Introduction
Visual impairment ranges from total blindness to low vision. A blind person is a person who, after receiving paramedical services, has a vision in one or both eyes of 20/200 (1.10) or less [1] and uses Braille to learn [2]. The prevalence of visual impairment in school-age children is 1 in 10 [3]. Currently, 217 million people worldwide and 180000 people in Iran have a moderate to severe visual impairment [4]. One of the most serious problems for people with visual impairments is poor social skills that reduce social acceptance, real feelings about themselves, and self-esteem [5, 6]. This issue can lead to emotional [7] and social problems [8]. Lack of sufficient opportunity to communicate with people in society and rejection of disability by the blind person is among the important factors in the formation of self-concept and self-esteem [9]. The coincidence of adolescence with puberty causes various changes in personality dimensions, including self-esteem. The quality of self-esteem includes self-satisfaction and attitude towards one’s values and consists of four components of social, family, educational, and self-esteem [10]. High self-esteem leads to self-confidence and adaptation to difficult situations [11]. One of the effective methods for improving self-esteem is Acceptance and Commitment Therapy (ACT), one of the third wave approaches of behavioral therapy) which emphasizes the role of context in understanding events. This treatment has been introduced by Hayes et al. since the early 1980s and is known by the acronym ACT [12]. Facing the person directly with the present moment experiences, eliminating the connection between thought and past experience, encouraging the person to accept real relationships, achieving more valuable goals, and facilitating the path of commitment to one’s values ​​are key components of ACT therapy [13]. The six key processes in this treatment are acceptance, being in the present moment, specification of values, cognitive diffusion, commitment to action, and attention to oneself as context [14]. 
Studies show the positive effect of ACT on increasing self-esteem in adolescents with stuttering [16], reducing depression in women after experiencing their first delivery [17], and promoting adolescent mental health [18]. Given the different educational and support systems for people with visual impairments, the presence of some people in boarding schools may affect their perception of moral, personal, physical, and social self-esteem. Also, the lack of a similar study in Iran and the importance of paying attention to the sensitivity of adolescence, the existence of more health problems and social problems in females due to physiological differences and gender roles and expectations of societies, it is expected to observe decreased self-esteem in adolescent females more than males [15]. The main study question is whether the ACT affects female students’ self-esteem with visual impairment.
Materials and Methods
The present quasi-experimental study has a pretest-posttest design with a control group and a 2-month follow-up. The statistical population consisted of visually-impaired females aged 14-20 years studying in the high school in the 2019-2020 academic year. The sample size was determined using similar studies with a type I error of 0.05, the test power of 0.84, and a possible dropout of at least 14 people (28 in total) in each group. The samples were selected by purposive sampling method from the boarding school of the blind in Tehran (educational district 4) City, Iran. The Cooper-Smith Self-esteem Questionnaire (CSSEQ) was used to assess the samples’ self-esteem. The questionnaire consists of 58 items and four subscales (general, social, family, educational/occupational) that identify a person’s feelings, beliefs, or reactions. The items are scored yes or no. The cut-off point in this questionnaire is ≤23 [18]. People who get higher scores have higher self-esteem. Studies in Iran indicate that the test has acceptable reliability and validity [19]. In the present study, reliability coefficients were obtained by the test-retest method for general (0.96), family (0.95), social (0.95), and academic (0.93) subscales. Also, the Intra-Class Correlation (ICC) coefficient for the relative reliability of the test-retest of the total score of the self-esteem questionnaire was calculated to be 0.84. The Pearson correlation coefficient was estimated to be 0.92 for the questionnaire to evaluate the reliability between test times (test and re-test). After receiving the code of ethics and obtaining the permit, the research objectives were explained to the boarding school officials for the blind females.
After obtaining their written consent, 50 females with visual impairment according to the inclusion criteria (ages 14-20 years, absolute to low vision impairment, moderate and higher IQ, no hearing impairment and behavioral problems, no simultaneous participation in similar intervention sessions) and exclusion criteria (absence of more than two therapy sessions) completed their self-esteem questionnaire individually. According to their age and educational background, 28 subjects who scored 23 or lower on their self-esteem questionnaire were selected and replaced by their peers in the experimental and control groups. Due to the increased probability of effectiveness of the ACT method in small groups, two sub-experimental groups (7 people in each group) participated in eight 75-minute ACT sessions (2 sessions per week). The control group participated only in the usually integrated programs. The treatment protocol was based on the “Acceptance and Commitment Therapy” [20] and “ACT in Action” books [21]. After the last treatment session, all subjects and the experimental group were re-evaluated two months later using the CSSEQ. Two experimental group members were excluded from the study during the treatment sessions due to a lack of cooperation. Data obtained from three pretest, posttest, and follow-up positions were statistically analyzed using multivariate analysis of covariance and the correlated t test. 
Results
The Mean±SD ages of students in the experimental and control were 16.64±2.16 and 16.71±1.97 years, respectively. Significance levels (P>0.705) and (P>0.100) obtained from the Chi-square test for the variables of age and level of education, respectively, indicated the similarity of the groups. Table 1 presents the Mean±SD of self-esteem scores (general, family, social, and educational) in the experimental and control groups in the pretest and posttest stages.


According to the results of Table 1, the mean scores of the experimental group’s self-esteem (general, family, social, and educational) increased significantly compared to the control group in the posttest stage. In contrast, the mean scores mentioned in the control group in the posttest stages were not significantly different from the pretest.
To test the hypothesis of whether group ACT increases self-esteem in female students with visual impairment, we employed a univariate analysis of covariance (Table 2).


The values obtained from the Shapiro-Wilk test were not significant in a group, so the condition of normal distribution of scores was established. The two groups are homogeneous in the pretest stage. The default analysis of variance homogeneity using Levene’s test showed that the value of F was not significant (P>0.05), so the assumption of variance homogeneity was established. The results of homogeneity of regression slope between self-esteem pretest and self-esteem posttest in the experimental and control groups showed that the interaction of self-esteem (general, family, social, educational) pretest and posttest are not statistically significant in the group (P>0.05). The default homogeneity of the variance-covariance matrix of self-esteem components in the study groups was confirmed according to the value of M Box (20.041), index F=1.634, and P>0.05.
Based on the results in Table 2, the participation of female students with visual impairment in group treatment sessions of acceptance and commitment has increased self-esteem (general, family, social, and educational) compared to the control group. Also, based on the Eta coefficients, participation in the group treatment program of acceptance and commitment at the rates of 71%, 78%, 78%, and 72%, explains the changes in the components of self-esteem (general, family, social and educational) of students with visual impairment, respectively.
To determine the stability of the ACT on the self-esteem of students with visual impairment, a correlated t test was used (Table 3).


The results of Table 3 show no significant difference between the posttest and the follow-up scores of the self-esteem variable and its components in the experimental group. So the effect of group therapy of acceptance and commitment on students with visual impairment self-esteem remains stable even two months after the end of the intervention.
Discussion and Conclusion
The results showed that students’ self-esteem increased after attending acceptance and commitment treatment sessions. This result is consistent with some studies [16, 17, 22] that ACT is effective in improving self-esteem, physical activity, and reducing anxiety, rumination, physical concerns, body image problems, and violent behavior in adolescents and leads to their acceptance among peers. Explaining the recent findings, it can be noted that in ACT, people, through active and effective confrontation with thoughts and feelings, not avoiding or changing their attitudes towards themselves, reconsider their values, goals, and responsibilities in life while adhering to them, devote all their efforts to accept the status quo and realize the existential value of themselves. In fact, instead of focusing on transforming the context, ACT helps individuals accept their experiences and increase their desire to experience current thoughts and feelings. Also, by performing exercises and using mindfulness techniques during treatment sessions. Therapists can focus on the knowledge and awareness of the clients and correct them. After receiving such valuable experiences, students realize that they have directed their thoughts and feelings towards the existence of visual impairment and disability in a way that they do not value themselves. Also, attending ACT meetings has helped them overcome these distorted thoughts, thus enhancing their self-esteem. 
ACT provides a new path and space for the students to pay attention to important and valuable things in their lives and, instead of focusing on inefficient and unsuccessful previous solutions, commit to behaviors that lead to problem-solving by creating acceptance and reducing the struggle with inner states. As a result, students can reduce the stress of visual impairment by adopting such behaviors and feel better while valuing themselves and understanding their existential value. Finally, continuing the exercises presented in ACT sessions and the emergence of appropriate behaviors result in new habits and attitudes and guides the people to empower and master the contextual situations and thus improve their self-esteem. 
Another finding of this study was that group therapy of acceptance and commitment improved all components of self-esteem (general, family, social, and educational) in female students with visual impairment. This finding is consistent with some studies that have shown that ACT increases social [23], educational [24, 25], and emotional adjustment, regulates emotions and moods [26] and improves psychological resilience [27]. To explain these findings, it can be said that the central processes in the ACT are the emphasis on people’s inner experiences and helps them to experience disturbing thoughts only as a thought, be aware of the dysfunctional nature of their current thoughts, and instead of responding to it, do activities that are in line with their values. In fact, dysfunctional and irrational thoughts are one of the predictors of low self-esteem [28]. Students seem to have been able to experience unpleasant inner events in the present moment and separate themselves from undesirable reactions, memories, and thoughts. 
Adolescents with visual impairments from the beginning considered themselves worthless to their peers and, in general, experienced negative thoughts and feelings throughout their lives. But, during ACT sessions, they learned that overcoming the feeling of worthlessness reduces anxiety and increases self-esteem [29]. In other words, the central processes in ACT taught students how not to restrain their thoughts, to get rid of annoying thoughts, to reinforce aspects of the real self instead of creating false images of their concept, accepting them instead of controlling internal events, pay more attention to their thoughts and thought process through mindfulness, and direct them towards goal-oriented activities. 
Females with visual impairments seem to have a weaker sense of self-concept than males, have fewer opportunities to make friends, and experience greater social isolation. While attending ACT sessions provided the context for them to discover their self-esteem among other adolescents and protect it from danger [30]. Based on the above mechanisms, one can expect an improvement in the components of self-esteem. Since the promotion and improvement of self-esteem in adolescence can positively affect the social, educational, family, and personal life of people with visual impairments and lead to a performance in all of these aspects, the results of recent research can be used by professionals who provide psychological services to students with special needs (especially visual impairment). It is an effective treatment for self-esteem and lead to increased positive functioning of adolescents in the social, educational, and family areas. 
Because of study limitations such as targeted sampling, choosing only female students with visual impairment, and using self-assessment tools, generalizability, and inference of results are limited. Therefore, to examine the dependent variables, it is suggested that other measurement methods such as interviews and the questionnaire be considered. Controlling some demographic variables in such studies can enrich the findings. Using random sampling and comparing a sufficient number of people with varying degrees of low vision can lead to a better generalization of research results. Finally, by introducing students’ competencies with visual impairment to other normal peers, some of the ambiguities in the field of vision problems are removed, and ordinary students can clearly understand people with disabilities.
Conclusion 
we conclude according to the findings of the present study that the acceptance and commitment group therapy can use for planning and policy making instructional courses suitable for students with visual impairments. Furthermore, the specialists who are working with these children can use the ACT as a practical technique for improving self-esteem and the adaptation in many areas such as family, social and educational areas in students with visual impaiments. Additionally, the ACT recommend improving self-esteem and positive performance of students with visual impairment in social, educational and family areas along side the routin instructional couses. However, the acceptance and commitment group therapy helps the students with visual impairment know how to control their thoughts and feelings in order to prevent problems from getting worse. This therapeutic method helps them to accept their behavioral changes through accepting the unpleasant thoughts and feelings.

Ethical Considerations 
Compliance with ethical guidelines
This research was approved by the Ethics Committee of the University of Rehabilitation Sciences and Social Health (Code: IR.USWR.REC.1398.170). To observe ethical considerations, the officials of the educational complex and parents and students were fully informed about the research objectives. While obtaining their written consent, they were assured that the information obtained from the questionnaires would remain confidential. The participation of students in the study was voluntary, and people who did not want to continue to cooperate were free to leave the research. During the investigation, proper attention was paid to the students’ mental states and fatigue, dignity, and human rights. After the intervention, the control group was acquainted with the content of the group treatment program based on acceptance and commitment in three intensive sessions.

Funding
This article is extracted from the Master’s thesis of Fatemeh Mir Mohammadi from the Department of Psychology and Education of Exceptional Children, University of Rehabilitation Sciences and Social Health.

Authors' contributions
Conceptualization: Fatemeh Mir Mohammadi, Masoumeh Pourmohammadreza-Tajrishi, and Behrooz Dolatshahi; Methodology: Fatemeh Mir Mohammadi, Masoumeh Pourmohammadreza-Tajrishi, and Mohsen Vahedi; References and validation: Fatemeh Mir Mohammadi, Masoumeh Pourmohammadreza-Tajrishi, Behrooz Dolatshahi, and Enayatollah Bakhshi; Analysis: Fatemeh Mir Mohammadi, Masoumeh Pourmohammadreza-Tajrishi, and Enayatollah Bakhshi; Research: Fatemeh Mir Mohammadi; Drafting the manuscript: Fatemeh Mir Mohammadi and Masoumeh Pourmohammadreza-Tajrishi; Editing and finalizing: Masoumeh Pourmohammadreza-Tajrishi, Behrooz Dolatshahi, Enayatollah Bakhshi; Supervision: Masoumeh Pourmohammadreza-Tajrishi, Behrooz Dolatshahi, and Enayatollah Bakhshi.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
We would like to thank the University of Rehabilitation and Social Health for its financial support and all individuals, especially education officials, teachers, counselors, and students of the Narges Blind Girls’ Boarding School, who helped us in this research.



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