The purpose of this study was to document the academic experiences of students with visual impairment in a doctor of chiropractic program.
Ten participants were recruited, including 3 students who are “legally blind,” 2 student notetakers, 3 faculty members who taught students with visual impairment, and 2 staff members from the Disability Services Office. For this qualitative study, the students were recruited through the Disability Services Office. The participants were audiotaped during approximately 1-hour interviews conducted in a semistructured manner within a private setting (a quiet office) on the campus during office hours. Thematic analysis was conducted using a deductive method for codes and an inductive method for themes.
We identified facilitators and barriers to the education of students with visual impairment. Notable facilitators were planning for accessible educational materials, accessibility of workable space, and support systems, such as notetakers and close interaction with faculty. Notable barriers were attitudes of students with visual impairment toward their education, lack of personnel training, and lack of disability awareness in the campus community.
Meticulous planning of resources and communication are key to enriching academic experiences of students with visual impairment.
In 2012, the World Blind Union presented a resolution at the 8th General Assembly to “encourage employment” of individuals with visual impairment (VI). In 2013, a systematic review article appeared in the British Medical Journal stating that the economic burden of VI and blindness was “considerable.” The highest costs disclosed by this extensive review were determined to be caused by loss of productivity.1,2
Training individuals with VI in the institutions of higher education presents some challenges. This leads to gross underrepresentation in many fields, including health care. Recent surveys in the United States (2017) reported that only 14.9% of individuals with VI have a bachelor's degree or higher education. Although currently in the United States 5.6 million people (20%) live with some type of disability, less than 3% of medical students have a disclosed disability. Not surprisingly, only 42% of individuals with VI are gainfully employed.3–6
In rare instances, students with VI have been admitted to medical schools. For example, a blind medical student completed his training and graduated into a successful practice in psychiatry at a university inpatient department. Published commentary further advocated including students with VI in medical schools.7,8
Neurological research has consistently demonstrated heightened tactile awareness in visually impaired individuals, particularly for textural mechanoreception. Enhanced tactile perception is particularly strong where the blindness has been congenital. Such research findings suggest that the individual with VI would be an asset in the areas of physical medicine.9–16
The scientific literature suggests that physiotherapy is an “excellent option” for people with disabilities and documents a long history of blind physiotherapists. Various physical therapy schools have successfully trained students with VI. A qualitative study was conducted to examine whether physiotherapy students with VI could be successful in their clinical placement. The study reported that, with individualized accommodations such as a reader to read screens, students with VI were able to complete their clinical training for bachelors of physiotherapy programs.17,18
Another study identified barriers and enablers to learning for students with VI in a physiotherapy program. This approach, along with the specific terminology used, derives in large part from work in France and Spain, proposing that disability is less a matter of personal impairment and can be humanistically addressed by removing cultural, societal, and economic constraints that constitute the barriers to the expression of their potential. Staff behaviors and resources were considered enablers, while the need for extra time and effort along with fear of disclosure of disability were identified as barriers to learning.19,20
A more recent qualitative study in India (2017) documented the experiences of students with VI in physical therapy pursuits. It included interviews of physical therapy students, clinicians, and teachers in an institution devoted specifically to the physical therapy training of blind and visually impaired individuals by faculty with and without VI. It is noteworthy that acceptance played a substantial role as a facilitator in the experiences of the blind students at this institution.21 Our research team found no literature indicating that blind students are currently studying occupational therapy despite the likelihood that there will be an increased need for such individuals to assist an aging population with its predicted increased prevalence of VI.
On the other hand, chiropractic has long held the tradition of including individuals with VI in the profession. Dr C. R. Johnston, the first blind chiropractor, graduated on August 28, 1918, and practiced in Peekskill, New York, until 1943.22,23 However, despite 100 years of inclusivity, no systematic attempt has been made to report the academic experiences involved with visually impaired students in a doctor of chiropractic program. To the best of our knowledge, this is the first such attempt. As such, it is an exploratory, qualitative study done with semistructured interviews. The purpose of this research is to document experiences in training students with VI in a doctor of chiropractic program in order to improve the delivery of chiropractic education to future students with VI.
Setting and Participants
On approval from the institutional review board of Life Chiropractic College West, we recruited 10 participants, including 3 students with VI who were “legally blind,” 2 student notetakers who assisted students with VI, 3 faculty members who taught students with VI, and 2 staff members from the Disability Services Office (DSO).
The principal investigator and coinvestigator met the DSO to begin recruitment. In order to maintain confidentiality regarding disability status of a student, all student participants were recruited through the DSO). The investigators prepared a recruitment flier that the DSO sent out to the students. The student notetakers recruited in the study had assisted in at least 3 or more classes. The volunteers for the study were screened by the Disability Services Officer for eligibility criteria. In the academic year 2016–2017, a total of 5 students with VI were enrolled in the doctor of chiropractic program, but only 3 met the study criteria (i.e., were “legally blind”). “Legally blind” is defined as “a medically diagnosed central visual acuity of 20/200 or less in the better eye with the best possible correction, and/or a visual field of 20 degrees or less.”3 The informed consent document was read to the students, and their verbal approval was recorded. The eligible 3 students were not enrolled in the same quarter.
The faculty members were recruited as volunteers directly from a list created by the investigators with representation from the spectrum of lecture and labs taken by the students over the course of the 3.5-year program, including their health center (HC) experience. All recruited faculty members had taught more than 1 student with VI over the previous 3 years, but only 1 per quarter of instruction. All faculty participants were full-time members and had completed the online disability awareness training. Additionally, faculty members who have students with disabilities registered for their classes undergo specific training by the DSO in advance. To avoid undue influence on student participants, the faculty who currently had students with VI in their class were excluded from the study. The staff from the DSO were recruited through direct contact as well. All staff participants had more than 5 years of work experience at the DSO. The participants were not paid any cash incentives or given any college credits.
All interviews were conducted between January 2017 and August 2017. The participants were audiotaped during an approximately 1-hour interview conducted in a semistructured manner either within a private setting (a quiet office) on the campus during office hours or by phone. All interviews were recorded, and transcripts were made of the call. If all questions from the interview guide were not covered within an hour, then a follow-up call was scheduled at a later date. To minimize effects of the interviewer's preconceptions, the interviewer used the institutional review board–approved interview guide and spoke minimally during the interview. The interviewer had extensive experience in interviewing participants in various qualitative studies. At the time of interview, the student participants had never been enrolled in the classes taught by the interviewer. Because 1 student had previously been in the interviewer's class, that student was interviewed by a member of the research department who is also an experienced interviewer. The staff and faculty participants were familiar with the interviewer as colleagues.
Our interview question guides were developed after conversations with a 4-person advisory board made up of experienced qualitative researchers and experts in disability policy and education. The questions in the guide were based on previous qualitative studies that collected data from people with different roles in a common phenomenon.19,24–26 Given the small number of students with VI at our institute, the question guide was not pilot tested on them. However, prior to its use, the interview question guide was piloted on faculty and staff. The interview question guide was provided to the participants for their review at least 24 hours prior to the interview.
The questions from the guide were posed to the participants (e.g., the participants were asked about the number of years spent at the college). They were asked about their learning or teaching experiences in the classroom, lab, and HC setting (as applicable). We probed and asked follow-up questions as new issues arose throughout the interview process. The students with VI were asked about accommodations, including instructional aids available (e.g., audio notes, Braille, and large print) and their effectiveness. They were asked about their experiences in using the tactile, visual, or audio modalities of learning and teaching. The students with VI were also asked about other student services, such as tutoring or access to the gym. Finally, they were encouraged to give open-ended comments and suggestions.
The staff, faculty, and notetakers were asked to describe their experiences in training students with VI (e.g., “please tell us about tactile model use in the labs”). Apart from the responses to interview questions, given the small sample size of the participants, no other sociodemographic data were collected. To maintain anonymity, neither the participants nor the interviewer referred to each other by name in their conversations. A complete set of interview guide questions is included in Appendix A, which is available as online content at http://www.journalchiroed.com.
All interviews were audio recorded. Participants were offered the opportunity to review the transcripts or, in the case of students with VI, the recordings and asked to make further comments or corrections, but none accepted. Using a professional transcription service, the digital recordings were transcribed verbatim. Both authors heard the audio recordings and read the transcripts. Dedoose Version 7.0.23 (Web application for managing, analyzing, and presenting qualitative and mixed method research data; SocioCultural Research Consultants, LLC, Los Angeles, California, 2016, http://www.dedoose.com) was used to analyze the data. We conducted a thematic analysis of the transcripts to identify similarities and variations in the data and to enable us to recognize unexpected, important elements that might arise in the interviews.27,28
The data analysis was done by both the authors, and the data were analyzed using an iterative and inductive method for codes. The codes were assigned to relevant statements in the interviews by both the authors. Further, the 2 authors discussed the codes and revised them as necessary. To support the reliability of our findings, we used a reflexive process to discuss interpretations of data and minimize potential personal biases. An audit trail was made for the coding process. The themes were drawn by a deductive method. A multilevel coding scheme was used to identify themes (e.g., facilitators vs barriers; tactile, visual, or audio facilitators, and so on). The quotes that were chosen to be included in this article are representative of the interviews conducted and illustrate variations in the data.29 While reporting the outcomes of the study, an effort was made to follow the guidelines for consolidated criteria for reporting qualitative research (COREQ).30
Analysis of data from the interview transcripts yielded 3 major themes: planning, technology and tools, and personnel. Within these themes, availability of resources and attitudes of participants emerged as barriers to or facilitators of student learning (Tables 1 and 2).
Theme 1: Planning
The study revealed that prior to enrolling the students with VI in various classes, planning of space and resources was done by the DSO, classroom faculty, and HC faculty. Within this theme, 3 facilitators and 3 barriers were noted.
The planning meetings played a crucial role in facilitating learning. At the beginning of each quarter, a planning meeting was organized. During this meeting, the faculty were made aware of the needs of students with VI. For example, the DSO staff explained the need to use very specific directional language. In contrast, “over here you can see such and such” provided no information for the student with VI. “We're encouraging them and even explicitly on the accommodation letter saying to use terminology like ‘anterior, posterior, upper left quadrant' of this or that so that the students can follow and understand what is being discussed.”
In addition to the planning meeting, an online training for faculty was provided to make them aware of the requirements under the Americans with Disabilities Act (ADA). The training enabled the faculty to adapt their teaching methods to meet the needs of the students with VI. It encouraged them to use verbal and tactile modalities while communicating with students. A student with VI reported, “The professors would work with me over breaks in their spare time to go over the specimens and actually . . . physically show me and allow me to feel the specimens . . . really descriptive . . . helping me through the lab process, both the core faculty and the adjunct faculty.”
The DSO planned conversion of lecture materials into an accessible format. The students with VI used their audio readers that can read Word documents. Hence, all the instructional materials needed to be converted into Word format. The DSO accomplished this task at the beginning of the quarter.
The HC planned logistics to allow for regulatory requirements when the students with VI advanced to the HC. To maintain both Health Information Portability and Accountability Act and ADA compliance, administrative staff made 2 key changes. The service dogs accompanied students with VI in the main campus and HC areas. In the HC, the floor plan was changed to limit the impact of service dogs on an HC environment. Next, a special HC office space with technical devices was allocated for the students with VI to read patient notes. This ensured confidentiality and privacy of patient records while all HC paperwork, such as intern notes, evaluation forms, and so on were converted into accessible formats.
The planning meetings had limited success due to lack of attendance, particularly by part-time faculty. This impacted classroom instruction and impeded communication.
The conversion of materials to the proper format was challenging in several ways. Faculty did not always send instructional materials to the DSO in a timely manner, delaying their availability to the students. Access to course notes prior to the beginning of the quarter was preferred, as it helped the students with VI feel prepared. It was also difficult to convert instructional materials that had images and graphs into an accessible format. The staff at the DSO provided a verbal description of the image or graph. Additionally, it was difficult to convert the images of old journal articles into an accessible format. The DSO converted important pieces, such as an abstract of the article, into audio format.
The online training module provided information about ADA law requirements but was targeted toward note-taking training to assist deaf students. A notetaker reported, “We struggled at first . . . , 'cause the note-taking training was for deaf people; we struggled to find the right balance as far as what (the student with VI) wanted me to provide.” Hence, it did not offer detailed insights on how best to train notetakers for students with VI.
Insufficient planning in 3 areas created barriers to education for the students with VI while working at the HC. Paperwork involved with patient transfer proved difficult and frustrating. Since the students with VI were not able to maintain the order of paperwork in the file, they anticipated adequate support to be provided. In some cases, fellow students had to help them out due to lack of other trained support. Visual exams were challenging. For example, in testing cranial nerve III or using an ophthalmoscope, the students with VI depended on their sighted assistants to describe the findings of the test for their interpretation. The sighted assistants were typically students without the necessary training for such a task.
Finally, HC experience varied with the students' expectations for assistance and the HC faculty members' beliefs about how best to assist. As 1 faculty member noted, “You'd have to be really careful that the assistant didn't know more than (the student with VI) did, because if the assistant knew more than they (the student with VI) did, then they wouldn't get the learning experience out of it. They're the ones that need to be in charge.” A student who had a “go-getter” attitude was able to get support from various resources, such as audio books or their peers, to complete work on time, while a more passive student, who preferred more support from the DSO or hoped that an assistant would do more of the work for them, progressed at a slower pace.
Theme 2: Technology and Tools
The availability of technological resources and tools emerged as facilitators with the analysis of the data. For example, several science textbooks are available in audio formats. The DSO staff provided a large-print (enlarged-font) set of instructional materials to the students with VI. Screen readers were also used to facilitate large fonts. Furthermore, it provided a measure of welcome inclusivity that an additional white cane was available in the DSO in case students lost theirs. These various resources facilitated a welcoming learning environment for students with VI.
Braille labels, 3D printouts, and plastic models served as kinesthetic learning tools for students with VI. The faculty used craft supplies such as heat-sensitive paper or glue to make diagrams or charts for students with VI. A student with VI reported, “Dr. H brought in models for example, the blood supply of the brain. And that was extremely helpful to have tactile models . . . when we had biomechanics Dr. H would just take my hands and show me the motions of the different bones and . . . in the cadaver labs . . . they would physically allow me to touch the specimens. So, that was very helpful.”
Based on interview transcripts, technology barriers to learning for students with VI were identified. There is a lack of audio books for chiropractic techniques and philosophy. Screen readers are useful to read the documents in Microsoft Word format but not for PDFs or slide decks. Finally, the learning management system (Canvas) was not compatible with certain electronic devices used by the students with VI.
The college community lacked general awareness about Braille labels. For example, students inadvertently moved Braille-labeled gym equipment, which posed challenges for students with VI. A student with VI stated, “So I know that there's a problem with moving equipment and unplugging this machine and plugging that one in, just having it be pretty chaotic. I know Ms. L or N has gone and put Braille labels on the cardio equipment. And then the next day or whatever, that won't be plugged in. So that's been frustrating.”
Theme 3: Personnel
Analysis of the audio transcripts revealed that the attitudes of the individuals toward their training, as well as the training itself, played a major role in facilitating or hindering learning.
Consistent with a service-oriented profession, faculty were generally inclined to be helpful to the students with VI. When properly informed, faculty adapted their teaching methods to become more descriptive and clear or used tactile modalities for training students. For example, students with VI were encouraged to touch lab specimens where feasible. In order to teach chiropractic adjustments, teachers demonstrated procedures on the students with VI so that they could feel the setup “firsthand.” Next, the instructor would hold the hands of students with VI in the proper position and guide them to adjust. Faculty also directly administered exams to the students with VI, in many cases reading the questions or describing structures. Efforts were made to match the students with VI and their HC mentors according to personality.
Participants reported that the most successful students with VI displayed a positive frame of mind and developed strong relationships with classmates. For example, classmates helped students with VI do the required HC paperwork when a chiropractic assistant was unavailable. The students with VI also benefited from informal group studies or peer tutor sessions available to them.
As reported by participants, the learning environment became unsupportive to the students with VI when trained personnel were lacking and when student study groups contained less serious students. Finding staff such as aides, chiropractic assistants, and notetakers proved to be a challenge. Few individuals responded to the ads posted for aides or chiropractic assistant roles. Furthermore, a short window of time was available to train chiropractic assistants to efficiently help the student with VI. Consequently, the DSO was left to fill the gaps. A DSO staff member mentioned, “We just had so much difficulty getting aides throughout their didactic portion of the program. So, [DSO staff member] and I sat through a lot of classes, a lot of labs, and we learned a lot.”
Studying for an exam with student groups including “sociable slackers” (unfocused or unmotivated students) was frustrating to students with VI, and when a professor was not available to administer tests requiring some technical guidance, such as descriptions of images, it proved stressful. When entering the HC, the lack of trained assistants became a barrier to filling out the proper paperwork. A student with VI noted that “we have to go to the CMRs [clinical management reviews] . . . that's when the care plans are approved by the doctors—and I'll go in and my file's not in the proper order, which it should be. You know, I would think that would be something a scribe could do, is to put the paperwork in the proper order. It's not something I can do. I mean, I can't tell you when it is in order.”
This novel exploratory study provides further insight into the academic experiences of students with VI in a health care–related field, specifically the doctor of chiropractic program. No previous study related to the chiropractic profession has documented the academic experiences of chiropractic students with VI. This study demonstrates how these students can become successful in this endeavor and provides evidence for enrolling students with VI in a doctor of chiropractic program.
The findings of this study identified facilitators and barriers to learning for students with VI. Detailed and descriptive verbal instruction, as well as tactile methods, such as 3D models, facilitated learning. These methods of instruction are used by other institutes of higher education.19,31 From anecdotal evidence and personal communications with faculty, it was noted that chiropractic colleges usually teach palpation and certain technique skills by temporarily blinding the sighted students; for example, “close your eyes and feel the area on the neck.” This method is well suited for training students with VI. In addition, technique faculty soon learned that demonstrating procedures on the student with VI was particularly effective.
The attitudes of students, both sighted and visually impaired, as well as faculty, shaped their interactions to either facilitate or impede learning. It is critical to consider that students with VI are students first and individuals with disabilities second. Similar to their sighted peers, the students with VI have diverse beliefs and expectations, work ethics, and personality traits. Clearly, 1 solution does not fit all. Educators need to be aware of the value to society that can be generated by assisting in the training of students with VI in health-related occupations such as chiropractic. That acceptance, along with a willingness to provide diverse learning solutions, can create a rewarding experience for all.
Much scientific evidence cited previously exists to suggest that a person with VI may be particularly suited to providing health care services by tactile means. This research project, combined with that evidence, creates a foundation for ongoing discussions regarding the value of the visually impaired person within the chiropractic profession. It suggests the need for future studies that might support or deny efforts at wider inclusion of persons with VI in a chiropractic program. Based on similar educational research, further consideration to include students with VI in medical and physical therapy schools has begun.7,17,19
Finally, one of the findings of this study was that the resources, such as personnel and funds to train students with VI, were quite limited. Making reasonable accommodations for the students with VI becomes more and more reasonable with increased resources. Therefore, this study highlights the need for more funding to support people with disabilities, particularly VI, in tactile methods of health care, such as those taught in a doctor of chiropractic program. Specific to chiropractic education is the acute need for additional funding to create audio textbooks in technique and philosophy. The research conducted in physiotherapy programs has reached similar conclusions.19
Ours was a convenience sample of current faculty, staff, and students with VI at our institution. While we were able to interview all of the students with VI and disability services staff, the small number of study participants placed limits on our ability to achieve thematic saturation. We were also unable to conduct participant checking. However, we explored consistencies and differences by triangulation involving interviewing people in multiple roles, probing and asking questions in several different ways throughout each interview, and making iterative changes throughout the progress of the study.29,30
Further studies with a larger sample size should be conducted for generalizability of the study outcomes. Since the number of students with VI in chiropractic programs is still very small, a next step would likely be a collaborative project between multiple institutions. Also, our study did not interview other campus personnel, such as librarians who assisted students with VI to conduct research, student tutors who may have occasionally coached the students with VI, or part-time faculty who taught students with VI but did not volunteer for the study. Although it does not create any critical knowledge gaps in the current study outcomes, future studies should include all individuals contributing toward the education and successful experiences of students with VI.
It was determined that meticulous planning of limited resources and proactive communication are key to enriching academic experiences of students with VI. Having students with VI in a doctor of chiropractic program can be a rewarding experience for everyone despite some obvious challenges along the way. The students with VI learned chiropractic, while their presence made faculty and staff better communicators and better educators. Although the material resources available were lacking from the ideal, the collaborative and accepting spirit on campus helped make the learning experience of the students with VI successful. Finally, chiropractic programs likely will need to participate in developing teaching resources, such as technique textbooks for students with VI. Future studies need to focus on developing policy guidelines to promote inclusion of students with VI in chiropractic programs.
We acknowledge Ms Mary Lou Breslin for consult on the interview guides, Dr Bonnie Glaser for her consult on the interview guides and assistance in data collection, Dr Monica Smith and Dr Donna Odierna for consults on research and interview guides, Ms Lori Pino for facilitating the recruitment, and Annette Osenga for bibliographical assistance.
FUNDING AND CONFLICT OF INTEREST
The study was funded internally. The authors have no conflicts of interest to declare relevant to this work.
Aditi Joshi is an associate professor in the Basic Science Department at Life Chiropractic College West (Room 134, Life Chiropractic College West, Industrial Boulevard, Hayward, California 94587; firstname.lastname@example.org). Sue Ray is a professor in the Basic Science Department at Life Chiropractic College West (Room 134, Life Chiropractic College West, Industrial Boulevard, Hayward, California 94587; email@example.com).
Concept development: SLR. Design: SLR, AJ. Supervision: SLR. Data collection/processing: SLR, AJ. Analysis/interpretation: SLR, AJ. Literature search: SLR, AJ. Writing: SLR, AJ. Critical review: SLR, AJ.