The social value and financial benefits of providing preventive and timely counselling to people with sight loss in Wales, UK

Background: Almost 2 million people in the UK live with sight loss, and this number is predicted to double by 2050. There is increasing recognition of the need to provide counselling services to people living with sight loss. Aim: The aim of this research was to assess whether there is an unmet need for coun - selling services for people living with sight loss in North Wales and to estimate the social value and budget impact of the potential roll-out of counselling services to this population. Method: Between December 2020 and May 2021, a telephone survey was completed by 192 people living with sight loss in North Wales, UK. The survey instrument was a 19-item questionnaire, which included the Short Warwick–Edinburgh Mental Well-being Scale (SWEMWBS). Using data from the SWEMWBS and published statistics, a social return on investment (SROI) and budget impact analysis were conducted. Results: Most respondents (84%, n = 161) had


| BACKG ROU N D
Across the globe, 2.2 billion people are living with a visual impairment (World Health Organization, 2023).In the UK, almost 2 million people live with sight loss, and this number is predicted to double by 2050 (NHS, 2018).One in five individuals will experience sight loss at some point during their lifetime (RNIB, 2021).In Wales,13,137 people are registered as blind or partially sighted (RNIB, 2021).The estimated cost of sight loss each year in Wales is nearly £1.44 billion, and this figure includes direct healthcare costs associated with sight loss and indirect costs such as productivity losses (RNIB, 2021).In order to plan and deliver services, local government authorities in Wales keep records of people who are registered as blind or partially sighted.
People living with sight loss are at a much greater risk of depression, anxiety and other psychological problems than individuals with normal vision (Kempen et al., 2012); consequently, there is increasing recognition of the need to provide counselling services to people living with sight loss.There is a well-established association between visual impairment and reduced emotional and psychological well-being (Barr et al., 2012;Thurston et al., 2013).Depression among individuals living with sight loss is often unrecognised, especially among older individuals (Fenwick et al., 2009;Renaud & Bédard, 2013).

| UK literature
In a population-based, large-scale, cross-sectional study conducted in 2007, researchers explored the association between visual impairment and depression and anxiety in older people in Great Britain.
Results found that 13% of people with a visual impairment had significant depressive symptoms, approximately three times greater than the general population of this age group (Evans et al., 2007).
More recently, as part of a large-scale randomised controlled trial conducted in 2016, 1008 patients attending low-vision rehabilitation centres in the UK were screened for depressive symptoms.Results indicated that 43% of patients reported significant depressive symptoms, and 74.8% were not being treated for their depression (Nollett et al., 2016).Older people with sight loss who live alone are three times more likely to experience depression than those with normal sight (Evans et al., 2007).When compared to the general population, blind and partially sighted people have lower well-being.Moreover, people with sight loss feel less optimistic about the future, feel less useful and feel less close to other people when compared to the general population (Pybis et al., 2016).One in four blind or partially sighted people rarely or never feel useful compared with one in 10 people in the general population (McManus & Lord, 2012).

| International literature
Looking further afield, in a US population survey of 2044 adults conducted in 2016, approximately 88% of respondents deemed eye health critical to overall health.Moreover, 47% considered vision loss the worst possible health condition that might befall them (Scott et al., 2016).In the Netherlands, rates of depression and anxiety have been found to be significantly higher in older adults with sight loss than in older adults without vision impairment and older adults with chronic illnesses such as cardiovascular and respiratory conditions (Kempen et al., 2012).In a survey of 22,486 participants from 10 European countries, low vision was found to have a highly significant negative impact on well-being (Mojon-Azzi et al., 2008).
Evidence from a systematic review of the worldwide literature found that sight loss experienced by young people is also linked with an increased risk of mental health issues, such as depression and anxiety (Augestad, 2017).
Sight loss substantially impacts not only the person living with it but also their family, friends and wider society (Welp et al., 2016).
Living with sight loss, whether it be a complete loss of vision or the ongoing decline of an existing eye condition, can be frightening and lonely, and many individuals will worry if they can continue to support themselves and keep up their independence (Mick et al., 2018;Welp et al., 2016).Living with vision loss impairs mobility and increases a person's risk of falls and injury (Ray et al., 2008).There are also links between visual impairment and diminished quality of life, mental health, social functioning, educational outcomes and employment (Lund & Cmar, 2019;Nyman et al., 2010;Welp et al., 2016).

| UK sight loss organisations
Organisations such as the Royal National Institute of Blind People (RNIB) and Wales Council of the Blind advocate the importance of

Implications for practice and policy
1.There is a time window of relevance for making preventive and timely counselling services available to people living with sight loss, especially for younger people who are newly registered and for individuals who experience sight loss suddenly.
2. Timely counselling is likely to improve an individual's ability to cope with sight loss and improve their quality of life over time.
3. Although timely support by a rehabilitation officer for visual impairment may improve the mental health and well-being of people with sight loss, some individuals require specialised counselling services.
4. When people living with sight loss do not have access to counselling services, the result may be a poorer quality of life and potentially greater health service use costs in future.The estimated social value generated from offering counselling services is likely to outweigh the financial costs of provision.
supporting the well-being of people living with sight loss to help people address issues early to avoid them exacerbating further (Dwyer & Vaughan, 2014).Secondary prevention aims for early detection and timely intervention to reduce the progression of mental health issues, such as anxiety and depression.Timely intervention can help individuals to get on a better trajectory and may be particularly important for younger people and those who have recently experienced sight loss.Guidance from the National Institute for Health and Care Excellence (NICE) recommends talking therapies for the treatment of anxiety and depression as numerous randomised controlled trials have shown that they are effective for a wide range of mental health conditions (Clark et al., 2018;NICE, 2022).
The North Wales Society of the Blind (NWSB) provides practical support, information and advice to blind and partially sighted people throughout North Wales.In Wales, UK, people living with sight loss can access emotional support through their rehabilitation officer for visual impairment (ROVI); however, some individuals may require the additional support of certified counselling services to help with depression and anxiety.

| Study rationale
Counselling is a type of talking therapy that can be tailored to meet individual needs and can be used to offer emotional support and coping mechanisms.Individuals living with sight loss can speak with a counsellor about their personal experiences when they feel they cannot or do not want to speak with family or friends.Despite increasing recognition of the need to provide counselling services to people living with sight loss, it was not known how many people living with sight loss in North Wales had been offered or had used counselling services in the past, or if they would be willing to consider using counselling services if they were made available.Consequently, the purpose of the survey was to assess whether there was an unmet need for counselling services among people living with sight loss in North Wales and what the estimated budget impact and social value of providing these services would be.The specific objectives were as follows: 1. to assess the mental health and well-being of people living with sight loss in North Wales; 2. to determine the percentage of people living with sight loss in North Wales who have been offered counselling or have used counselling in the past; 3. to determine whether people living with sight loss would consider using counselling services if they were made available; 4. to explore how people with sight loss feel about the usefulness of a new counselling service; and 5. to explore the social value and budget impact of providing a counselling service for people with sight loss in North Wales.

| Study design
A telephone survey was commissioned and funded by the NWSB.
All members with full contact details listed on the NWSB register were invited to take part in telephone calls conducted by members of the NWSB staff team.The telephone survey is a valuable method for exploring attitudes and experiences and serves as a practical, cost-effective method of conducting research when it is difficult or unfeasible to access certain populations (Couper, 2000).Telephone surveys allow access to large samples and provide instant results compared with postal surveys (Choi, 2004)

| Computer-assisted telephone interviewing
Responses to survey questions were inputted onto a password-protected online survey platform using a data collection method known as computer-assisted telephone interviewing (CATI).Computerassisted telephone interviewing is a telephone survey mode in which an online survey platform displays questions on a screen.The interviewer reads the questions to the respondents over the phone and then enters answers directly into the survey platform (Choi, 2004).
Survey data are then transferred into a spreadsheet from which descriptive analysis can be undertaken.Computer-assisted telephone interviewing helps to minimise missing data and generates an immediate warning sign if a response lies outside the acceptable range of answers (Choi, 2004).Computer-assisted telephone interviewing methodology has been used in many published studies of visual impairment (Drzyzga & Kucia, 2019;Heppe et al., 2020;Horowitz et al., 2005;Kef, 1999).

| Analysis
Descriptive statistics were calculated for the closed-ended responses using the Microsoft Excel software.Frequencies were calculated for the closed-ended questions, which required   Woods, 2011).The framework approach was chosen due to its transparency and clarity, and its suitability to policy and applied research (Ward et al., 2013).The framework analysis was applied using Microsoft Excel spreadsheets, which provided a clear visual matrix structure that facilitated the generation of themes (Gale et al., 2013).
Responses to the survey and previously published statistics were used to calculate the potential social value of counselling services for people with sight loss using a social return on investment (SROI) methodology (Trotter & Rallings Adams, 2017).
The survey findings and previously published statistics were also used in a budget impact analysis (BIA) to estimate the potential financial impact of adopting a new counselling service for people living with sight loss in North Wales.Budget impact analyses are economic assessments used to explore the affordability of implementing a new intervention or service and can be used to assist with decision-making regarding the allocation and reallocation of finite resources (Health Information and Quality Authority, 2014; Mauskopf et al., 2007).

| Sample
The survey target population were all registered NWSB members with full contact details who were deemed eligible to participate in the study.During the time of data collection, there were 1600 members registered blind or partially sighted on the society's records.Of the 970 members with full contact details, 118 members were not deemed eligible to be contacted (i.e., if they were children or if they had high-level care needs).Telephone call attempts were made to 852 members who were deemed eligible for participation, and of these, 627 members were successfully contacted and invited to participate in the survey.Of the 627 contacted, 192 (31%) agreed to participate in the study and 435 (69%) declined (Figure 1).

| Participant demographics
Of the 192 respondents who participated in the study, 119 were female and 71 were male.
The majority of respondents were older adults; 37% were aged 55-74, and 42% were aged 75 and over.Only 3% of the sample were in the 18-34 age group category.There are far fewer visually impaired people in this age group in the UK because most individuals lose their eyesight in older age.Our sample of survey respondents is what you might expect to see in this population (RNIB, 2021; Table 1).
The main cause of sight loss among the survey respondents was macular degeneration.More than half of the survey respondents were registered blind (54%), and approximately a third (34%) were registered as sight impaired (Table 2).Seventy-three per cent of respondents had lived with their sight loss for more than 10 years.Only 1% of the sample had been experiencing sight loss for less than 1 year.The typical respondent of the survey was female, over the age of 55 years, and had been living with their sight loss for more than 10 years.

| Main survey findings
accessing counselling; willingness to use new service if offered; timing of when counselling would be most beneficial; and preferred mode of delivery for counselling.Very few survey respondents (15%) had been offered counselling in the past to help with their sight loss; however, 39% of respondents stated that they would be willing to use a new counselling service if it were made available (Table 3).More than half of the survey respondents (61%) would prefer face-to-face counselling, and 35% of respondents stated that the offer of counselling would have been most beneficial when they first experienced sight loss (Table 3).

| Mental well-being
The SWEMWBS questionnaire asked respondents to specify their level of agreement to seven statements about their mental well-being within the last 2 weeks of completing the survey (Tennant et al., 2007).
The SWEMWBS is scored by first summing the scores for each of the seven items, which are scored from 1 to 5. Total scores can range from 7 to 35, with higher scores indicating higher mental well-being.
According to the SWEMWBS scoring system, a score of 17 or less refers to 'probable depression', 18-20 refers to 'possible depression', 21-27 refers to 'average mental well-being' and 28-35 indicates 'high mental well-being'.The mean score for the 83 respondents in our survey who completed the SWEMWBS was 24.96, which indicated 'average mental well-being'.Of the respondents who completed the SWEMWBS (n = 83), approximately half reported average mental well-being, a quarter reported high mental well-being and a quarter reported low mental well-being and possible depression.

| Social value and budget impact of counselling services
We conducted a BIA to estimate the financial impact of rolling out a counselling service to people living with sight loss across North Wales.In our sample, approximately 25% of people who completed the SWEMWBS reported low mental well-being and probable depression.Clinical guidance on depression in adults recommends between six and 10 counselling services for people with depression at an average cost of £50 per session, depending on the counsellor's experience and location of service (BIDVINE, 2021;NICE, 2009).
Our findings revealed that 39% of our respondents would use a counselling service if it were available.
There are 3003 registered blind or partially sighted people in North Wales (RNIB, 2021).Taking into account a 25% prevalence of depressive symptoms among people living with sight loss (based on our survey findings using the SWEMWBS), it is estimated that 751 people who are registered as blind or partially sighted living in North Wales may be experiencing depressive symptoms.If 39% of these people (n = 293) sought counselling at a cost of £50 per session, the estimated total costs would be £117,200 for eight counselling sessions.Previous RNIB research indicates that providing structured practical and emotional support to blind or partially sighted people (i.e., 'Striding Out Programme') can substantially increase mental well-being (RNIB, 2012).When well-being valuation using the HACT Mental Health Social Value Calculator (2018) was applied to baseline and 4-month SWEMWBS data from 16 UK 'Striding Out Programmes', the average social value increase was estimated at £1366 per person.
Assuming that eight sessions of counselling could yield at least the same social value (£1366 per person) as the two-day RNIB 'Striding Out Programme', then the total social value generated for 293 North Wales counselling participants would be £400,238.When the total social value of £400,238 is compared with the total costs of £117,200, the SROI is £3.42 for every £1 invested in counselling services.3.5.2| Family support was an important factor in whether people wanted counselling services Many respondents felt that counselling services are important, especially for people living alone or without any support from family or friends.However, for those respondents with family support, a few stated that they did not want to burden their families with their problems.They expressed the need for having private conversations with professionals as they found it challenging to talk with family and friends.

| Open-ended question synthesis
The option of counselling services for the family and friends of those living with sight loss was also mentioned by a few survey respondents.

| There is a time window of relevance for counselling services
Most of our survey respondents felt that counselling services are important for younger people, those who are newly registered and individuals who experience sight loss suddenly.
Others stated that counselling services are important at any stage when vision starts to deteriorate.Some people stated that they would appreciate knowing that a counselling service would be available if they needed to access these services at some point in future.

| Counselling services are important, but not needed by everyone
Many people surveyed stated the importance of counselling for people living with sight loss, but some felt that counselling was unnecessary for them.This was especially true for people who had been living with sight loss for many years.A few stated that they TA B L E 3 Main survey findings.had never thought about counselling services in the past, and one respondent stated that they did not feel that counselling was needed for people living with sight loss.

| DISCUSS ION
The main aims of this survey were to assess whether there is an unmet need for counselling services for people living with sight loss in North Wales and to estimate the potential budget impact and social value of providing these services.Our survey provided evidence of an unmet need for counselling services for people with sight loss in North Wales.Over a third of respondents (39%) stated that they would use a new counselling service if it were available.The survey also revealed that the majority of people (84%) had never been offered counselling in relation to their sight loss.Only 8% of our survey respondents said that they had received counselling in relation to their sight loss, and 67% of these people felt that the counselling they had received was helpful.A third of the people surveyed (33%) said that at some point during their lives, there had been a time when they felt that they had needed counselling to help cope with their sight loss.The most common reasons for not being able to access counselling were that there were no services locally, not knowing where to get access and a lack of specialist services available for sight loss.
Our findings have important implications for practice as we found that counselling services may be particularly important for people who have recently experienced sight loss.Respondents felt that there was a critical window of time when they would have benefitted from counselling services.We therefore recommend that if new counselling services are made available, the most appropriate time to offer services is at the time when an individual first experiences sight loss.As the demand for psychotherapist services is often high, counselling services should be prioritised for people recently diagnosed with sight loss.However, some respondents also stated that counselling is important and should be available at any stage of sight loss.We acknowledge that our sample consisted of mainly older adults who had been living with sight loss for more than Based on our survey findings, taking into account a 25% prevalence of depressive symptoms and a 39% treatment uptake for counselling, estimated total costs for a new counselling service for people with sight loss in North Wales would be £117,200 for eight sessions per person.When the costs are compared with the estimated total social value that eight sessions of counselling could provide (based on a previous RNIB study), the SROI was estimated at £3.42 for every £1 invested.Our analysis of the potential social value of counselling services used two recommended HM Treasury Green Book methodologies, well-being valuation and social cost-benefit analysis (SCBA), to capture the social value of public health interventions (Ashton et al., 2020;HM Treasury, 2021).
Our telephone response rate of 31% (192/637) was similar to other CATI telephone surveys (Creswell, 2008).In a previous study exploring telephone survey participation, the average response rate for CATI was 39% (O'Toole et al., 2008).Although our sample consisted of mainly older individuals living with sight loss for more than 10 years, our sample is consistent with the percentage of older people living with sight loss in Wales as the prevalence of sight loss increases with age.
Our findings are also similar to two published reports conducted by the RNIB.In their evaluation of the 'Striding Out Programme', which provided structured emotional support to individuals with sight loss, the RNIB also used the SWEMWBS to assess changes in well-being among participants (RNIB, 2012).In the 2012 RNIB report, the average SWEMWBS score at baseline was 22.69, which was similar to the average SWEMWBS score of 24.96 reported in our survey.In the RNIB report, the average follow-up SWEMWBS score after the 'Striding Out Programme' was 25.12, indicating an improvement of 2.43 points in mental well-being.This improvement indicates the value of structured emotional support for people living with sight loss (RNIB, 2012).
The 2015 'My Voice' report conducted by the RNIB surveyed 1200 registered blind or partially sighted people across the UK.
Only 17% of their sample of adults who had experienced sight loss had been offered counselling or emotional support, and our survey found that 16% of respondents said they had been offered counselling (RNIB, 2015).
Our sampling methodology meant that 65% (627/970) of NWSB members with full contact details were successfully contacted and invited to participate in this survey.These telephone calls enabled NWSB staff to provide a 'welfare' call as well as a survey invitation.Those who were identified as having low mental well-being were referred to ROVIs for follow-up.The opportunity for NWSB staff to provide a welfare call was well-received by its members.Nevertheless, it is important to note that only 192 people (31%) living with sight loss agreed to participate in the survey, which may mean that our sample is not fully representative of the whole population of people living with sight loss in North Wales.This may explain the relatively high percentage of our sample (53%) reporting average mental well-being as indicated by the SWEMWBS scores.In fact, the rates of depression and low mental well-being among people with sight loss living in Wales may be much higher than indicated in our findings.Non-response bias is a common issue in surveys as it is likely that non-responders may have provided very different answers to the survey questions (Bethlehem, 2010).Moreover, self-selection bias is also an issue that impacts the interpretation of our findings as the individuals . Data collection was conducted between December 2020 and May 2021.This study abided by the Declaration of Helsinki on the ethical principles involving human participants.Ethics approval was received from the Bangor University Medical and Health Sciences Academic Ethics Committee.Verbal consent was received from all participants who completed the survey.The survey questions were informed and developed by the literature on sight loss, and advice sought from the NWSB and people living with sight loss.The survey questions were first piloted through the NWSB with 20 service users, and their feedback was then used to refine the survey questions.The final survey instrument was an 18-item questionnaire with one open-ended question.
categorical responses, and then the percentage of responses for each categorical option was calculated.The survey also included the Short Warwick-Edinburgh Mental Well-being Scale (SWEMWBS;Tennant et al., 2007).This standardised questionnaire with a 5-point Likert response scale asks respondents to specify their level of agreement to seven statements about their mental well-being within the last 2 weeks and includes the following variables: the degree to which they are feeling useful, relaxed, close to others, thinking clearly, ability to deal with problems and optimistic about the future.A broad open-ended question was included at the end of the survey to ask respondents to provide their general views regarding counselling in order to allow themes to emerge inductively from the data.The open-ended responses were analysed using the framework approach (Ritchie & Lewis, 2003).The framework method of qualitative analysis is a systematic, five-stage matrix that allows for both theme-based and case-based analyses (Dixon- Our survey included an open-ended question asking respondents the following: What do you think about the need for counselling for people who are affected by sight loss?Four major themes emerged.TA B L E 1 Demographics of the survey participants. 10 years.Consequently, in order to bridge the evidence gap, future research would be useful to assess the need for counselling services for younger individuals and those who have recently experienced sight loss.A quarter of respondents (25%) were scored on the SWEMWBS as having low mental well-being or probable depression.The COVID-19 pandemic may have contributed to the well-being scores reported in our sample as depression levels of the UK general population increased from 9.7% in July 2019 to 19.2% in June 2020 (Office for National Statistics, 2020).

Table 3
provides descriptive statistics of the main survey findings in relation to the following variables: prior offer of counselling; problems Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/capr.12721 by Welsh Assembly Government, Wiley Online Library on [23/11/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 17461405, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/capr.12721 by Welsh Assembly Government, Wiley Online Library on [23/11/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License