Questions/Answers

To be a hospital that provides holistic care through eye services. In addition to the treatment of visual impairments, to afford continuing care through the provision of vision rehabilitation services for ‘the visually disabled’. Despite many patients being treated for ophthalmic diseases, they still lose their vision, or they develop visual disabilities related to conditions such as glaucoma and retinal degeneration. In Thailand, some support is available to help the visually disabled through organizations such as foundations for the blind or blind schools. Nevertheless, these institutions do not provide medical help, but social help. In addition, most are geographically scattered and not usually coordinated, making it difficult for the visually disabled to access support. This initiative of providing medical help for the visually disabled has the characteristics of ‘holistic care through vision rehabilitation services’. To be exact, it involves the provision of mental support, counselling to develop individual plans for rehabilitation, the conducting of vision rehabilitation services by medical personnel operating within multidisciplinary teams in the hospital, and coordination with external resources as a one-stop service. Moreover, the initiative is provided for the visually disabled of all ages—from infancy to the elderly.

Decades ago, eye services in Thailand focused on treatment through medication or surgery. Incurable eye diseases were regarded as ‘visual disabilities’ and no further medical help was provided. This resulted in the disabled being unable to help themselves, feeling a burden to their families, and losing hope. A loss of sight during early childhood also undermined children’s global development. With the aim of not leave them behind, this initiative of medical help has been developed. The ongoing service can be accessed readily through a collaborative system of multidisciplinary teams to ensure there is holistic care through vision rehabilitation services.

Siriraj Hospital, the largest center in Thailand, serves 116,000 ophthalmic patients annually with the goal of achieving ‘good health and well-being’ for all patients. In addition to treating visual impairments, this initiative aims to broaden the medical help available for the visually disabled who, despite having incurable eye conditions, should still have the opportunity to achieve ‘good well-being’ through holistic care of vision rehabilitation (SDG 3). Consequently, they can live more independently and increase their educational and professional opportunities. In turn, this ‘reduces inequities’, and promotes ‘justice, strong institutions’, and ‘sustainable cities and communities’ (SDG 10, 11, 16).

According to WHO reports, of the 1.3 billion people with a visual impairment worldwide, 20% have incurable diseases and are visually disabled. Most of the visually disabled (90%) live in developing countries, with 2 million in Thailand. Many more members of their families are also affected by the burdens arising from the visual disabilities. A global survey of 195 countries (Chiang PP 2011) found that there was a shortage of medical services to help people with visual disabilities in many countries, including Southeast Asia and Thailand. Public and private help is mostly social (non-medical) support and is scattered, making access difficult for the disabled. This problem is found in many regions of the world (O’Connor PM 2008). This initiative of ‘holistic care through vision rehabilitation services’ is therefore an innovative model in Thailand which allows hospitals to provide medical help to people with visual disabilities. This rehabilitation service coordinates multi-agency partnerships to improve the quality of life of the visually disabled so that they can take care of themselves, reduce the burdens on their families, and be of value to their community and country.

A literature review has confirmed that this initiative is an innovation for Thailand and the region. Holistic care through vision rehabilitation services is available to the visually disabled at public hospitals, with coverage of all ages. The holistic services offered via a one-stop service include mental support, the provision of visual aids, physical training in daily activity skills, coordination of vocation and education, stimulation of global development for young children in collaboration with the Department of Pediatrics, and the development of innovation in assistive technology (e.g., an obstacle warning device) in conjunction with the Faculty of Engineering.

This is an original concept developed from a model proposed by the WHO for the provision of vision rehabilitation services for the visually disabled. The service commenced at Siriraj Hospital in 2002, with the provision of mainly visual aids. However, the service model at that time did not cover all of the contexts of people with disabilities. Over the many subsequent years, more services were progressively added: mental support and rehabilitation counselling, training in the skills of daily-living activities, mobility and travelling services, coordination of vocation and education, and stimulation of global development in young children.

The knowledge has been transferred by including it in the training course for residency in ophthalmology at Siriraj Hospital. The hospital itself has also been a study and training resource for medical personnel in the government and private sectors over the years. The initiative has been transferred and adapted for use in public hospitals that have ophthalmic services in many provinces nationwide in order to expand the services available to the visually disabled. Appropriate adaptation of the model had also been undertaken to match the context of each hospital (for example, a small general hospital versus a large medical center).

As the holistic vision rehabilitation service is an ongoing eye care service, most of the human resources involved are medical personnel who are already available in the hospital. However, they needed to broaden the scope of their services and create clear, collaborative working systems. The personnel include ophthalmologists, mental rehabilitation consultants for people with disabilities, life skill and traveling trainers, pediatricians involved in the stimulation of development in young children, and rehabilitation medicine physicians. The visual aid devices are provided without charge by the government for individuals with legal disabilities, in accordance with Thai law.

The inclusion of this ‘holistic care through vision rehabilitation services’ as part of the medical services available in a public hospital ensures sustainable support for the visually disabled in four ways. Firstly, after the treatment of the disease, the service involves a continuum of medical services which already exist in the hospital. In fact, these services are not found in private hospitals or other for-profit organizations in Thailand. In addition, the service has developed clear working systems and coordination mechanisms for the internal and external agencies involved. Thirdly, the service is provided as the first form of aid for the visually disabled, before the problem of the visual disability becomes more burdensome to the family and society. Finally, the service is holistic, covering all contexts of the disabled (mental, physical skills, the occupational and educational aspects, and children’s developmental aspects) so that the whole well-being of the visually disabled can be improved. When the visually disabled can take care of themselves, they can return to work and benefit ‘society’. This reduces the burdens on their families and society sustainably, which creates a ‘good environment’ within society and results in a positive ‘economic impact’ for the country.

Yes

This initiative to help the visually disabled was evaluated by the change in the quality of life scores after receiving the services, as reported by the visually disabled themselves, and assessed by a prospective research study. This study was entitled ‘Quality of Life of Low-Vision Patients and Outcome of Low-Vision Rehabilitation at Siriraj Hospital’. It was presented at the 40th Academy Meeting of Royal College of Ophthalmologists of Thailand in 2017, and won second place for the Best Research Award.

The change in well-being or quality of life was assessed by questionnaires, of which the English and Thai versions had been validated. The 3 indicators were 1) the low-vision quality of life questionnaire (LVQOL), which is specific for patients or disabilities with visual conditions; 2) the EuroQol five-dimensional questionnaire (EQ-5D), which is generic (i.e., not vision-specific), for patients or disabilities related to any disease; and 3) International Classification of Functioning, Disability and Health (ICF) by the WHO, which classifies the abilities of the patients or the disabilities in performing activities and social participation.

The results of the 3 indicators corresponded in that they found the visually disabled demonstrated improved abilities to perform activities and participate socially after receiving holistic care through the vision rehabilitation services. The difficulty scores for the performance of those activities also decreased significantly. Moreover, significant improvements were found in the quality-of-life scores relating to the mental and emotional states of the visually disabled, and in the reading, daily activity, and traveling dimensions.

This initiative responded to the Thai government’s policy to improve the well-being of people with visual disabilities. This is in turn stemmed from revisions made to Thai laws relating to the rights and equality of people with disabilities to access public services, including medical rehabilitation services. The Department of Ophthalmology was the main agent for the development of new work systems. It expanded the range of eye care services available to the hospital’s patients after their treatment for visual impairment by broadening the responsibilities and skills of the Department’s medical personnel (viz., ophthalmologists, mental rehabilitation consultants for people with disabilities, visual aid device trainers, and life skill and traveling trainers). As to stimulating the development of young children, the revised work system was developed in collaboration with the Departments of Pediatrics and of Rehabilitation Medicine. In addition, there was academic collaboration with Ratchasuda College, Mahidol University (the higher education institution for people with disabilities), and the Faculty of Engineering, Chulalongkorn University (Assistive Technology Research Group); collaboration in the supply of visual aids with Sirindhorn National Medical Rehabilitation Institute, Ministry of Public Health; and collaboration in the provision of other benefits to people with disabilities with the National Health Security Office.

The ‘holistic care through vision rehabilitation service’ has helped to improve the well-being of the visually disabled and should be promoted as a continuing eye-care service in public hospitals nationwide. Similar to many countries in the region, however, there is still a shortage of this kind of medical support in Thailand. To date, the model has been primarily implemented in large hospitals and large medical centers. Therefore, Siriraj Hospital is simplifying the service models for the various processes to make them easier to follow, so that the service can be more widely disseminated at the small-hospital level.