Introduction
Visual impairment (VI) is defined as a visual acuity of <6.12 that cannot be treated or corrected to normal with regular glasses or lenses (Evans & Rowlands, 2004). The term blindness is also used for complete or nearly complete loss of vision (Burton et al. 2020). VI affects all aspects of a person’s life and is associated with reduced functional ability (Park et al., 2015). This impairment is a crucial public health concern worldwide and has an irreparable impact on the mental and economic health of individuals, as well as the well-being of families, society, and country (Otuka, 2021). Typically, emotional reactions, loss of self-confidence, and dependence on others are observed in visually impaired people (Szubielska, 2018). Visually impaired people face challenges in performing daily activities. Thus, it is unsurprising that stress, whether congenital or acquired with VI, is a major issue for affected people (Nyman et al., 2012). Studies have shown about 36 million people who are completely blind, 217 million people with moderate to severe VI, and 253 million people with (mild) VI around the world (Ezinne et al., 2022). In Iran, according to the released statistics, 600000 to 700000 people have been identified as having VI, of whom 115000 people are completely blind (Khodabakhshi-Koolaee & Amogholi, 2024). Blindness and VI are problems and challenges that make affected people face many psychological and social problems (Bhagchandani, 2014). In addition to psychological and social problems, these people have poor participation in social activities, a lack of independent life, and even incompatibility with urban space and public transportation (Aslan et al., 2012).
The consequences of VI that affect a person’s physical and mental health are widespread and include a person’s lack of independence and dependence on others in doing housework, personal affairs, and other routine life activities, loneliness and social isolation, non-participation in social and religious activities, difficulty in reading, lack of interest in and motivation for activities, restlessness, the occurrence of cognitive and functional disorders, decreased performance, increased dependence on others, low hope for the future, wishing for death, increased risk of accidents with vehicles, falling, and fractures (Lam et al., 2008). Moreover, people with VI experience stress and psychological distress in their daily lives due to having no access to information, social expectations, and the need for body movement and coordination with environmental situations (Lyngroth et al. 2023). People with VI often have limited physical and self-regulation abilities. However, doing yoga and mindfulness activities can improve the physical and mental health of affected people by reducing stress and improving their mood and well-being (Stone, 2022).
Depression, independent of the level of visual impairment, is another source of disability for visually impaired people (Rovner et al., 2002). These people show higher levels of depressive symptoms and loneliness than their sighted peers (Pinquart & Pfeiffer, 2011) and usually have more difficulty making new friends. Due to visual and social limitations, people with VI have problems with their developmental tasks and maturity (Aghaee-Joshghani et al., 2023). Thus, they need early intervention and rehabilitation services that aim to improve daily life functioning, social participation, and possibly more general aspects of well-being such as quality of life (QoL) and psychosocial functioning (Koolaee, 2017; Khodabakhshi-Koolaee & Amogholi, 2024).
The term well-being does not have a single definition; however, the consensus is about the presence of positive emotions and states (e.g. satisfaction, happiness), positive functioning, feeling healthy and energetic, the absence of negative emotions (e.g. depression and anxiety), and satisfaction with life (Feldman, 2010). Depending on their area of interest, researchers may refer to well-being, which can involve physical, social, developmental, activity-based, emotional, psychological, life satisfaction, domain-specific satisfaction, engaging activities, and work (Marquès, 2012). This study was conducted to assess the factors affecting psychological, emotional, and social well-being.
Colleen et al. (2017) examined the most effective interventions that facilitate occupational engagement of older adults with age-related vision loss. The results showed that three interventions, including self-management programs, compensatory interventions (such as assistive devices and self-regulation strategies), and social support (such as relying on others, community resources, and peer support) were effective in facilitating occupational engagement of older adults with age-related vision loss.
Rees et al. (2017) showed that multidisciplinary rehabilitation services have a limited effect on the levels of depression symptoms of visually impaired people, but may improve other aspects of psychological well-being, such as QoL. Specifically designed psychoeducational programs improve a range of psychological outcomes and may be able to prevent depressive symptoms in people with VI. 
Mullins conducted a realistic study of the conceptual implementation of therapy to reduce depression and cognitive distortions and improve problem-solving abilities for visually impaired and blind people. While the level of depression was not reduced significantly, the changes along with cognitive distortions indicated an increase in cognitive flexibility and a subjective sense of success and well-being. The resulting cognitive flexibility may predict more positive outcomes for behavioral health in the future. The results indicated that a flexible, innovative, and adaptive evidence-based approach is necessary to work with visually impaired people due to the many challenges faced by these people (Mullins, 2019).
Vander et al. (2016) in their systematic review study examined psychosocial interventions to improve mental health in visually impaired adults and did not observe any significant general effects on symptoms of anxiety, psychological distress, mental exhaustion, and mental health. The interventions had only modestly significant effects on depressive symptoms, and interventions delivered in the context of VI rehabilitation care (which may increase accessibility for people with VI) were more effective than interventions delivered in other settings (e.g. hospitals/clinical settings). The sample size of the studies was often small and the follow-up phase was short.
Given the prevalence of psychological distress in visually impaired people and the reciprocal relationship between depression and disability, it is vital to understand the impact of vision rehabilitation on mental health. Moreover, it is essential to determine whether psychological interventions can improve mental health or prevent psychological problems or whether it is required to integrate specific psychological interventions into rehabilitation programs. More detailed studies are needed to understand the effectiveness, mechanisms, moderators, and cost-effectiveness of psychological intervention programs on psychological well-being in visually impaired people. Given the growing variety of available interventions and increasing efforts to professionalize health care, there is a strong need for evidence on the effectiveness of interventions in achieving positive outcomes. Visually impaired people have the right to benefit from the most effective rehabilitation programs, and the importance of evaluating the effectiveness of interventions has been emphasized by the World Health Organization (WHO) and the United Nations Convention on the Rights of Persons with Disabilities (CRPD) United Nations, 2006). To this end, the present study was conducted to provide a systematic analysis of studies to investigate the effectiveness of psychological interventions on the psychological well-being of visually impaired people and introduce the most effective interventions.

Materials and Methods 
This systematic review analyzed the studies that addressed interventions to promote psychological, emotional, and social well-being. The research population included all documents related to the effectiveness of psychological interventions in the psychological well-being of visually impaired people using experimental or quasi-experimental designs with intervention and control groups and pre-test/post-test with or without follow-up. The data were collected by searching Google Scholar, Elsevier, Science Direct, PubMed, and Scopus databases using the keywords, “psychological well-being in visually impaired people”, “effectiveness of psychological interventions in people with VI”, “depression in blind people”, “stress in visually impaired people”; “effectiveness of cognitive behavioral therapy (CBT)”, “behavioral approach”, “rational emotive behavior therapy”, “schema therapy”, “cognitive therapy”, “mindfulness”, “orientation”, “acceptance and commitment therapy (ACT)”, “music therapy”, “rational emotive behavior therapy (REBT)”, “narrative therapy”, “compassion therapy”, “adventure”, “play therapy”, “meaning therapy”, and “group counseling” on visually impaired people. Each keyword was searched separately. The search was conducted on the published documents from 2003 to 2023. In the end, 211 studies were extracted through the mentioned search engines, and 8 studies were selected from other databases, such as Magiran. After removing duplicates, 176 articles were analyzed and 10 irrelevant articles and 24 articles whose full texts were not available were excluded. Finally, 142 articles were analyzed, of which 25 articles met the inclusion criteria. The inclusion criteria included all cross-sectional studies that addressed the effectiveness of psychological interventions in the cognitive and social factors in visually impaired people using a pre-test and post-test or a repeated measurement design and a quantitative approach. The exclusion criteria included studies not relevant to the subject in question. Two researchers searched the articles simultaneously and to increase the validity and reliability of the research procedure, they evaluated the quality of the articles separately based on the inclusion and exclusion criteria. To select the articles, a list of titles and abstracts of all the articles available in the databases was prepared by the researcher and examined to determine and select relevant articles. Then, related articles were assessed independently. Finally, 25 articles that had inclusion criteria were enrolled in the systematic review study (Figure 1).



Results

Characteristics of the research population 
Appendix 1 presents a summary of the reviewed studies. The data indicated that the number of participants in 23 studies (92%) of the studies varied from 16 to 120 persons. Moreover, the number of participants in 2 studies (8%) that adopted a single-subject design, varied from 1 to 2 persons. In 2 studies (8%), the participants were only female. In addition, 17 studies (68%) assessed both males and females, and 2 studies (8%) only examined male participants. Furthermore, 4 studies (16%) did not specify the gender of the participants. In 22 studies (88%), the participants’ ages ranged from 6 to 24 years, and in 1 study (4%), the mean age of participants was 43 years. In addition, in 2 single-subject studies (8%), the participants were 77, 12, and 14 years old. The results also indicated that a vast majority of studies focused on adolescents and young adults.

Research design 
The data revealed that 9 studies (36%) adopted a randomized controlled trial design, 14 studies (56%) used a quasi-experimental research design, and 2 studies (8%) adopted a single-case design with repeated measurements.

Psychological indicators 
A total of 44 different psychological variables were assessed in the reviewed studies. The psychological components included psychological distress, stress, and anxiety (3 cases), self-concept (2 cases), assertiveness, and psychological well-being in 7 studies; the emotional components included depression (4 cases) and aggressive behavior (2 cases); and the social components (6 cases) included communication skills, empathic tendencies, social participation, and social anxiety (2 cases), QoL (3 cases), and creative abilities, interpersonal openness and self-esteem (12 cases). 

Interventions
The reviewed studies assessed the effectiveness of various psychological interventions, such as assertiveness, emotional intelligence (2 cases), life skills, REBT (3 cases), music therapy, ACT, positive thinking, creative skills, logotherapy, computer games, spiritual therapy, training to facilitate independent mobility and orientation (2 cases), communication skills, stress management, choice theory training, a guide to treating depression symptoms, and cognitive behavioral therapy (5 cases). The interventions were conducted in 8 to 48 sessions and 10 studies had a follow-up of 2 to 18 months.

Discussion
Systematic review data indicated that the psychological interventions to improve psychological, emotional, and social well-being were mostly conducted on adolescents, especially students. However, one case study was conducted on a 77-year-old woman (Utoyo, 2015). The largest number of interventions focused on CBT in 6 articles. The results indicated that CBT was effective in promoting self-esteem and self-confidence and reducing depression and social anxiety (Utoyo, 2015; Elsherbiny, 2015; Soleimani Sefat et al., 2017; Eka et al., 2019). One study confirmed the effectiveness of cognitive-behavioral group therapy in improving self-concept in four aspects, including intellectual ability, work efficiency, physical attractiveness, and social skills, but did not find a positive effect on virtues and vices (Yaghotian et al., 2016). One study examined the impact of CBT on anxiety and found that the positive and motivating program (PAM) did not significantly reduce anxiety symptoms in visually impaired children, and the overall mean score in each group remained virtually unchanged from T1 to T4 (Visagie et al., 2021). REBT was the second most frequent intervention used in 3 articles to reduce depression, anxiety, and worry and decrease the negative evaluation of people, leading to a positive effect on psychological variables in all three studies reviewed (Jalali et al., 2014; Liziana, 2018; Abiogu et al., 2020). Emotional intelligence-based interventions were also effective in reducing the level of aggression and improving psychological well-being as reported in 2 studies (Eniola, 2007; Eniola, 2013). Interventions aimed to facilitate independent mobility and orientation were also effective in improving the QoL, openness, and the meaning of life in 2 studies, but in the long term, they only had a positive effect on interpersonal openness (Kamali & Ashori, 2021; Elewiat & Keshky, 2022). Assertiveness training had no significant effect on improving social self-expression skills and reducing students’ cognitive distortions (Kim, 2003). Life skills training in the form of group and individual CBT is an effective rehabilitation intervention for young and middle-aged adults who suffer from psychological distress associated with acquired visual impairment. The communication skills training program was able to improve the empathic tendencies and communication skills of visually impaired adolescents (Ueda, 2010). Music can also significantly reduce the level of aggression (Hashemian et al., 2015). The mentoring intervention with a focus on positive thinking and successful experiences can improve people’s social participation (Heppe et al., 2015). Teaching the concepts of choice theory is effective in the hope and QoL of blind individuals (Khodabakhshi Koolaee et al., 2017). The data also indicated that ACT was effective in improving the self-esteem of adolescents with VI (Mirmohammadi et al., 2021). Moreover, meaning therapy was effective in reducing the social anxiety of blind adolescents (Adulrahman, 2021). Spiritual interventions can also help improve the QoL and spiritual intelligence in visually impaired students (Gohari et al., 2023). The SEE game had more positive effects on academic self-concept and social well-being. No significant difference was observed between the coping strategies in the intervention and control groups (Lievense et al., 2021). The stress management protocol reduced stress in both rounds of the intervention. However, stress was significantly reduced only in the second phase of the intervention (Paige & Elise, 2017). The results indicated that a research-made program stimulated the development of 8 aspects of the creative abilities of the participants (Kholoud et al., 2015). The intervention program improved communication skills, empathic tendencies, and communication skills of visually impaired adolescents (Yildiz & Duy, 2013). 
In conducting this research, a linguistic bias was observed. Some articles published in different countries were not in English and only their English abstracts were available, which were eventually excluded, which ultimately reduces the generalizability of the results. Given the prevalence of psychological distress in visually impaired people and the reciprocal relationship between depression and disability, it is essential to understand the impact of vision rehabilitation on mental health. In addition, investigating the effectiveness of psychological interventions to increase the QoL and self-concept of people with visual impairments can help promote mental health and prevention and develop rehabilitation programs.

Conclusion
Visually impaired people need effective and early interventions in life due to their limited vision. The results indicated that CBT was the most frequently used intervention, but it cannot have a positive effect on some variables. Three studies reported that REBT had positive effects. Given that thinking, feeling, and action are intertwined in arousing a person, it seems that cognitive therapies can improve psychological well-being in visually impaired people, with cognitive behavioral therapy and rational emotional behavioral therapy (CBT and REBT) playing a more effective role. 

Researcher’s interpretation 
Studies have shown that psychological interventions are effective in the psychological well-being of visually impaired people. According to the studies conducted by the researchers, their close connections with visually impaired people, and looking at the world from their perspective, psychological services provided by counselors along with group therapies with peers and non-peers can play an effective role in improving the psychological well-being of visually impaired people. 

Ethical Considerations

Compliance with ethical guidelines
The article was registered in the Iran National Committee for Ethics in Biomedical Research (Code: IR.IAU.SRB.REC.1401.254). To comply with the ethical principles of voluntary participation, written informed consent was obtained from the participants for conducting and recording the interviews. The participants were also reassured of the confidentiality of their information.

Funding
This article was extracted from the Ph.D. thesis of Alireza Malekitabr at Department of Counseling, Faculty of Litreature, Humanities and Social Sciences, Science and Research Branch, Islamic Azad University, Tehran.

Authors' contributions
All authors equally contributed to preparing this article.

Conflict of interest
The authors declared no conflict of interest.



References