Occupational Therapists’ perspectives of implementing a new rehabilitation intervention for visual field loss due to stroke

Stroke, vision, rehabilitation, scanning training, qualitative, feasibility, hemianopia, interviews ALL Metrics - Views Downloads How to cite this article Hazelton C, Harding S, Angilley J et al. Occupational Therapists’ perspectives of implementing a new rehabilitation intervention for visual field loss due to stroke [version 1; peer review: 2 approved, 2 approved with reservations]. NIHR Open Res 2025, 5:57 (https://doi.org/10.3310/nihropenres.13984.1) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente Select a format first ▬ ✚ Research Article [version 1; peer review: 2 approved, 2 approved with reservations] Christine Hazelton1, Sam Harding https://orcid.org/0000-0002-5870-2094 2, Jayne Angilley3, Alexandra Palombi https://orcid.org/0000-0001-9230-093X 4, Audrey Bowen https://orcid.org/0000-0003-4075-1215 5, Phil Clatworthy6Christine Hazelton1, Sam Harding https://orcid.org/0000-0002-5870-2094 2, [...] Jayne Angilley3, Alexandra Palombi https://orcid.org/0000-0001-9230-093X 4, Audrey Bowen https://orcid.org/0000-0003-4075-1215 5, Phil Clatworthy6 PUBLISHED 04 Jul 2025 Author details Author details 1 Glasgow Caledonian University School of Health and Life Sciences, Glasgow, Scotland, UK 2 Research and Development, North Bristol NHS Trust, Westbury on Trym, England, UK 3 NHS Cornwall & Isles of Scilly, Truro, UK 4 Royal Holloway University of London School of Life Sciences and the Environment, Egham, England, UK 5 The University of Manchester Division of Psychology and Mental Health, Manchester, England, UK 6 Department of Neurology, North Bristol NHS Trust, Westbury on Trym, England, UK 2 Research and Development, North Bristol NHS Trust, Westbury on Trym, England, UK 3 NHS Cornwall & Isles of Scilly, Truro, UK 4 Royal Holloway University of London School of Life Sciences and the Environment, Egham, England, UK 5 The University of Manchester Division of Psychology and Mental Health, Manchester, England, UK 6 Department of Neurology, North Bristol NHS Trust, Westbury on Trym, England, UK Christine Hazelton Roles: Data Curation, Formal Analysis, Funding Acquisition, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Roles: Data Curation, Formal Analysis, Funding Acquisition, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Sam Harding Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Jayne Angilley Roles: Conceptualization, Writing – Review & Editing Roles: Conceptualization, Writing – Review & Editing Alexandra Palombi Roles: Conceptualization, Writing – Review & Editing Roles: Conceptualization, Writing – Review & Editing Audrey Bowen Roles: Conceptualization, Writing – Review & Editing Roles: Conceptualization, Writing – Review & Editing Phil Clatworthy Roles: Conceptualization, Data Curation, Writing – Review & Editing Roles: Conceptualization, Data Curation, Writing – Review & Editing OPEN PEER REVIEW REVIEWER STATUS This study aimed to explore the barriers and facilitators of implementing rehabilitation interventions for visual field loss due to stroke. The study was a qualitative exploration using one-to-one interviews coded using template analysis and the COM-B a-priori framework. Participants were five occupational therapists from hospital (n=4) and community (n=1) National Health Service (NHS) stroke care settings in England. The intervention experienced by the participant was a standardized goal-based visual scanning and search training for stroke survivors with visual field loss, delivered by occupational therapists (OTs), supported by information sheets and a dedicated website (HABIT). HABIT provides a structured approach for delivering scanning and visual search training. HABIT resources aided participants’ understanding and self-management. HABIT was considered similar to current practice as practiced by study participants and of most value to trainees and newly qualified therapists. However, resources had limited accessibility due to a lack of computer access and difficulty in reading text; modifications were required to make training activity examples more suitable for ward settings. Within ward settings, the delivery of HABIT was highly limited by time constraints; therapists ranked activities linked to safety and early discharge as higher priority. Clinicians noted that stroke survivors' lack of awareness of their visual loss and its impact limited their engagement with the HABIT, making delivery difficult. Prioritization of vision rehabilitation in highly pressurized acute settings is a key factor in implementing HABIT. The findings will enable further refinement of HABIT content and delivery to address the barriers identified and improve its suitability in acute hospital settings. The research investigated which aspects promote and which obstacles prevent the application of the new stroke rehabilitation program, HABIT. HABIT stands for *Hemianopia Activity-Based Intervention* and serves as a treatment approach for stroke patients with visual field loss. The researchers conducted interviews with five occupational therapists (OTs) to assess HABIT's effectiveness of HABIT in real-world healthcare settings. Four of the occupational therapists worked in hospitals together with one therapist who operated in a community setting within NHS stroke services across England. The research team used the COM-B framework to analyse the interview data that examined behaviour and motivation. What was found: - The therapists found HABIT provided a structured approach for visual rehabilitation. - New and less seasoned therapists found the program especially useful for their practice. - The resources provided patients with the necessary information about their condition while boosting their self-management of visual impairments. - Therapists faced difficulties when using the website and printed resources because they did not have enough access to computers and had trouble reading materials in a busy hospital environment. - Several example activities within the program proved unsuitable for hospital ward implementation because of space constraints and limited availability of time and equipment. - The hospital stroke units operated under severe time constraints that limited the time therapists could dedicate to their patients. Hospital settings with limited resources and busy environments cause visual rehabilitation programs, such as HABIT, to become less important. The effectiveness and adoption of HABIT will increase when its design aligns with hospital realities. The adaptation process should focus on creating simpler materials while introducing activities suitable for hospital wards and providing patients with a better understanding of the effects of vision loss. The findings of this research will guide improvements in HABIT for better hospital implementation. Stroke, vision, rehabilitation, scanning training, qualitative, feasibility, hemianopia, interviews Corresponding Author(s) Sam Harding ([email protected]) Grant information: This study was funded by the National Institute for Health Research NIHR [Research for Patient Benefit (PB-PG-0418-20040)]. The views expressed are those of the author(s) and not necessarily those of the NIHR or Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © Crown copyright, 2025 Hazelton C et al.. This open access work is licensed under the Open Government Licence v3.0 How to cite: Hazelton C, Harding S, Angilley J et al. Occupational Therapists’ perspectives of implementing a new rehabilitation intervention for visual field loss due to stroke [version 1; peer review: 2 approved, 2 approved with reservations]. NIHR Open Res 2025, 5:57 (https://doi.org/10.3310/nihropenres.13984.1) First published: 04 Jul 2025, 5:57 (https://doi.org/10.3310/nihropenres.13984.1) Latest published: 04 Jul 2025, 5:57 (https://doi.org/10.3310/nihropenres.13984.1) The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. HABIT (“Hemianopia Activity-Based Intervention”) is a new intervention designed to support provision of goal-based rehabilitation for people with visual field loss due to stroke. HABIT was seen as a potentially valuable tool for the structural delivery of visual rehabilitation and is of great value to practitioners new to the topic. The provision of rehabilitation for visual field loss (including the HABIT web-based tool) was not seen as a priority by occupational therapists working in a time-pressured acute stroke service in the context of COVID-19. HABIT delivery is hampered by the highly visual nature of materials, need for specific resources (such as tablets or laptops), and time required. More activities suitable for use in the acute ward setting need to be included to maximize the use by clinicians. Stroke occurs in more than 100,000 people in the UK each year1,2 and is a leading cause of disability both nationally and internationally3–7. Vision is affected in up to half of all strokes, and a range of visual functions may be impaired, including eye movements, visual attention, visual perception, and visual fields. Visual field loss (homonymous hemianopia) is the inability to see up to half of the visual space in both eyes8,9. Visual field loss persists in approximately 20% of stroke survivors10,11. It reduces mobility and wayfinding, causes collisions and falls, limits reading and writing, and leads to the loss of driving and recreational activities12–14. Stroke survivors with visual field loss have limited engagement in rehabilitation and a poorer quality of life15,16. Occupational therapists (OTs) most often manage visual field loss caused by stroke. National guidance on how OTs should do so is limited by the lack of evidence, and expert opinion suggests that compensatory training is considered17,18. Compensatory training does not aim to recover lost visual field, but instead uses repeated practice to develop more effective use of the intact visual field to improve function. The most recent Cochrane Review found low-quality evidence that compensatory training may improve quality of life19. Compensatory training comprises of two main approaches. First, scanning training aims to teach a more regular pattern of large, accurate horizontal eye or head movements to the side of visual field loss to provide a broad overview of the visual scene. Second, search training aims to improve the efficiency of eye movements used when searching for visual space; these patterns tend to break down and become disorganized due to visual field loss. Surveys have shown that OTs currently deliver scanning training for visual field loss. However, they reported that their practice is limited by a lack of treatment protocols, lack of specialist training, and poor awareness of the best treatment options20,21. To date, there are no standardized OT-led training interventions developed for use within UK settings, and stroke rehabilitation guidelines lack any practical description of how compensatory visual training might be undertaken. Hemianopia Activity-Based Intervention (HABIT) is a rehabilitation intervention that was developed to address this gap. HABIT is founded on stroke-specific visual field rehabilitation practice grounded in compensatory training, as practiced by rehabilitation and vision specialists in the research team. It was constructed by incorporating specific evidence-based training elements from the visual rehabilitation literature into standard OT best practice; it was further developed in consultation with people with lived experience of visual field loss due to stroke and via consensus agreement with expert therapists22,23. It is aimed at both acute/ward-based care and later/community care, with a focus group of people with lived experiences of visual field loss, stressing the need for vision to be incorporated at an early stage of the rehabilitation process. Currently, HABIT is being refined for delivery. Key questions in this refinement process relate to the feasibility of implementation in existing National Health Service (NHS) stroke rehabilitation services without the need for extensive service reconfiguration. Existing research in this field does not adequately address implementation and feasibility. Feasibility encompasses whether something can be done, whether it should be done, and, if so, how. Early consideration of feasibility is vital to ensure that an intervention is acceptable to patients, caregivers, and staff. Crucially, it is deliverable by the healthcare system in which it is intended to be used24. Studies of compensatory visual training have evaluated feasibility using quantitative measures, such as dropout and adherence rates (seen as measures of tolerability)25,26, and quantitative scales of acceptability27. Only one qualitative study explored stroke survivor perspectives, finding that the ease of setting up and then using the tool, plus the level of carer support required, were key factors28. We are aware of only one study gathering clinician opinions on feasibility: poor knowledge of visual function, unclear responsibility, lack of clear pathways and time constraints (barriers), and a strong belief in the importance of fully considering vision (a facilitator) were key issues29. However, these findings are related to vision screening within the Norwegian care system, as opposed to rehabilitation, within the Norwegian care system and thus, have limited applicability. This study aimed to explore the perceived feasibility of delivering HABIT within existing stroke care settings, specifically the UK National Health Service (NHS), by identifying barriers and facilitators to its implementation. Patient and public involvement is at the heart of the HABIT program. The patients were heavily involved in the development and design of this study. Wider stakeholder engagement in the form of healthcare professionals from a range of specialties as well as patient representatives collaborated with the research team to advise on the data collection methodology and the content of the interview schedule. This qualitative research was part of a larger feasibility study. This study was reviewed by the Wales Research Ethics Committee 4 Wrexham Research Ethics Committee (REC: 20/WA/0093) and by the Health Research Authority and Health and Care Research Wales (IRAS: 270718). The study was conducted from October 2019 to November 2021 and included the height of the COVID-19 pandemic. There were five sites that delivered the new HABIT intervention: four hospitals and one community stroke care setting. HABIT is designed to enable standardized, comprehensive, best practice OT care for stroke survivors with visual field loss. It incorporates the principles and practical methods of both visual search and scanning training for visual field loss, as described above, and OT care, using activity-based training tailored to the impairments and valued activities of the individual, with increasing complexity and intensity. It also includes the provision of information, which is seen as a key first step in achieving effective compensatory behaviours. Key stages in delivering HABIT to a stroke survivor with field loss are: 1. an initial visit to confirm visual field loss and to explain and provide information on this. 2. Selection of tasks and strategies for practice – in discussion with the client, and that are relevant to the patient’s goals and current setting. Examples are provided for clinicians to help guide their choices. 3. Reviewing and grading practice - to determine progress, find ways to vary the practice, and grade the training to maintain a challenge. The intervention materials consisted of tools to train therapists on how to deliver HABIT. These cover the rationale, key components, and methods to conduct HABIT processes and activities with stroke survivors in a range of settings. Training materials are a therapy manual and online training via a recorded video and live problem solving. Second, tools help support the delivery of HABIT to individual patients, their families, and caregivers. These include written materials such as information sheets, practice activities leaflet, and vision screening summary, plus a dedicated website including videos on the experience and impact of visual field loss and examples of successful rehabilitation. All OTs who delivered HABIT during the feasibility study were approached to be interviewed, and all agreed. Therefore, all recruiting sites were represented in the data collection, and all participants had recent experience in delivering the HABIT intervention. Informed consent was obtained in writing during site initiation visits. Data were collected through semi-structured online interviews, lasting up to one hour, conducted using Zoom (Zoom Video Communications Inc.). Interviews were undertaken by SH, a Health Psychologist and Research Fellow. The interviews were audio-recorded and transcribed verbatim. The interview schedule covered participants’ thoughts about the barriers and facilitators of HABIT implementation in healthcare practice (Interview schedule is available at https://osf.io/3cwmf/). The interviews covered the full scope of the intervention, including training, intervention delivery, supporting materials, and the website. The analysis was performed by two authors (CH and SH). CH is an Optometrist and Research Fellow. Both CH and SH had training and experience in undertaking and reporting qualitative research. Both were female with doctoral qualifications (PhDs). The template analysis methodology was applied to the interview transcripts. This method supports a hybrid approach of both deductive (a priori) and inductive qualitative analysis; in this case, the a priori implementation framework (COM-B) remains open to the possibility that the framework was not completely implementable within the study context30,31. Following the transcription of the interviews, NVivo 1232 was used with the King & Brooks28 template process to facilitate qualitative content analysis. Integrating initial thoughts, the researchers looked for diversity and similarity in the transcripts, started to make meaning from the dataset, and applied labels to specific segments of the transcript/data. Subsequently, the a priori framework of COM-B was applied33. The COM-B framework breaks the drivers of behaviour (B) into three categories: capability (C), opportunity (O), and motivation (M). Capability refers to an individual’s ability to participate in an activity and consists of both physical and psychological components. Opportunity relates to external factors that make a target behaviour possible and can be both social and physical. Motivation concerns internal processes that influence decision making and behaviours. Barriers and facilitators of implementation were drawn into themes under these categories; participants' individual comments were reported where they illuminated their particular experiences. Interviews were conducted with five OTs, four of which were based in hospital settings (one hyperacute stroke unit, one acute stroke unit, two non-acute/rehabilitation wards), and one in the community. All had experience working with stroke survivors, ranging from to 1–10 years. Opinions relating to barriers and facilitators in the delivery of HABIT, identified through the application of the COM-B framework, were as follows: Overall, HABIT was perceived to be similar to what the OT participants were already doing. For some participants, this acted as a validation of their work, reassuring them that what they delivered was backed by the research: "I think it was really reassuring more than anything…. The stuff that's recommended is things that we have we have thought about before (and) we try and do with patients. So, I think in that sense…, it affirms that we're not, like totally, like, off the track with not doing the right things.” Other OTs reported disappointment regarding the limited development of their underlying level of knowledge and practical skills used in delivering care: "what we were perhaps a little bit gutted about is that there wasn’t necessarily anything new to us… They were things that we were doing anyway." "I just don’t feel like it’s added anything into our practice." HABIT was perceived as most valuable for those less familiar with treating visual field loss, such as OTs new to stroke care and members of other professions in the stroke team, with its main function as a training tool. "I do really think that some of the things that are proposed are equally as valid for other professionals of course and perhaps other professionals have less awareness of hemianopia than we have." A number of OTs reported benefits to their practice relating to how HABIT provided both new ideas and approaches for, and a structure for, the management of visual field loss. This increased the consistency and thoroughness with which vision was addressed and provided a framework for vision-related goal setting. HABIT also increased the attention and time paid to vision; the HABIT paperwork supported this structured approach. "...it did give us a bit more time... to stop and think: well, actually, what could we do with this person that wants to be able to read, but you know they're struggling? So, let's sit down and look at some strategies.” "How do we treat these patients? …Are we doing these things routinely? You know, I, I know about scanning, but… how am I doing scanning? And … how do you set it up? …maybe what was quite good was that [HABIT] got me thinking a bit more... about the goal. So, say they want to find their items in a wardrobe. Well, then you might do the scanning practice…. So, I guess it just gave me a few more thoughts about how I structure my treatments.” Of particular value was the sheet where the OTs could record and display the nature of a patient’s visual loss. OTs reported that this improved their ability to explain an individual’s visual field loss to them and their families. "And so, I did quite like that. And that was easy to fill in. And I thought was easy for the patients to follow" The online tool and examples were noted to increase capability in some stroke survivors, enabling self-practice and self-management of their visual field loss, with online case studies acting as a form of peer support. The opportunity to use HABIT was limited by factors related to HABIT resources and the environment of the intervention delivery. Resource concerns centered on features of the HABIT tool itself: A key barrier was the requirement to complete a range of paperwork, covering provision of information, goal setting and achievement, and records of visits, which were considered excessive. In the acute hospital setting, the paperwork related to goal setting was difficult to complete because there was insufficient time for the patient and therapist to identify important goals: “I found it difficult to fill it in because I was going off such little information. So, I was trying to come up with some quick at home stuff to do on somebody that I've had a very short time.” The inclusion of online components was a concern because devices such as laptops or tablets were not always available in the ward. OTs working in acute settings felt that the intervention was designed primarily for use in a community setting, and as the examples were primarily for a home setting, it was difficult to implement. To do so required the addition of new activities that could be conducted in the ward and further consideration and discussion by the team to tailor the given examples to an inpatient setting. Motivation was key to determining the extent to which HABIT was implemented. Two elements were highlighted: goal priority and beliefs about patients' capabilities and opportunities. Goal priority. The priority given to vision by the OTs was critical to their motivation to use HABIT. It was evident that OTs’ prioritization of vision care included consideration of a range of individual, service, and participant-related factors. From the participants' responses, this prioritization related to addressing vision as a whole, and not just the use of HABIT to do so. In the interviews, prioritization was described as an intersection between an opportunity factor (the amount of time available) and motivation (the relative importance given to addressing visual impairment compared to other elements of post-stroke care). This dynamic interaction was influenced by context and was most notable in an acute rather than a community setting. In an acute setting, the OTs clearly stated a lack of time to complete a broad range of tasks for each patient: "We don’t have the time to because that needs to be incorporated in somebody’s routine and you have none of that in the acute because they’re going to be here for maybe two days so there is no time to be creating HABITs or anything." OTs prioritized the issues they considered to be most important: vision was often not considered important, nor was it a main concern for care. The most important aspects were discharge, assessment and management of mobility, and risk management. Consequently, HABIT is not used by everyone. The OTs stated that if they tried to address vision, it would take time away from these, higher priority, and clinical issues. "Hemianopia is a tiny problem, tiny clinical observation amongst all of strokes…But if you were going to write a textbook, an OT textbook of stroke, hemianopia would probably be one page out of 200." "If you're doing HABIT with people you have less time to do other things." Clinicians stated that patient priorities should be considered. When patients themselves did not place importance on their vision, it was difficult to motivate them to engage in vision rehabilitation. Again, this was linked specifically to an acute setting, where patients were primarily focused on getting home and OT care that would enable this. Additionally, as they (the patient) were in unfamiliar surroundings, OTs felt that patients were not fully aware that they had lost half of their vision. Patients had not yet experienced the impact this could have on their daily lives, and so did not stress this element of care. "it's not their priority right than their priority is getting home. So, actually, working on the specifics of their vision. If it's not having that huge an impact to them at that point, it doesn't feel like that huge of an issue. But actually, I'm going home today or tomorrow or there's something else that you know the walking feels more of a difficulty then that always has an impact, I think." Hospital-based clinicians stated that ‘community is the best place’ for HABIT implementation, due to the factors of time, ability to goal set and practice in relevant tasks and patient motivation noted above. Beliefs about patients' capabilities and opportunities. The OTs’ motivation was linked to their beliefs about the capability of a patient to engage with and benefit from the intervention. This is related in part to the interaction between the patient and the tools. Visual, language, and cognitive impairments could limit the patients' ability to benefit. In particular, supporting materials, such as written information documents and online tools, are very visual in nature, with both text and graphics. Patients had visual impairment and struggled to engage with these materials, which limited their benefit from the intervention. However, online videos were considered useful because the narrative could be listened to by the patients. "I didn't quite know how they were meant to access it. If they couldn't really scan across all the slides, and I don't think I had any patients where I felt confident that they would be able to access it on their own." "I didn’t find useful all the other written stuff, … because the majority of people with hemianopia do not read." The perceived lack of familiarity with, or access to, computers was also a barrier. "the kind of patient we had were generally elderly. I would say probably most of them didn't have a computer at home anyway. The ones that did I didn't feel that they would be able to access it" The OTs frequently mentioned the relevance of tools within their care settings. Some participants felt that the examples and activities provided were appropriate and pertinent. Where this was the case and when a patient was considered able to engage fully, this was highly motivating. " ‘I personally, with the patient…, he was quite young and cognitively able, quite an intelligent guy. He did find, a lot of kind of… I was quite excited when I saw it’s got all these different kinds of examples of day-to-day tasks that you might struggle with, that … was kind of common sense with the strategies used" This study provides the first evidence of clinicians’ perspectives towards implementing a visual rehabilitation intervention in NHS stroke care settings. Analysis of participants' accounts provides clear insights into the factors affecting HABIT implementation and how these interact with a given patient in a specific care setting. At its core, HABIT was seen to provide a structured approach for the treatment of visual field loss after stroke. This is in line with the stated aim of HABIT to operationalize best practices in OT-led vision rehabilitation for stroke survivors. HABIT did not differ significantly from current practice, and while some therapists found this disappointing, others found it reassuring, and participants in general valued the structure and focus that HABIT brought to treatment as well as providing new ideas and approaches. HABIT, therefore, also addresses the identified gap in training in this area19,20 and thus is an important step in improving vision services for stroke survivors. The study also provides clear areas for further development of HABIT to improve its implementation. These relate to the topics of accessibility, importance, and delivery efficiency. Participants reported that the use of HABIT was limited by difficulties in accessing online materials and the inability of patients to use written HABIT documents. OTs found it difficult to access the electronic devices required to use online resources. One tablet was provided per site; however, this was insufficient and meant that devices could not be left with patients to explore the HABIT website themselves. In addition, OTs’ beliefs about older patients’ poorer ability to use digital technology have reduced its introduction. It is not clear whether these beliefs aligned with patients’ actual ability to use computers or instead reflected participants’ preconceptions about more elderly patients34. Accessibility of written content, which was a core element of the intervention, was limited to patients with visual, cognitive, and/or language impairments. Given that the target population was those with visual field loss, this was a central barrier to address. The development process involved the multidisciplinary HABIT team (including two people with visual loss due to stroke) and a focus group of people with lived experience of visual loss after stroke, but materials proved challenging. In the future, HABIT must find new ways to enable access to written and visual information. These may include simplification of presentation and language, greater use of audio, using a more participatory approach to the design process, and greater input from low-vision rehabilitation specialists35. The participants stated that they felt that visual field loss was a minor problem for stroke survivors. This view conflicts with the current evidence on the broad and long-lasting impact of visual loss due to stroke14 and must be challenged. However, the reason for this is unclear. The impact on quality of life is not always fully evident until months after stroke15 and therefore may not have been visible to those working in acute services. This may reflect a lack of vision-specific training for OTs, with stroke survivors in another study reporting a “lack of knowledge and limited interest” from healthcare professionals36. Interestingly, a study assessing the implementation of a vision assessment program in Norway found that training on the impact of visual impairment caused by stroke was a key factor driving clinicians’ motivation to implement the intervention, as it made them aware of the importance of addressing vision as soon as possible37. Further research is needed into OTs’ awareness and understanding of visual field loss and its impact, and how any barriers arising could best be addressed via amendments to HABIT, or other educational approaches. OTs also stated that HABIT may be more appropriate for the community setting; in other words, addressing visual field loss was more important in the post-acute stage. OTs felt that stroke survivors lacked awareness of field loss while in the unfamiliar ward setting ward, and thus did not see the value of vision rehabilitation. They also stated that goal setting and rehabilitation, which should be founded on everyday activities, should largely wait until patients are discharged home. At present, there is insufficient evidence to determine the optimal timing for vision rehabilitation19, and further work, including gathering stroke survivors’ opinions, is required. OTs noted prioritizing activities that enabled a fast and safe discharge, which often focused on motor skills; time spent delivering HABIT was seen as time diverted away from key tasks. The associated paperwork was also considered to be too long and onerous. These points and wider study findings suggest potential refinements to make HABIT more suitable for the acute context. First, HABIT should include exercises that combine visual search training with activities addressing OTs’ priorities, such as balance and mobility, so that each is addressed in a time-efficient manner. HABIT should include clear ward-based examples so that OTs can practically operationalize this training. Second, HABIT should enable greater flexibility regarding which elements should be delivered in the acute stage. Participants valued documents that facilitated information provision to patients; they also identified that patients would not be sufficiently aware of their visual loss and its impact. Together, these findings suggest that increasing the understanding of visual field loss and its impact on activities should be an early focus of HABIT. Third, HABIT paperwork should be edited to reduce the time required to complete it. We recognize that this study took place when UK hospital time pressures were particularly severe owing to COVID-19. Although this critical time point has passed, pressures on NHS services remain severe, and these findings are likely to reflect ongoing concerns38. This study is the first to explore clinicians’ perspectives on implementing any vision rehabilitation intervention for any post-stroke visual impairment in a UK care setting. A strength of this study is the use of first-hand accounts, which enabled the gathering and exploration of a range of opinions. Interviews promoted flexibility and participant engagement, and fostered reflexivity while appreciating the complexity of human opinions. Interviews were conducted by a researcher who was not previously known to the participants, acting to minimize bias towards more favourable socially desirable responses39. Thematic Analysis offers a systematic yet flexible framework for data analysis tailored to specific research objectives, ensuring comprehensive data exploration31. The use of the accepted COM-B framework for coding and analysis allowed for the identification of factors associated with behaviour change and their interactions. The involvement of researchers from two relevant and complementary fields in the analysis (psychology and optometry) allowed a deeper understanding of the data presented through their different perspectives. While the study sample was small, the interviews revealed rich information pertinent to the successful implementation of HABIT, providing insights relevant to the design and implementation of other interventions. This study has shown that HABIT can successfully support the delivery of compensatory rehabilitation approaches within real-world NHS settings. Factors associated with the successful delivery of HABIT provide avenues for actionable improvement: tailoring the intervention to improve its suitability for hospital settings, exploring OTs knowledge and understanding of the impact of vision loss, and accessibility of materials for those with visual impairment. This work is a sub-study of an ethically approved program assessed by Wales Research Ethics Committee 4 Wrexham Research Ethics Committee (REC: 20/WA/0093) and by the Health Research Authority and Health and Care Research Wales (IRAS: 270718). Informed consent was obtained in writing during site initiation visits. Owing to the qualitative nature of the collected data, it has not been linked or uploaded to any publicly archived dataset. If researchers would like access to these data, they can approach the corresponding author with a written request. Qualitative data collected and reported herein are not available for sharing due to stakeholder views during development, which may impact peoples’ willingness to participate in the interviews. The study participants did not provide consent to upload their qualitative data to a repository. If readers want to apply for access to anonymized data, they can email the corresponding author ([email protected]). This email should specify the use to which the data will be put, the timeframe of the project, and the institution that will hold responsibility for the governance of the project for which the data is being requested. Ideally, ethical approval will be provided to cover the requester project. As the study was part of a trial, it was registered in the ISRCTN Clinical Trial database with the Registry Number ISRCTN54718796 https://doi.org/10.1186/ISRCTN54718796 Study related documents such as the protocol, information sheets and consent forms can be viewed at Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). NVivo 12 [20] is proprietary software. A free open access equivalent to this would be QualCoder, available from GitHub (https://github.com/ccbogel/QualCoder/releases/tag/3.6). We wish to thank our stroke survivor contributors John Crump and Tony Mulverhill for their input in the design of HABIT and the conduct of this project. We wish to acknowledge the vital work of the staff who managed this research project (including Hannah Sheridan), which included all the amendments needed to respond to the COVID-19 pandemic, and Dr. Ailie Turton, who was part of the research team in Bristol. We also wish to thank the co-applicant Fiona Rowe for all her input in the design and conduct of the project. Faculty Opinions recommendedReferences - 1. Public Health Scotland: Scottish stroke improvement programme annual report 2023. Edinburgh, 2023. Reference Source - 2. Sentinal Stroke National Audit Programme: The ninth SSNAP annual report the road to recovery. UK, 2023; [cited 2025 March 15]. Reference Source - 3. Census 2021; Office for National Statistics: Leading causes of death, UK: 2001 to 2018. 2020; [cited 2023 Jun 29]. Reference Source - 4. Tsao CW, Aday AW, Almarzooq ZI, et al.: Heart disease and stroke statistics—2023 update: a report from the American Heart Association. Circulation. 2023; 147(8): e93–e621. PubMed Abstract | Publisher Full Text | Free Full Text - 5. World Health Organisation: The global health observatory. 2025; [cited 2025 Mar 15]. Reference Source - 6. King D, Wittenberg R, Patel A, et al.: The future incidence, prevalence and costs of stroke in the UK. Age Ageing. 2020; 49(2): 277–82. PubMed Abstract | Publisher Full Text | Free Full Text - 7. GBD 2017 DALYs and HALE Collaborators: Global, regional, and national Disability-Adjusted Life-Years (DALYs) for 359 diseases and injuries and Healthy Life Expectancy (HALE) for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease study 2017. Lancet. 2018; 392(10159): 1859–922. PubMed Abstract | Publisher Full Text | Free Full Text - 8. Rowe F, Brand D, Jackson CA, et al.: Visual impairment following stroke: do stroke patients require vision assessment? Age Ageing. 2009; 38(2): 188–93. PubMed Abstract | Publisher Full Text - 9. Rowe FJ, Hepworth LR, Howard C, et al.: High incidence and prevalence of visual problems after acute stroke: an epidemiology study with implications for service delivery. PLoS One. 2019; 14(3): e0213035. PubMed Abstract | Publisher Full Text | Free Full Text - 10. Ali M, Hazelton C, Lyden P, et al.: Recovery from poststroke visual impairment: evidence from a clinical trials resource. Neurorehabil Neural Repair. 2013; 27(2): 133–41. PubMed Abstract | Publisher Full Text - 11. Rowe FJ, Wright D, Brand D, et al.: A prospective profile of visual field loss following stroke: prevalence, type, rehabilitation, and outcome. Biomed Res Int. 2013; 2013: 719096. PubMed Abstract | Publisher Full Text | Free Full Text - 12. Warren M: Pilot study on Activities of Daily Living limitations in adults with hemianopsia. Am J Occup Ther. 2009; 63(5): 626–33. PubMed Abstract | Publisher Full Text - 13. de Haan GA, Heutink J, Melis-Dankers BJM, et al.: Difficulties in daily life reported by patients with Homonymous Visual Field Defects. J Neuroophthalmol. 2015; 35(3): 259–64. PubMed Abstract | Publisher Full Text - 14. Hazelton C, Pollock A, Taylor A, et al.: A qualitative exploration of the effect of visual field loss on daily life in home-dwelling stroke survivors. Clin Rehabil. 2019; 33(7): 1264–1273. PubMed Abstract | Publisher Full Text - 15. Gall C, Franke GH, Sabel BA: Vision-related Quality of Life in first stroke patients with homonymous Visual Field Defects. Health Qual Life Outcomes. 2010; 8: 33. PubMed Abstract | Publisher Full Text | Free Full Text - 16. Papageorgiou E, Hardiess G, Schaeffel F, et al.: Assessment of vision-related Quality of Life in patients with Homonymous Visual Field Defects. Graefes Arch Clin Exp Ophthalmol. 2007; 245(12): 1749–58. PubMed Abstract | Publisher Full Text - 17. Intercollegiate Stroke Working Party: National clinical guideline for stroke for the UK and Ireland. London, 2023. Reference Source - 18. National Institute for Health and Care Excellence 2023: Stroke rehabilitation in adults. [cited 2025 Mar 15]. Reference Source - 19. Pollock A, Hazelton C, Rowe FJ, et al.: Interventions for visual field defects in people with stroke. Cochrane Database Syst Rev. 2019; 5(5): CD008388. PubMed Abstract | Publisher Full Text | Free Full Text - 20. Pollock A, Hazelton C, Brady M: Visual problems after stroke: a survey of current practice by Occupational Therapists working in UK stroke inpatient settings. Top Stroke Rehabil. 2011; 18 Suppl 1(5): 643–51. PubMed Abstract | Publisher Full Text - 21. Rowe F: Care provision and unmet need for post stroke visual impairment. Final report. London, 2013. Reference Source - 22. Turton AJ, Angilley J, Longley V, et al.: Search training for people with visual field loss after stroke: a cohort study. Br J Occup Ther. 2018; 81(5): 255–65. Publisher Full Text - 23. Turton AJ, Angilley J, Chapman M, et al.: Visual search training in occupational therapy – an example of expert practice in community-based stroke rehabilitation. Br J Occup Ther. 2015; 78(11): 674–87. Publisher Full Text - 24. Skivington K, Matthews L, Simpson SA, et al.: A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance. BMJ. 2021; 374: n2061. PubMed Abstract | Publisher Full Text | Free Full Text - 25. Modden C, Behrens M, Damke I, et al.: A randomized controlled trial comparing 2 interventions for visual field loss with standard Occupational Therapy during inpatient stroke rehabilitation. Neurorehabil Neural Repair. 2012; 26(5): 463–9. PubMed Abstract | Publisher Full Text - 26. Pambakian ALM, Mannan SK, Hodgson TL, et al.: Saccadic visual search training: a treatment for patients with homonymous hemianopia. J Neurol Neurosurg Psychiatry. 2004; 75(10): 1443–8. PubMed Abstract | Publisher Full Text | Free Full Text - 27. Aimola L, Lane AR, Smith DT, et al.: Efficacy and feasibility of home-based training for individuals with Homonymous Visual Field Defects. Neurorehabil Neural Repair. 2014; 28(3): 207–18. PubMed Abstract | Publisher Full Text - 28. Hazelton C, Pollock A, Dixon D, et al.: The feasibility and effects of eye movement training for visual field loss after stroke: a mixed methods study. Br J Occup Ther. 2021; 84(5): 278–288. Publisher Full Text - 29. Mathisen TS, Eilertsen G, Ormstad H, et al.: Barriers and facilitators to the implementation of a structured visual assessment after stroke in municipal health care services. BMC Health Serv Res. 2021; 21(1): 497. PubMed Abstract | Publisher Full Text | Free Full Text - 30. King N, Brooks J: Template analysis for business and management students. Los Angeles: Sage, 2017. Publisher Full Text - 31. Gale NK, Heath G, Cameron E, et al.: Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013; 13(1): 117. PubMed Abstract | Publisher Full Text | Free Full Text - 32. QSR: Nvivo 12. 2020; [cited 2023 Jun 29]. Reference Source - 33. Michie S, van Stralen MM, West R: The Behaviour Change Wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011; 6(1): 42. PubMed Abstract | Publisher Full Text | Free Full Text - 34. OfCOME: Adults' media use and attitudes report. 2024; [Internet cited 2025 Mar 15]. Reference Source - 35. Kim HN: Guidance for best practices in participatory design involving people with visual impairment. Ergon Des. 2021; 32(2): 48–54. Publisher Full Text - 36. Falkenberg HK, Mathisen TS, Ormstad H, et al.: "Invisible" Visual Impairments. A qualitative study of stroke survivors` experience of vision symptoms, health services and impact of visual impairments. BMC Health Serv Res. 2020; 20(1): 302. PubMed Abstract | Publisher Full Text | Free Full Text - 37. Mathisen TS, Eilertsen G, Ormstad H, et al.: ‘If we don’t assess the patient’s vision, we risk starting at the wrong end’: a qualitative evaluation of a stroke service knowledge translation project. BMC Health Serv Res. 2022; 22(1): 351. PubMed Abstract | Publisher Full Text | Free Full Text - 38. Cooksley T, Clarke S, Dean J, et al.: NHS crisis: rebuilding the NHS needs urgent action. BMJ. 2023; 380: 1. PubMed Abstract | Publisher Full Text - 39. Adams AS, Soumerai SB, Lomas J, et al.: Evidence of self-report bias in assessing adherence to guidelines. Int J Qual Health Care. 1999; 11(3): 187–92. PubMed Abstract | Publisher Full Text - 40. Sam H, Phil C: Hemianopia Activity-Based InTervention (HABIT): refining and operationalising a rehabilitation intervention for visual field loss after stroke. OSF. 2025. http://www.doi.org/10.17605/OSF.IO/3CWMF Author details Author details 1 Glasgow Caledonian University School of Health and Life Sciences, Glasgow, Scotland, UK 2 Research and Development, North Bristol NHS Trust, Westbury on Trym, England, UK 3 NHS Cornwall & Isles of Scilly, Truro, UK 4 Royal Holloway University of London School of Life Sciences and the Environment, Egham, England, UK 5 The University of Manchester Division of Psychology and Mental Health, Manchester, England, UK 6 Department of Neurology, North Bristol NHS Trust, Westbury on Trym, England, UK 2 Research and Development, North Bristol NHS Trust, Westbury on Trym, England, UK 3 NHS Cornwall & Isles of Scilly, Truro, UK 4 Royal Holloway University of London School of Life Sciences and the Environment, Egham, England, UK 5 The University of Manchester Division of Psychology and Mental Health, Manchester, England, UK 6 Department of Neurology, North Bristol NHS Trust, Westbury on Trym, England, UK Christine Hazelton Roles: Data Curation, Formal Analysis, Funding Acquisition, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Roles: Data Curation, Formal Analysis, Funding Acquisition, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Sam Harding Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Jayne Angilley Roles: Conceptualization, Writing – Review & Editing Roles: Conceptualization, Writing – Review & Editing Alexandra Palombi Roles: Conceptualization, Writing – Review & Editing Roles: Conceptualization, Writing – Review & Editing Audrey Bowen Roles: Conceptualization, Writing – Review & Editing Roles: Conceptualization, Writing – Review & Editing Phil Clatworthy Roles: Conceptualization, Data Curation, Writing – Review & Editing Roles: Conceptualization, Data Curation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information This study was funded by the National Institute for Health Research NIHR [Research for Patient Benefit (PB-PG-0418-20040)]. The views expressed are those of the author(s) and not necessarily those of the NIHR or Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright © Crown copyright, 2025 Hazelton C et al.. This open access work is licensed under the Open Government Licence v3.0 metrics VIEWS $counts.viewCount downloads Citations CITE how to cite this article Hazelton C, Harding S, Angilley J et al. Occupational Therapists’ perspectives of implementing a new rehabilitation intervention for visual field loss due to stroke [version 1; peer review: 2 approved, 2 approved with reservations]. NIHR Open Res 2025, 5:57 (https://doi.org/10.3310/nihropenres.13984.1) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. track receive updates on this article Track an article to receive email alerts on any updates to this article. Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 04 Jul 2025 Views 0 How to cite this report: Hodgson TL. Reviewer Report For: Occupational Therapists’ perspectives of implementing a new rehabilitation intervention for visual field loss due to stroke [version 1; peer review: 2 approved, 2 approved with reservations]. NIHR Open Res 2025, 5:57 (https://doi.org/10.3310/nihropenres.15202.r36978) The direct URL for this report is: https://openresearch.nihr.ac.uk/articles/5-57/v1#referee-response-36978 https://openresearch.nihr.ac.uk/articles/5-57/v1#referee-response-36978 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Reviewer Report 10 Sep 2025 Timothy L Hodgson, University of Lincoln, Lincoln, England, UK Approved VIEWS 0 This report presents a qualitative evaluation of Occupational Therapists (OTs) experience of delivery of the HABIT protocol for rehabilitating visual field loss in adults following stroke. Although small in scale, the study reports very interesting data from interviews with OTs ... Continue reading I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close This report presents a qualitative evaluation of Occupational Therapists (OTs) experience of delivery of the HABIT protocol for rehabilitating visual field loss in adults following stroke. Although small in scale, the study reports very interesting data from interviews with OTs on their experience and perception of visual field loss, its impact on patients and the relative importance / priority given to it in acute settings. The most salient finding to me was that overall it is clear that OTs in acute settings do not give visual field loss a high priority and so were not able to allocate enough time to deliver aspects of the HABIT protocol. Some of the quotes from OTs were worrying (although maybe not unsurprising), with respect to their limited understanding of visual field loss and its significance for patients. The discussion acknowledges the issue of low awareness of visual problems and their perceived importance amongst OTs and it is suggested that “lack of knowledge and limited interest” is the problem and addressing this may be key to overcoming this issue (p.8). If anything, I would maybe go a bit "stronger" on the point in this section and emphasize the contrast between the OTs dismissal of visual field loss as a "tiny problem" (p.7) with the evidence presented in the opening paragraph of the introduction (p.4). I note that only 1 out of the 5 OTs was working in a community setting, so perhaps some further (hopefully more positive) evaluation of HABIT delivery could be carried out in the future focussing on community OTs. The most salient finding to me was that overall it is clear that OTs in acute settings do not give visual field loss a high priority and so were not able to allocate enough time to deliver aspects of the HABIT protocol. Some of the quotes from OTs were worrying (although maybe not unsurprising), with respect to their limited understanding of visual field loss and its significance for patients. The discussion acknowledges the issue of low awareness of visual problems and their perceived importance amongst OTs and it is suggested that “lack of knowledge and limited interest” is the problem and addressing this may be key to overcoming this issue (p.8). If anything, I would maybe go a bit "stronger" on the point in this section and emphasize the contrast between the OTs dismissal of visual field loss as a "tiny problem" (p.7) with the evidence presented in the opening paragraph of the introduction (p.4). I note that only 1 out of the 5 OTs was working in a community setting, so perhaps some further (hopefully more positive) evaluation of HABIT delivery could be carried out in the future focussing on community OTs. - Is the work clearly and accurately presented and does it cite the current literature? Yes - Is the study design appropriate and is the work technically sound? Yes - Are sufficient details of methods and analysis provided to allow replication by others? Yes - If applicable, is the statistical analysis and its interpretation appropriate? Not applicable - Are all the source data underlying the results available to ensure full reproducibility? No source data required - Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Vision and Cognitive Neuroscience; Oculomotor Control; Hemianopia rehabilitation. CITE HOW TO CITE THIS REPORT Hodgson TL. Reviewer Report For: Occupational Therapists’ perspectives of implementing a new rehabilitation intervention for visual field loss due to stroke [version 1; peer review: 2 approved, 2 approved with reservations]. NIHR Open Res 2025, 5:57 (https://doi.org/10.3310/nihropenres.15202.r36978) The direct URL for this report is: https://openresearch.nihr.ac.uk/articles/5-57/v1#referee-response-36978 https://openresearch.nihr.ac.uk/articles/5-57/v1#referee-response-36978 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. Views 0 How to cite this report: Cushley LN. Reviewer Report For: Occupational Therapists’ perspectives of implementing a new rehabilitation intervention for visual field loss due to stroke [version 1; peer review: 2 approved, 2 approved with reservations]. NIHR Open Res 2025, 5:57 (https://doi.org/10.3310/nihropenres.15202.r36982) The direct URL for this report is: https://openresearch.nihr.ac.uk/articles/5-57/v1#referee-response-36982 https://openresearch.nihr.ac.uk/articles/5-57/v1#referee-response-36982 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Reviewer Report 08 Sep 2025 Approved with Reservations VIEWS 0 Thank you for asking me to review this interesting paper. I have some comments and questions:

- 'Vision is affected in up to half of all strokes, and a range of visual functions may be ... Continue reading I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close

- 'Vision is affected in up to half of all strokes, and a range of visual functions may be ... Continue reading Thank you for asking me to review this interesting paper. I have some comments and questions:

- 'Vision is affected in up to half of all strokes, and a range of visual functions may be impaired, including eye movements, visual attention, visual perception, and visual fields' - do you have some references you could add to this?

- how did you confirm visual field? VF machine or through other methods? - any reason why you decided to have written materials on paper? Were the font sizes etc. altered for low vision/visual impairment? Was it accessible? - did the two analysts review the data separately or together? It would be more robust if separately and then discussion occurred for conflict resolution especially as both had different backgrounds. Was there a third more senior person to resolve conflicts?

- I think the first part of the conclusion is probably strengths and should be in the discussion section - A limitation section should also be included in the discussion - the conclusion could be written more impactfully with the essential findings from the study - there were some real challenges stated within the interviews - these need to be in the conclusion.

- 'Vision is affected in up to half of all strokes, and a range of visual functions may be impaired, including eye movements, visual attention, visual perception, and visual fields' - do you have some references you could add to this?

- how did you confirm visual field? VF machine or through other methods? - any reason why you decided to have written materials on paper? Were the font sizes etc. altered for low vision/visual impairment? Was it accessible? - did the two analysts review the data separately or together? It would be more robust if separately and then discussion occurred for conflict resolution especially as both had different backgrounds. Was there a third more senior person to resolve conflicts?

- I think the first part of the conclusion is probably strengths and should be in the discussion section - A limitation section should also be included in the discussion - the conclusion could be written more impactfully with the essential findings from the study - there were some real challenges stated within the interviews - these need to be in the conclusion. - Is the work clearly and accurately presented and does it cite the current literature? Yes - Is the study design appropriate and is the work technically sound? Yes - Are sufficient details of methods and analysis provided to allow replication by others? Yes - If applicable, is the statistical analysis and its interpretation appropriate? Not applicable - Are all the source data underlying the results available to ensure full reproducibility? Yes - Are the conclusions drawn adequately supported by the results? No Competing Interests: No competing interests were disclosed. Reviewer Expertise: Ophthalmology, Visual Impairment, Low Vision, Qualitative Methodology CITE HOW TO CITE THIS REPORT Cushley LN. Reviewer Report For: Occupational Therapists’ perspectives of implementing a new rehabilitation intervention for visual field loss due to stroke [version 1; peer review: 2 approved, 2 approved with reservations]. NIHR Open Res 2025, 5:57 (https://doi.org/10.3310/nihropenres.15202.r36982) The direct URL for this report is: https://openresearch.nihr.ac.uk/articles/5-57/v1#referee-response-36982 https://openresearch.nihr.ac.uk/articles/5-57/v1#referee-response-36982 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. Views 0 How to cite this report: Heutink J. Reviewer Report For: Occupational Therapists’ perspectives of implementing a new rehabilitation intervention for visual field loss due to stroke [version 1; peer review: 2 approved, 2 approved with reservations]. NIHR Open Res 2025, 5:57 (https://doi.org/10.3310/nihropenres.15202.r36750) The direct URL for this report is: https://openresearch.nihr.ac.uk/articles/5-57/v1#referee-response-36750 https://openresearch.nihr.ac.uk/articles/5-57/v1#referee-response-36750 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Reviewer Report 03 Sep 2025 Approved VIEWS 0 This is a very relevant, well-executed and useful feasibility study. Visual impairments resulting from acquired brain injury (ABI) can lead to limitations in activities that hinder the participation of people with ABI. These visual impairments are certainly ... Continue reading I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close Visual impairments resulting from acquired brain injury (ABI) can lead to limitations in activities that hinder the participation of people with ABI. These visual impairments are certainly ... Continue reading This is a very relevant, well-executed and useful feasibility study. Visual impairments resulting from acquired brain injury (ABI) can lead to limitations in activities that hinder the participation of people with ABI. These visual impairments are certainly not uncommon. They are known to have a high prevalence and a major impact after a stroke, but the recognition of these problems, the understanding of their impact and the possibilities for intervention leave much to be desired, both among patients themselves and their caregivers. In recent years, this problem has been addressed in a clear and well-substantiated manner, both in science, healthcare and healthcare policy. Efforts are being made to improve identification of visual impairments and provide adequate care, both of which must be appropriate to the phase of care and recovery and the context in which this care takes place. This study focuses precisely on that: what is needed to ensure that an intervention targeting the behavioural consequences of visual field loss after stroke, the HABIT (Hemianopia Activity-Based Intervention), is optimally compatible with current stroke care in the acute and subacute phases in terms of content and feasibility. HABIT focuses on raising awareness of visual field loss in patients, the consequences it can have in daily life (such as missing relevant information, difficulty reading and problems with orientation and mobility) and how the intact part of the visual field can be used optimally to compensate for the loss of function, thus limiting the impact of visual field loss on daily life. The content of HABIT is not only based on available scientific evidence, but has also been compiled on the basis of input from people with visual field loss, their close relations and those involved in their care. Before proceeding with implementation, the researchers explore which factors could promote the likelihood of successful rollout within the NHS and which factors could hinder it. Five occupational therapists participated in the study and their input provides important input for the content of HABIT itself, but also for the accessibility of the material for both patients and care providers, as well as the preconditions and context in which this training is offered. Since four of the five participating occupational therapists work in subacute stroke care, the results mainly apply to that specific context. If the intention is to roll out HABIT in the context of later care (the community setting) as well, it would be in line with expectations for the researchers to investigate feasibility in a similar manner by gathering a little more input from a few occupational therapists who actually work in that care setting. To the best of my judgement, the study was conducted thoroughly, the data is clearly presented (and made available), and the analyses and conclusions are correct. I have only a few minor comments and questions for clarification. It is not necessary to revise the text. Consider them suggestions or thoughts. 1. P4. The sentence “Second, search training aims to improve the efficiency of eye movements used when searching for visual space; these patterns tend to break down and become disorganized due to visual field loss” could do with a reference. 2. p4. However, these findings are related to vision screening within the Norwegian care system, as opposed to rehabilitation, within the Norwegian care system and thus, have limited applicability” [suggestion: add ‘outside Norway’ or ‘in the context of the NHS’ 3. p5 Several years have passed between the conduct of the study (October 2019 – November 2021) and this publication. Have any changes been made to HABIT or the training of occupational therapists in the meantime? Has implementation continued in the meantime? 4. p5. Key stages of HABIT #2: are ‘client’ and ‘patient’ the same? 5. p6. “Overall, HABIT was perceived to be similar to what the OT participants were already doing” (…with regard to hemianopia? With regard to visual impairments?” 6. p7 "I didn’t find useful all the other written stuff, … because the majority of people with hemianopia do not read.” The last “ is in bold 7. p7 “This is in line with the stated aim of HABIT to operationalize best practices in OT-led vision rehabilitation for stroke survivors. HABIT did not differ significantly from current practice, …” Differ significantly’ put me a bit on the wrong foot here. Significantly = meaningfully? I think it refers to the extent to which, in the opinion of the OTs, HABIT deviated from their current treatment practice. Is it an opinion (of the OTs) or is this a fact? The end of the same paragraph “to treatment as well as …. stroke survivors”. This paragraph mainly establishes a link with the overarching objective of HABIT. It could be linked more directly (or clearly) to the objective of the feasibility study. For example: If OTs would have experienced a significant difference between HABIT and their current working method, this would likely have been a potential obstacle to further implementation. 8. p8 paragraph “Accessibility of written content…” Will the authors consider an app instead of a website, and perhaps use spoken content (and voice control)? 9. p8 Visual impairment caused by stroke was not seen as important. The authors argue that better training could offer a solution. That may be correct (considering the study in Norway), but this study involved occupational therapists who state that they were already familiar with hemianopia and compensation training. So what should training focus on? Is more than training needed to raise the profile of rehabilitation for visual disorders in stroke care? Or would this be at the expense of other care in the subacute phase? 10. p8 “They also stated that … opinions, is required.” This is reflected upon in general, but maybe a few sentences could be added to what this means for further implementation in the NHS context. Until there is more clarity on this matter, the advice would be to be not to stop treating visual problems in the acute phase. 11. p8 I could imagine that the focus of interventions during the acute phase would be different from that in the later phases of rehabilitation. For example, in the first phase, there could be more focus on awareness than on activities? 12. p8 Could the authors provide a little more information about what this “associated paperwork” entailed (its nature and quantity)? 13. p8. “Second, HABIT should enable greater flexibility regarding which elements should be delivered in the acute stage.” 14. p8. "Second, HABIT should enable greater flexibility regarding which elements should be delivered in the acute stage." Not a comment, but a thought: such flexibility may also inadvertently lead to a lack of commitment, especially when occupational therapists are not convinced of the importance of interventions for visual field defects. Visual impairments resulting from acquired brain injury (ABI) can lead to limitations in activities that hinder the participation of people with ABI. These visual impairments are certainly not uncommon. They are known to have a high prevalence and a major impact after a stroke, but the recognition of these problems, the understanding of their impact and the possibilities for intervention leave much to be desired, both among patients themselves and their caregivers. In recent years, this problem has been addressed in a clear and well-substantiated manner, both in science, healthcare and healthcare policy. Efforts are being made to improve identification of visual impairments and provide adequate care, both of which must be appropriate to the phase of care and recovery and the context in which this care takes place. This study focuses precisely on that: what is needed to ensure that an intervention targeting the behavioural consequences of visual field loss after stroke, the HABIT (Hemianopia Activity-Based Intervention), is optimally compatible with current stroke care in the acute and subacute phases in terms of content and feasibility. HABIT focuses on raising awareness of visual field loss in patients, the consequences it can have in daily life (such as missing relevant information, difficulty reading and problems with orientation and mobility) and how the intact part of the visual field can be used optimally to compensate for the loss of function, thus limiting the impact of visual field loss on daily life. The content of HABIT is not only based on available scientific evidence, but has also been compiled on the basis of input from people with visual field loss, their close relations and those involved in their care. Before proceeding with implementation, the researchers explore which factors could promote the likelihood of successful rollout within the NHS and which factors could hinder it. Five occupational therapists participated in the study and their input provides important input for the content of HABIT itself, but also for the accessibility of the material for both patients and care providers, as well as the preconditions and context in which this training is offered. Since four of the five participating occupational therapists work in subacute stroke care, the results mainly apply to that specific context. If the intention is to roll out HABIT in the context of later care (the community setting) as well, it would be in line with expectations for the researchers to investigate feasibility in a similar manner by gathering a little more input from a few occupational therapists who actually work in that care setting. To the best of my judgement, the study was conducted thoroughly, the data is clearly presented (and made available), and the analyses and conclusions are correct. I have only a few minor comments and questions for clarification. It is not necessary to revise the text. Consider them suggestions or thoughts. 1. P4. The sentence “Second, search training aims to improve the efficiency of eye movements used when searching for visual space; these patterns tend to break down and become disorganized due to visual field loss” could do with a reference. 2. p4. However, these findings are related to vision screening within the Norwegian care system, as opposed to rehabilitation, within the Norwegian care system and thus, have limited applicability” [suggestion: add ‘outside Norway’ or ‘in the context of the NHS’ 3. p5 Several years have passed between the conduct of the study (October 2019 – November 2021) and this publication. Have any changes been made to HABIT or the training of occupational therapists in the meantime? Has implementation continued in the meantime? 4. p5. Key stages of HABIT #2: are ‘client’ and ‘patient’ the same? 5. p6. “Overall, HABIT was perceived to be similar to what the OT participants were already doing” (…with regard to hemianopia? With regard to visual impairments?” 6. p7 "I didn’t find useful all the other written stuff, … because the majority of people with hemianopia do not read.” The last “ is in bold 7. p7 “This is in line with the stated aim of HABIT to operationalize best practices in OT-led vision rehabilitation for stroke survivors. HABIT did not differ significantly from current practice, …” Differ significantly’ put me a bit on the wrong foot here. Significantly = meaningfully? I think it refers to the extent to which, in the opinion of the OTs, HABIT deviated from their current treatment practice. Is it an opinion (of the OTs) or is this a fact? The end of the same paragraph “to treatment as well as …. stroke survivors”. This paragraph mainly establishes a link with the overarching objective of HABIT. It could be linked more directly (or clearly) to the objective of the feasibility study. For example: If OTs would have experienced a significant difference between HABIT and their current working method, this would likely have been a potential obstacle to further implementation. 8. p8 paragraph “Accessibility of written content…” Will the authors consider an app instead of a website, and perhaps use spoken content (and voice control)? 9. p8 Visual impairment caused by stroke was not seen as important. The authors argue that better training could offer a solution. That may be correct (considering the study in Norway), but this study involved occupational therapists who state that they were already familiar with hemianopia and compensation training. So what should training focus on? Is more than training needed to raise the profile of rehabilitation for visual disorders in stroke care? Or would this be at the expense of other care in the subacute phase? 10. p8 “They also stated that … opinions, is required.” This is reflected upon in general, but maybe a few sentences could be added to what this means for further implementation in the NHS context. Until there is more clarity on this matter, the advice would be to be not to stop treating visual problems in the acute phase. 11. p8 I could imagine that the focus of interventions during the acute phase would be different from that in the later phases of rehabilitation. For example, in the first phase, there could be more focus on awareness than on activities? 12. p8 Could the authors provide a little more information about what this “associated paperwork” entailed (its nature and quantity)? 13. p8. “Second, HABIT should enable greater flexibility regarding which elements should be delivered in the acute stage.” 14. p8. "Second, HABIT should enable greater flexibility regarding which elements should be delivered in the acute stage." Not a comment, but a thought: such flexibility may also inadvertently lead to a lack of commitment, especially when occupational therapists are not convinced of the importance of interventions for visual field defects. - Is the work clearly and accurately presented and does it cite the current literature? Yes - Is the study design appropriate and is the work technically sound? Yes - Are sufficient details of methods and analysis provided to allow replication by others? Yes - If applicable, is the statistical analysis and its interpretation appropriate? Yes - Are all the source data underlying the results available to ensure full reproducibility? Yes - Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Assessment and rehabilitation of visual complaints and visual disorders resulting from acquired brain injury CITE HOW TO CITE THIS REPORT Heutink J. Reviewer Report For: Occupational Therapists’ perspectives of implementing a new rehabilitation intervention for visual field loss due to stroke [version 1; peer review: 2 approved, 2 approved with reservations]. NIHR Open Res 2025, 5:57 (https://doi.org/10.3310/nihropenres.15202.r36750) The direct URL for this report is: https://openresearch.nihr.ac.uk/articles/5-57/v1#referee-response-36750 https://openresearch.nihr.ac.uk/articles/5-57/v1#referee-response-36750 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. Views 0 How to cite this report: Lindsay RK. Reviewer Report For: Occupational Therapists’ perspectives of implementing a new rehabilitation intervention for visual field loss due to stroke [version 1; peer review: 2 approved, 2 approved with reservations]. NIHR Open Res 2025, 5:57 (https://doi.org/10.3310/nihropenres.15202.r36260) The direct URL for this report is: https://openresearch.nihr.ac.uk/articles/5-57/v1#referee-response-36260 https://openresearch.nihr.ac.uk/articles/5-57/v1#referee-response-36260 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Reviewer Report 27 Aug 2025 Approved with Reservations VIEWS 0 The study explores the barriers and facilitators of implementing a rehabilitation intervention for visual field loss due to stroke. Although the sample is small, the findings do offer insight in to how the intervention could be adapted so it is ... Continue reading I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close The study explores the barriers and facilitators of implementing a rehabilitation intervention for visual field loss due to stroke. Although the sample is small, the findings do offer insight in to how the intervention could be adapted so it is more feasible and effective in any further studies. Below I have provided suggestions which I believe could strengthen the article: Plain English summary: Visual field loss is a technical term that would benefit from being explained in the plain English summary.

The aim is misleading as it suggests the paper is exploring the implementation of multiple rehabilitation interventions. Consider rephrasing "This study aimed to explore the barriers and facilitators of implementing rehabilitation interventions for visual field loss due to stroke" to "This study aimed to explore the barriers and facilitators of implementing a rehabilitation intervention for visual field loss due to stroke." In this sentence "HABIT resources aided participants’ understanding and self-management." It is not clear who the participants are, it implies the patients but the participants in this study are occupational therapists.

The introduction provides a strong rationale for the study, justifying the importance and novel angle of the research.

It would be helpful to have more detail on the patient and public involvement. How many people, what were their backgrounds, how did they change the study. Further details on stakeholder engagement would also improve this section, for example which health professionals were involved and how many, how did stakeholder engagement take place and were the patients in this stakeholder group the same as those included in the patient and public involvement group? While I recognize that the intervention is described in more detail in the feasibility study, it would be useful to include in this study how much of the intervention was delivered to patients.

It would be helpful for the quotes to be labelled with a participant number or pseudonym to allow the reader to assess if the quotes represent a range of views. The results would benefit from being broken down further in to the constructs of the COM-B model, if the data allows for such in-depth analysis, e.g. opportunity could be broken down in to physical and social opportunity. The last point made in the capability section "the online tools and examples were noted to increase capability in some stroke survivors" seems to be related to outcomes of the intervention, rather than barriers and facilitators to implementation. The opportunity section focuses a lot on the barriers in acute settings, what were the barriers/facilitators discussed with OTs not in these settings? In the motivation section, the statement "This dynamic interaction was influenced by context and was most notable in an acute rather than a community setting", may be too bold a claim to make given that only one participant worked in the community.

The first paragraph would be more suitable as part of the final paragraph currently included in the discussion, and could be developed further to acknowledge the study's limitations more fully. For consistency, it would be helpful to refer to the method used as template analysis, rather than thematic analysis, as thematic analysis is a broader term than template analysis. The claim that "This study has shown that HABIT can successfully support the delivery of compensatory rehabilitation approaches within real-world NHS settings." seems too bold given the barriers to implementation identified in the present study. Overall comment: While focusing on implementation from the perspective of OTs is important, a lot of the data described barriers and facilitators that were a result of the patients themselves, and given the small sample size of OTs, the study could have been strengthened by including patient interviews as part of the methods. Plain English summary: Visual field loss is a technical term that would benefit from being explained in the plain English summary.

The aim is misleading as it suggests the paper is exploring the implementation of multiple rehabilitation interventions. Consider rephrasing "This study aimed to explore the barriers and facilitators of implementing rehabilitation interventions for visual field loss due to stroke" to "This study aimed to explore the barriers and facilitators of implementing a rehabilitation intervention for visual field loss due to stroke." In this sentence "HABIT resources aided participants’ understanding and self-management." It is not clear who the participants are, it implies the patients but the participants in this study are occupational therapists.

The introduction provides a strong rationale for the study, justifying the importance and novel angle of the research.

It would be helpful to have more detail on the patient and public involvement. How many people, what were their backgrounds, how did they change the study. Further details on stakeholder engagement would also improve this section, for example which health professionals were involved and how many, how did stakeholder engagement take place and were the patients in this stakeholder group the same as those included in the patient and public involvement group? While I recognize that the intervention is described in more detail in the feasibility study, it would be useful to include in this study how much of the intervention was delivered to patients.

It would be helpful for the quotes to be labelled with a participant number or pseudonym to allow the reader to assess if the quotes represent a range of views. The results would benefit from being broken down further in to the constructs of the COM-B model, if the data allows for such in-depth analysis, e.g. opportunity could be broken down in to physical and social opportunity. The last point made in the capability section "the online tools and examples were noted to increase capability in some stroke survivors" seems to be related to outcomes of the intervention, rather than barriers and facilitators to implementation. The opportunity section focuses a lot on the barriers in acute settings, what were the barriers/facilitators discussed with OTs not in these settings? In the motivation section, the statement "This dynamic interaction was influenced by context and was most notable in an acute rather than a community setting", may be too bold a claim to make given that only one participant worked in the community.

The first paragraph would be more suitable as part of the final paragraph currently included in the discussion, and could be developed further to acknowledge the study's limitations more fully. For consistency, it would be helpful to refer to the method used as template analysis, rather than thematic analysis, as thematic analysis is a broader term than template analysis. The claim that "This study has shown that HABIT can successfully support the delivery of compensatory rehabilitation approaches within real-world NHS settings." seems too bold given the barriers to implementation identified in the present study. Overall comment: While focusing on implementation from the perspective of OTs is important, a lot of the data described barriers and facilitators that were a result of the patients themselves, and given the small sample size of OTs, the study could have been strengthened by including patient interviews as part of the methods. - Is the work clearly and accurately presented and does it cite the current literature? Yes - Is the study design appropriate and is the work technically sound? Yes - Are sufficient details of methods and analysis provided to allow replication by others? No - If applicable, is the statistical analysis and its interpretation appropriate? Not applicable - Are all the source data underlying the results available to ensure full reproducibility? No source data required - Are the conclusions drawn adequately supported by the results? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: I am a researchers in healthcare improvements, with a focus on qualitative research and a background in visual impairment and physical activity promotion research. CITE HOW TO CITE THIS REPORT Lindsay RK. Reviewer Report For: Occupational Therapists’ perspectives of implementing a new rehabilitation intervention for visual field loss due to stroke [version 1; peer review: 2 approved, 2 approved with reservations]. NIHR Open Res 2025, 5:57 (https://doi.org/10.3310/nihropenres.15202.r36260) The direct URL for this report is: https://openresearch.nihr.ac.uk/articles/5-57/v1#referee-response-36260 https://openresearch.nihr.ac.uk/articles/5-57/v1#referee-response-36260 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. Alongside their report, reviewers assign a status to the article: - Approved - Approved with reservations - Not approved | Invited Reviewers | |||| |---|---|---|---|---| | 1 | 2 | 3 | 4 | | | Version 1 04 Jul 25 | read | read | read | read | Sign up for content alerts You are now signed up to receive this alert Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. Consider the following examples, but note that this is not an exhaustive list: Examples of 'Non-Financial Competing Interests' - Within the past 4 years, you have held joint grants, published or collaborated with any of the authors of the selected paper. - You have a close personal relationship (e.g. parent, spouse, sibling, or domestic partner) with any of the authors. - You are a close professional associate of any of the authors (e.g. scientific mentor, recent student). - You work at the same institute as any of the authors. - You hope/expect to benefit (e.g. favour or employment) as a result of your submission. - You are an Editor for the journal in which the article is published. Examples of 'Financial Competing Interests' - You expect to receive, or in the past 4 years have received, any of the following from any commercial organisation that may gain financially from your submission: a salary, fees, funding, reimbursements. - You expect to receive, or in the past 4 years have received, shared grant support or other funding with any of the authors. - You hold, or are currently applying for, any patents or significant stocks/shares relating to the subject matter of the paper you are commenting on. Sign up for content alerts and receive a weekly or monthly email with all newly published articles Register with NIHR Open Research Already registered? Sign in close Error If you are a previous or current NIHR award holder, sign up for information about developments, publishing and publications from NIHR Open Research. We'll keep you updated on any major new updates to NIHR Open Research Sign In If you've forgotten your password, please enter your email address below and we'll send you instructions on how to reset your password. Email us for further assistance. The email address should be the one you originally registered with F1000. Email address not valid, please try again You registered with F1000 via Google, so we cannot reset your password. To sign in, please click here. If you still need help with your Google account password, please click here. You registered with F1000 via Facebook, so we cannot reset your password. To sign in, please click here. If you still need help with your Facebook account password, please click here. Code not correct, please try again Server error, please try again. If your email address is registered with us, we will email you instructions to reset your password. If you think you should have received this email but it has not arrived, please check your spam filters and/or contact for further assistance. Please wait...