Title: Hemianopia Activity-Based InTervention (HABIT): refining and operationalising a rehabilitation intervention for visual field loss after stroke
Funder: Department of Health and Social Care

Abstract: This study will produce a rehabilitation intervention for visual field loss after stroke for use in NHS stroke services. Background Stroke is a leading cause of disability in the UK and worldwide(1); approximately two-thirds of stroke survivors leave hospital with disability(2). There are over 1.2 million UK stroke survivors, projected to exceed 2 million by 2035(3). Stroke costs the UK an estimated 25.6 million pounds annually(3). Persistent visual field loss affects approximately 20% of stroke survivors, about 250,000 people in the UK (4, 5), resulting in disability(6, 7) and reduced quality of life(8, 9). Visual scanning is the most evidence-based treatment(4, 10-13). Treatment is usually provided by occupational therapists (OTs), but many provide no specific treatments(14, 15). Aims and objectives This study will refine and operationalise an OT intervention, the Hemianopia Activity-Based InTervention (HABIT), based on expert community OT practice published by the applicants(16, 17), including training materials, treatment manual, standardised checklist(18) and videos, and tailoring following feedback, for use across UK stroke services without service reconfiguration. Methods 44 participants with new stroke-induced visual field loss and clear rehabilitation goals, will be recruited from two inpatient and two community NHS stroke rehabilitation sites. Six OTs/assistants will receive HABIT training. Staggered recruitment will allow for focussed refinements to training materials and creation of supporting videos. Therapists will use HABIT in routine practice, using treatment checklists recording use of intervention strategies to provide a record of fidelity. Activities and goals chosen, goal achievement and patient satisfaction will be measured using the Canadian Occupational Performance Measure(19). Therapists will provide telephone feedback on usability and potential future implementation(20, 21). Patients will provide feedback on treatment and everyday use of HABIT. Mixed qualitative and quantitative analysis of feedback from sites 1&2 will include framework analysis(22) and descriptive statistics; this will guide refinement of HABIT. The refined training and treatment will be delivered in sites 3&4. Treatment will be delivered in all sites for a further 3 months, followed by further feedback and analysis across sites. Finally, two patient and two therapist groups will be convened, using Nominal Group Technique to identify important barriers, facilitators and suggested improvements to HABIT. Further analysis and refinement will produce the final HABIT intervention. Timelines The study runs from 1/9/19 for 20 months. Following necessary approvals, sites 1&2 open recruitment in month 6; feedback with analysis in months 7-10; refining materials and creating videos months 9&10. Sites 3&4 open in month 10. Recruitment ends in month 14 (target 44 participants). Final feedback groups months 15&16; final refinement months 17&18. Dissemination and planning for next steps months 17-20. Impact and dissemination This project will lead to a further funding application to evaluate HABIT. The intervention will be made available as soon as this will not jeopardise the evaluation study. HABIT will produce clinical and economic impact through reducing disability, lost productivity and social care costs, while improving quality of life for those affected. Results of analyses will be published in journals, sent to participants and presented at stroke and neuro-rehabilitation conferences.

Lay abstract: The aim of this project is to produce a treatment for loss of vision after stroke in adults that can be used in NHS services from early hospital-based rehabilitation to rehabilitation and care at home. Visual field loss, the inability to see to one side (&ldquo;hemianopia&rdquo;), affects around one third of people with stroke; in the UK that s more than 30,000 people each year, and 5 million worldwide. Clinicians, patients and carers say treating visual problems after stroke is a top research priority. People with hemianopia have the impression of a complete visual world, yet often have severe difficulties because of their visual loss. Many people cannot find things or read easily, lose balance or bump into things and sometimes fall when walking, become overwhelmed by crowded spaces and cannot drive. This reduces confidence, independence and quality of life and increases loneliness. There is no standard treatment for stroke-related visual field loss; no treatment has enough evidence to be recommended for use across the NHS. Occupational therapists are the main people who treat visual field loss, but lack of knowledge about how to treat people limits what can be done. Best research evidence supports training people to compensate for visual field loss by &ldquo;scanning&rdquo; (looking repeatedly across into the affected area of vision), teaching them to search for and pay attention to the affected side of vision, and re-training them in reading. The study team have previously published how visual rehabilitation based on these principles can be used in community occupational therapy. We need to make these treatments work for everyone who needs them. We will work with people with visual loss after stroke, their carers and therapists to design a manual showing how to use the treatment, and videos for training and educating health professionals, patients and carers. We will then try out the training, manual and videos in several different NHS centres, and improve them based on feedback from therapists, stroke survivors and carers. People with hemianopia will be involved throughout the study. Local stroke survivors with hemianopia are supporting the study and have helped to develop this project. Two of these people will be invited to join the Study Management Group and others to help with videos and written materials. When this study ends we will publicise the results to scientists, stroke survivors and the public, by giving talks, posting on the web and publishing results in journals. We will ensure people with visual problems can access this material. This information will help patients and the NHS improve care. We will then apply for further money to evaluate the usefulness of this approach.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: STROKE