic approach to counseling and psychotherapy (Cooper & McLeod, 2011; Smith & de la Prida, 2021), and its embrace of a philosophical pluralism proposing the reality and usefulness of multiple and even contradictory perspectives with none holding absolute truth (Rescher, 1993), the principles challenge any overarching and determining role for academic experts. Associated with postmodernism (McLennan, 1995) and its refusal to unduly privilege standpoints from power or status (Wilber, 2000), pluralism's valuing of diversity is rarely the solution to challenges on its own (McLennan, 1995). Not to be confused with a relativism that suggests all related expression is germane (Connolly, 2005), instead, a pluralistic approach facilitates harnessing the full range of relevant experience, whatever the source, in the service of intended goals (Samuels, 1997). Nonhierarchically involving those whose care is being considered in efforts towards understanding of that care provides key expertise (Brown & Smith, 2023). Thus, the relative positioning of people with visual impairments within the included papers, and the ramifications of that positioning, become relevant to this scoping review's purpose of mapping the key concepts that underpin research on the mental health of people with visual impairments.

Among the included papers are a systematic review and meta-analysis (Van der Aa et al., 2016) and a literature review (Demmin & Silverstein, 2020) that addressed nonpharmaceutical mental health interventions for people with visual impairments. This paper should be read not only as a form of update on that work, but also as an inquiry into its terms of reference. If “limited evidence” (Van der Aa et al., 2016, p. 584) for intervention effectiveness has been found, and “proper attention” (Demmin & Silverstein, 2020, p. 4246) to the mental health of visually impaired people and their options for treatment has been called for, what is considered crucial to responsible research should be critically examined.

Methods

Search Strategy

The scoping review was conceptualized by authors Harriet Bird, Amanda Hawkins, and Mhairi Thurston. Search terms were collaboratively agreed upon by Christina Thurston and Mhairi Thurston. Databases APA PsycArticles, CINAHL, ProQuest Dissertations and Theses, PubMed, and Scopus were accessed by Christina Thurston for the first search, which covered publications from January 2016 to August 2021 and resulted in 1,130 papers being identified for potential inclusion. The second search, by Christina Thurston, accessed APA PsycArticles, CINAHL, ProQuest Dissertations and Theses, and PubMed for papers from September 2021 to November 2023 and identified 718 for potential inclusion. Zotero 5.0 was utilized by Mhairi Thurston for the first search to remove duplicate articles and for subsequent relevance screening, and Zotero 6.0 (Corporation for Digital Scholarship, 2022) was involved in the same process for the second search.

Evidence Selection and Criteria for Inclusion and Exclusion

In the first stage of evidence selection, application of the inclusion and exclusion criteria, by Mhairi Thurston, to titles and abstracts left 38 papers. The next stage, full-text screening by Mhairi Thurston, reduced the number of papers to 28. Thirteen additional papers that were searched for manually and full-text screened by Mhairi Thurston were also added, bringing the total to 41. As the final stage, and in preparation for drafting, Richard Warden repeated the full-text review process in consultation with Mhairi Thurston.

For the second search, inclusion and exclusion criteria were applied by Mhairi Thurston to titles and abstracts, which reduced the number of papers to 13. Full-text screening by the same author left nine papers that were again reviewed by Richard Warden, in consultation with Mhairi Thurston.

The 50 papers included from both searches were published in English from January 2016 to November 2023, focused on people aged 16 years or older with visual impairments comorbid to mental health problems, and noted nonpharmaceutical interventions related to those problems that were considered to be counseling, psychotherapy, or emotional support.

Papers were excluded if they were not in English, published before 2016, did not address mental health in a substantial manner (e.g., the paper was essentially a medical or scientific paper concerning an eye condition), or the counseling involved was advice-giving, coaching, or genetic counseling.

Data Extraction

From the 50 papers remaining after selection, the following data were extracted by Mhairi Thurston: author or authors, publication year, country, design, sample size, focus, and findings. The papers were subsequently grouped into focus themes. As further preparation for drafting, Richard Warden carried out a second extraction of the same data. Richard Warden then made adjustments to the thematic groupings in consultation with Mhairi Thurston.

Results

Search Results

After searching, deduplication, title and abstract relevance screening, and full-text screening, 50 papers published between January 2016 and November 2023 were included in this scoping review.

The included research originated from 24 countries. Thirty-eight (76%) of the papers emerged from Australia, Canada, Europe, New Zealand, and the United States, without other areas participating. The country involved in the highest number of papers was the United Kingdom (17, 34%), followed by the United States (16, 32%), Australia (6, 12%), and India (6, 12%).

Reviews of other titles (four literature reviews, two systematic reviews, one systematic review and meta-analysis, and one meta-analysis) made up 16% (8) of the included papers. Longitudinal design was found in 20% (10) of the papers, 16% (8) were cross-sectional, 6% (3) were randomized controlled trials, and 4% (2) took quasi-experimental approaches. Mixed methods papers constituted 6% (3) of the total, while qualitative work contributed 22% (11) of them. All the mixed methods papers emerged from 2021 through 2023 (essentially, the second half of the overall publication timeframe of 2016–2013), as did six of 11 qualitative studies.

Twenty-two percent (11) of the papers involved randomization of participants. Studies of researcher-instigated interventions totaled 16% (8) of these papers, not including four studies of the effect of the eye care liaison officer role. Just over half of the included papers (27, 54%) referenced counseling or psychotherapeutic journals or both.

Those papers that allowed for open-ended research contributions (as opposed to a predetermined range of answers) from people with visual impairments represented 24% (12) of the total, and those including direct quotations from people with visual impairments made up 16% (8). All but two of the eight papers incorporating direct quotations emerged from the 2021–2023 period rather than 2016–2019, and seven of 11 papers with open-ended contributions were also from the later period. No papers involved participatory action research or research co-produced by people with visual impairments.

Key Themes

Analysis of included papers resulted in the identification of six overarching thematic areas.

Mental Health Problems

Anxiety and Depression

Anxiety and depression were the mental health problems most often noted in the included papers. There was an overall association found between visual impairment and anxiety in middle-aged and older adults (Zhang et al., 2023). The anxiety could be chronic in nature (Binder et al., 2020) and related to progressive vision loss in adults with childhood glaucoma (Knight et al., 2021). Young people with visual impairments also showed higher than average levels of anxiety (Sims et al., 2021).

Anxiety About Specific Treatments

Anxiety about specific treatments had the potential to be prompted by concern around intravitreal injections for wet age-related macular degeneration (AMD) (Sii et al., 2018) or cataract surgeries (Muley et al., 2020; Obuchowska & Konopinska, 2021). Studies that focused on depression found it to be common in those who attended low vision rehabilitation programs (Holloway et al., 2018; Nollet et al., 2016a; Parravano et al., 2021). In papers that addressed both anxiety and depression, these problems were noted to have been affected by visual impairment (Boagey et al., 2022), to have been more common for people with a variety of visual impairments than those without (Clancy et al., 2022; Frank et al., 2019; Heesterbeek et al., 2017; Lee et al., 2022), and to have been significant for older people with AMD (Cimarolli et al., 2016), although one paper found abnormal scores for anxiety but not depression for people with end-stage macular degeneration (Young et al., 2023).

Other Mental Health Problems

Other mental health problems connected with visual impairments include sleep disorders (Lee et al., 2022), as well as grief and stress (Boagey et al., 2022), and increased risk of suicidal ideation (Cosh et al., 2019).

Demographics and Social Context

Young People With Visual Impairments

Young people with visual impairments were not only found to be prone to greater anxiety than their peers, as noted in the previous section, but also to social withdrawal and to having lower adaptive skills and resilience (Sims et al., 2021). Suicidal behavior was at a higher prevalence in people with visual impairments of this age group (Akram & Batool, 2020).

Visual Impairment and Social Ties

Exploration of visual impairment and social ties revealed more loneliness (Brunes et al., 2019; Hajek et al., 2017) for people with visual impairments than for others. This state was twice as likely for visually impaired people who are single (Amilon & Siren, 2021).

Visual Impairment in Minority Ethnic Communities

Visual impairment in minority ethnic communities was complex in its effects. Study participants from Asian communities had significantly poorer mental well-being than Black participants (Heinze & Castle, 2023). Although minority ethnic group members were more likely than white participants to rate as important emotional support in coming to terms with visual impairment and to feel optimistic about their visual impairment (Heinze & Castle, 2023), they were significantly less likely to agree that they were receiving the emotional support that they needed (Heinze & Castle, 2023). A risk factor for significant depressive symptoms in people with visual impairments was found to be nonwhite ethnicity (Nollett et al., 2019).

Barriers

Barriers to addressing mental health problems were connected with various involved actors. Many who could benefit from interventions were not being offered them (Holloway et al., 2018; Nollett et al., 2019). People with visual impairments did not always recognize symptoms (Dillon et al., 2020; Van Munster et al., 2021); thus, some did not seek assistance. Such individuals could face health care providers who also failed to respond to problems, either due to a lack of sufficient training to identify them (Van Munster et al., 2021) or a failure to consider it their responsibility to respond to such issues (Trott et al., 2023). Additionally, even if the need for intervention was acknowledged by a professional on an “eye health care pathway,” including “primary care optometrists and GPs [general practitioners], secondary care optometrists, ophthalmologists, ophthalmic nurses, orthoptists and ECLOs [eye care liaison officers], and secondary care psychiatry and tertiary / community mental health and social care professionals and service providers” (Trott et al., 2023, p. 2558), adequate guidance could be hampered by insufficient knowledge of provision options and by related information not being available in easily shared and utilized forms (Trott et al., 2023).

Specialist Roles: Education and Training

Research attention has been devoted to how health care roles relevant to people with visual impairments operate regarding mental health and how associated training could be offered and improved. The eye care liaison officer, a position growing in the United Kingdom since the 1990s that facilitates early post-diagnosis links between people with vision impairment to voluntary and social care services (Llewellyn et al., 2019), has been found to be an important source of emotional support (Llewellyn et al., 2019; Menon et al., 2020) and well positioned to assess if more assistance is needed, which has often been determined to be the case (Trott et al., 2023). Ophthalmologists have also been identified as having a part to play in such assistance (Garcia et al., 2017), extending to sensitive delivery of challenging diagnoses (Ferrey et al., 2022). Training of health care professionals, including those involved in low vision rehabilitation, could not only improve the detection of mental health problems (Dillon et al., 2020; Van Munster et al., 2021) but also enhance related communication between them and clients or patients (Van Munster et al., 2021). Mental health professionals working with people with visual impairments should be well informed not only of the effect of the condition on psychological health (Demmin & Silverstein, 2020) but also on health overall and approaches that are best suited for engaging with this group (Roche & Chur-Hansen, 2021). Those affected by visual impairments may benefit from better education and training to support them in adjusting to life with vision loss (Dillon et al., 2020); such supports may also benefit their caregivers (Khare et al., 2016).

Interventions

Specified Interventions

Specified intervention papers regarding the mental health of people with visual impairments observed or reflected upon the deployment of named psychological approaches. Depression was addressed via behavioral activation, which improved visual functioning (Deemer et al., 2017). Problem-solving treatment resulted in depressive symptom improvement (Nollet et al., 2016b) and was seen to be a worthwhile and practical intervention by low vision rehabilitation professionals and a clinical psychologist (Holloway et al., 2018). Young people with visual impairments were found to have their self-concept, social interactions, and mental health improved by cognitive behavioral therapy (Yaghotian et al., 2016), while reductions in their negative personal value systems were lessened by rational emotive behavioral therapy (Abiogu et al., 2020). Group therapy of 16 weeks decreased symptoms of stress (Naylor & Labbé, 2017).

General Interventions

Research to do with general interventions did not specify a named psychotherapy, counseling, or emotional support approach. Preoperative counseling, along with the provision of relevant information, was aimed at reducing anxiety ahead of cataract surgery (Muley et al., 2020) and in combination with not only information, but also manual massage and music (Obuchowska & Konopinska, 2021); both of these combined approaches were determined to be helpful. A study of counseling by volunteers (Gray & Manning, 2022) showed positive results, and a multidisciplinary approach to end-stage macular disease that included counseling was deemed to be promising by those involved (Young et al., 2023). A decrease in depressive symptoms was reported to be due to a social worker intervention in which counseling was involved (Hark et al., 2019). The work of eye care liaison officers was also deemed to be beneficial for the mental health of people with visual impairments (Llewellyn et al., 2019; Menon et al., 2020). Although not an intervention that can be imposed or predicted, friendship among those with visual impairments was proposed to contribute to a better quality of life (Silverman et al., 2017).

Reviews of Interventions

Reviews of interventions made up several of the included papers. A systematic review and meta-analysis of psychosocial interventions for people with visual impairments found that evidence for the effectiveness of psychosocial intervention was limited, and that more and better-designed research studies were advisable (Van der Aa et al., 2016). Stress as both a cause and a consequence of vision loss was examined in a literature review that proposed a wide-ranging psychosomatic approach to the problem (Sabel et al., 2018). A literature review on interventions addressing depression in people with AMD suggested behavioral activation, cognitive behavioral therapy, emotion-focused techniques, and self-management techniques; emphasis was placed on tailoring interventions to individuals (Senra et al., 2019). The usefulness of various treatment options was explored in a review that called for more rigorous evaluations over longer terms with larger sample sizes (Demmin & Silverstein, 2020). Utilization of a wider range of approaches, including longstanding and emerging therapies alongside religious and spiritual philosophies, was encouraged in an overview that explored interventions around visual impairment and other disability issues (Haque et al., 2020).

Recommendations

Provision of Mental Health Interventions

Provision of mental health interventions was a recommendation of all included papers that found benefit in the treatments they examined. Some papers called for an intervention, however, not because research had been conducted into one, but because clarity on the need for action had become apparent. A study on the psychosocial and quality of life impact of primary glaucoma asserted that counseling should take place for those newly or recently diagnosed with the condition (Kalyani et al., 2020), while another paper proposed regular psychological support for those with glaucoma-related one-eye blindness (Holló et al., 2021).

Integration of Mental Health Support

Integration of mental health support, such as standard referrals to mental health services for people with visual impairments who needed this step, was supported for ophthalmologists in particular (Garcia et al., 2017; Rai et al., 2019) and ophthalmology-related practice in general (Burnett et al., 2016; Cimarolli et al., 2016; Demmin & Silverstein, 2020). A meta-analysis that found depression in people with visual impairments to be a common problem suggested a related screening protocol and potential referral to a general practitioner (Parravano et al., 2021). As detailed in the Specialist Roles: Education and Training section, improved detection and readiness to engage with the mental health problems of people with visual impairments would ease this integration.

Research Advancement

Research advancement around the mental health of people with visual impairments was advised by many of the included papers, whose authors included calls for examining the effects of visual impairment (Demmin & Silverstein, 2020; Galiano et al., 2018) and the effectiveness and efficacy of interventions (Demmin & Silverstein, 2020; Van der Aa et al., 2016). Authors also issued more general pleas for additional research that will further reveal the nature, causes, amelioration, and prevention of mental health problems (Binder et al., 2020).

Discussion

This scoping review mapped research literature published in English from January 2016 to November 2023 on the mental health of people with visual impairments and related nonpharmaceutical interventions. Fifty papers from two searches (including four literature reviews, two systematic reviews, one systematic review and meta-analysis, and one meta-analysis) matched the search and screening parameters. A pluralistic perspective on research (Smith et al., 2021) informs the approach taken to assessing the nature and extent of the literature.

Methodologically, the included literature represents a variety of approaches, with no one method being clearly dominant. Despite a plea having been made for an increased number of randomized controlled trials in the field of visual impairment and mental health near the beginning of the period covered (Van der Aa et al., 2016), this methodology is deployed by only 3% of the papers. The belief that a randomized controlled trial is the “gold standard” of methodologies has been seen to be problematic in the realm of research that addresses human experiences in its complexity and unpredictability (Greenhalgh et al., 2015). Mixed methods or qualitative methodologies were utilized in 28% of the total; the fact that nine of the 11 papers were published from 2020 to 2023 suggests a trend toward such approaches. Nevertheless, many papers (72%) did not include mixed methods. Although pluralistic research inquiry does not favor subjective over objective studies (Smith et al., 2021), it would also be consistent with the approach that a closer balance is achieved. Also significant is the lack of co-produced work or participatory action research. The presence of such studies would not only augment methodological inclusiveness, in itself a positive development (Smith et al., 2021), but also have the potential to heighten research contributions towards improved health care services (Robert, 2013).

Not unconnected to the absence in the included papers of co-produced studies and participatory action research, and the relatively low number of mixed methods and qualitative approaches overall, is the paucity of direct lived experiences being incorporated in the work in one form or another. The voices of patients have been asserted as central to health care research in general (de Casterlé et al., 2011; Shannon et al., 2021). In regard to ophthalmological research, in particular, the voices of patients being fully heard by practitioners has been said to provide “more complete understanding of what [ophthalmology] patients are actually experiencing through their disease and what their priorities are for treatment” (Dean et al., 2017). Additionally, there is the ethical demand for epistemic justice in health care (Smith et al., 2021); that evidence from those being engaged with by professionals is respected and understood (Fricker, 2007). People with visual impairments responding to questions set by others that allow for a limited range of responses, however helpful it may be toward statistical analyses, does not address epistemic injustice concerns (Dean et al., 2017).

Co-production and participatory action research have the potential to contribute positively to the situation, but there are other steps to be taken short of insistence upon those methodologies being utilized. Randomized controlled trials can be productively ensconced within mixed methods approaches (Bennett et al., 2019; Hanley et al., 2016). Other means to quantitative data generation contribute to three included mixed methods papers (Boagey et al., 2022; Clancy et al., 2022; Gray & Manning, 2022), and their publication dates suggest a trend towards increased deployment of this methodology. Some of the included qualitative and mixed methods papers have presented quotes from people with visual impairments in addition to analysis of their responses (Boagey et al., 2022; Burnett et al., 2016; Dillon et al., 2020; Ferrey et al., 2022; Holloway et al., 2018; Knight et al., 2021; Roche & Chur-Hansen, 2021; Trott et al., 2023; Van Munster et al., 2021), while others incorporated quotes from eye care liaison officers (Llewellyn et al., 2019; Menon et al., 2020), and counselors (Gray & Manning, 2022). The majority of such papers fall within the 2020–2023 period, suggesting that the use of quotations is becoming more common in the service of richer, more nuanced evidence and just representation. In further interrogation of the extent to which the latter has taken place, it must be noted that papers specifically addressing the experiences of young adults with visual impairments (Akram & Batool, 2020; Garcia et al., 2017; Nollett et al., 2019; Sims et al., 2021) and members of minority ethnic groups (Heinze & Castle, 2023; Nollett et al., 2019) were few.

Further regarding considerations of justice, the pluralistic research principles assert that studies should be oriented toward accomplishing social justice goals (Smith et al., 2021). The association between visual impairments and an increased probability of mental health problems has been well established by papers included in this review (e.g., Cosh et al., 2019; Frank et al., 2019; Heesterbeek et al., 2017; Knight et al., 2021; Lee et al., 2022; Nollet et al., 2016a, 2016b; Zhang et al., 2023) and elsewhere. It is desirable that people with visual impairments lead lives that are free from, or minimally constrained by, mental health concerns. It follows that ophthalmologically related health care is ethically obliged to do all that it reasonably can do to facilitate a high quality of life. Related study activity requires that researchers “better understand the wide-ranging impact of [visual impairment] on an individual's mental health, quality-of-life, and overall well-being” (Demmin & Silverstein, 2020, p. 4229), which is only adequately achieved by incorporating lived experience perspectives (Dean et al., 2017). Thus, the social justice of ongoing and maximized improvement in intervention outcomes and in helpful modification of professionals’ interactions with people with visual impairments, exemplified in several included papers (Dillon et al., 2020; Ferrey et al., 2022; Roche & Chur-Hansen, 2021; Van Munster et al., 2021), is tied to the epistemic justice of people with visual impairments being involved as subjects, not as objects (Dean et al., 2017). Otherwise, the research is missing crucial steps and perspectives.

Methodological openness, alongside practically and ethically motivated attention to epistemic and social justice demands, contributes toward inclusive dialogue, which in turn can serve as a measure of the quality and utility of research conclusions (Smith et al., 2021). Studies calling for better integration of mental health–related activity and ophthalmological services (Burnett et al., 2016; Cimarolli et al., 2016; Demmin & Silverstein, 2020; Garcia et al., 2017; Parravano et al., 2021; Rai et al., 2019) can be considered as encouraging generative communication. Similarly, there are included papers that suggest research should more often bring aspects from a wider scope into dialogue (Binder et al., 2020; Demmin & Silverstein, 2020). Although papers included in this scoping review noted the mental health of people with visual impairments, only just over half of them (27, 54%) involved the consultation of counseling or psychotherapy journals or both. It appears that pertinent data and findings are not contributing all that they could to the conversation about the mental health of this population.

Implications for Practitioners

One included review of research literature on the mental health of people with visual impairments and related nonpharmaceutical interventions stated that it was “critical to increase our understanding of the range of psychological and psychosocial effects associated with visual disability” (Demmin & Silverstein, 2020, p. 4246), while another saw its content as “essential to allow a targeted approach to reduce or prevent mental health problems in people with visual impairment” (Van der Aa et al., 2016, p. 585). However, neither of these papers states that it is critical or essential for the unmediated experiences of people with visual impairments to inform such studies and their published results, let alone for them to participate fully in research framing, design, execution, and interpretation. Papers suggesting greater interdisciplinarity of study contributions, integration of services, appreciation of visual impairment effects, and resultant modification of health care professionals’ engagement, while welcome, will fall short of informing and encouraging ethical and best practice if they fail to take those who have the most important perspectives fully into account (Smith et al., 2021).

Limitations

There are limitations to this review. Two separate literature searches were conducted; MEDLINE was not among the publication databases searched, and the second search did not include Scopus. Since the initial review stages were not conducted within an existing scoping review framework, it precluded retrospective application of the PRISMA Extension for Scoping Reviews (PRISMA-ScR) checklist. Only literature available in English was included. Instead of two researchers concurrently and independently extracting data and developing themes from the included papers before comparing results, the earlier work of one researcher was available to the other, potentially creating bias toward the replication of existing material. No coding was undertaken. The inclusion of literature reviews, systematic reviews, and meta-analyses allowed indirect influence from papers beyond the inclusion criteria timeframe.

Conclusion

This scoping review suggests that research on the mental health of people with visual impairments and related nonpharmaceutical interventions is changing in nature, although not as quickly and thoroughly as demanded. Calls to put the person with visual impairment at the actual and active, rather than the nominal or numerical, center of intervention explorations, and to have that placement supported methodologically, are not new. Progress is being made through the increasing presence of open-ended responses, direct quotation, and qualitative or mixed methods approaches. Yet, despite encouraging signs, most of the literature in this context continues to examine a population's mental health and impactful factors without its expansively agentive involvement, and none of the identified papers allow for co-production or participatory action research. Pluralistic research principles offer a theoretical and practical way forward. However much this perspective is adopted, matters of voice, representation, and key involvement for those ultimately most concerned are about more than methodological and procedural preferences. They are not dependent upon commitments to social and epistemic justice for their merits. Conscientious approaches to inclusiveness in research concerning the mental health of people with visual impairments are also justified, ethically and otherwise, by offering what promises to provide the most effective and efficacious results.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Richard Warden

Harriet Bird

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