Modifying homes for persons with physical disabilities in Thailand.

PROBLEM: Thailand passed the Persons with Disabilities Empowerment Act in 2007. The Act, which is in compliance with the United Nations Convention on the Rights of Persons with Disabilities, ensures that registered persons with disabilities are entitled to home environment modifications' benefits up to a maximum of 20 000 baht (670 United States dollars); however, the Act's enforcement is still weak in Thailand. APPROACH: In 2013, researchers developed a home modification programme, consisting of a multidisciplinary team of medical and nonmedical practitioners and volunteers, to modify homes for persons with disabilities. The programme recruited participants with physical disabilities and assessed their functioning difficulties. Participants' homes were modified to address identified functioning difficulties. LOCAL
SETTING: The project was implemented in four provinces in collaboration with staff from 27 district hospitals located in north-eastern Thailand. RELEVANT CHANGES: After the home modifications, all 43 recruited participants reported reduced difficulties in all areas, except for participants with severe degrees of difficulties, such as those reporting being unable to walk and unable to get up from the floor. The participants' quality of life had also improved. The average EQ-5D-5L score, measuring quality of life, increased by 0.203 - from 0.346 at baseline to 0.549 after the modifications. LESSONS LEARNT: Home modifications in low-resourced settings are technically and financially feasible and can lead to reducing functioning difficulties and improving the quality of life of persons with disabilities. Implementation requires government subsidies to finance home modifications and the availability of technical guidelines and training on home modifications for implementing agents.

Introduction

Home environment modifications are essential to improve the quality of life of persons with disabilities. Parts of a home and its surroundings, together with the built environment should be changed according to the impairments of persons with disabilities to minimize difficulties in activities of daily living and to alleviate the burden on carers. Article 28 of the United Nations Convention on the Rights of Persons with Disabilities ratified by Thailand in 2008 endorsed the right of persons with disabilities to independent living. International experiences show different countries use more than one funding mechanism to finance home environment modifications that aim to enhance the independent living of persons with disabilities.– A regulation promulgated by the Thai Ministry of Social Development and Human Security describes the appropriate home surroundings and built environment to be accessible by persons with disabilities, however the enforcement of the regulation is still weak.

Local setting

Thailand is an upper middle-income country with an estimated population of 68 million in 2015. Thailand passed the Persons with Disabilities Empowerment Act in 2007. The Act which is in compliance with the United Nations Convention on the Rights of Persons with Disabilities, ensures that registered persons with disabilities are entitled to government subsidies for home environment modification to a maximum of 20 000 Thai baht (equivalent to 670 United States dollars). Provincial social development and human security offices are responsible for implementing this benefit. In addition, the provincial rehabilitation fund, which has been set up by a 50–50 contribution from the Thailand National Health Security Office and the Provincial Administration Organization, also provides financial support for home modifications to persons with disabilities.

Approach

In 2013, researchers from Mahasarakham University, faculty of medicine, developed a home environment modification programme for persons with physical disabilities. The researchers formed a project team consisting of two architects, two engineers, a group of local builders, nurses and social workers from communities where the selected homes were located. The project was implemented in four provinces Kalasin, Khonkaen, Mahasarakham and Roi-Et, in collaboration with 27 district hospitals located in the provinces. These hospitals have health-care teams, consisting of physical therapists, nurses and health care volunteers who visit persons with disabilities in their homes. We asked these teams to recruit persons with physical disabilities, including elderly people, residing in these provinces to participate in the programme. Researchers from the faculty of medicine ran four training sessions for the project team on universal design concept application and on how to do home and built-environment modifications in order to enhance the functions of persons with disabilities.

Functioning difficulty assessment

The physical therapists and primary care nurses working in the four district hospitals identified, selected and clinically examined eligible participants in their homes and asked the participants to sign the consent form. The project team set the participants’ selection criteria, based on the type of functioning difficulties the identified person with disabilities had. Functioning was measured using the International classification of functioning, disability and health (ICF)., Seven difficulty levels as defined in the ICF were used as selection criteria: (i) having difficulties walking (ICF code d450); (ii) having difficulties getting up from the floor (d4101); (iii) having difficulties getting up from a chair or bed (d4103); (iv) having difficulties moving around (d460); (v) having difficulties climbing (d4551); (vi) moving around using equipment (d465); (vii) having at least some difficulties walking (d450) with assistive devices or with assistive devices and personal support. Quality of life and risk from fall were measured using EQ-5D-5L and the Berg Balance Scale Test, respectively. EQ-5D-5L is a standardized instrument used to measure quality of life using five dimensions: mobility, self-care, usual activities, pain and discomfort, and anxiety and depression. The Berg Balance Scale Test is used to monitor dynamics and static balance abilities to predict fall risk. The other criteria for participant selection were home ownership and willingness to participate in the modification programme. The researchers visited the homes identified for modification to document the existing structure and the surrounding neighbourhood. The researchers took photographs and short video clips that show the general condition of the homes and parts of the homes to be modified and the daily activities performed by the persons with disabilities residing in the homes. The physical therapists and primary care nurses reassessed the participants’ functioning difficulties after the home modifications were completed through assessments in the participants’ homes.

Home modifications

We assigned the selected homes into four groups according to the type of modifications needed. Group 1 included those homes that required minimal changes, such as installing handrails or building wider doors. Group 2 included those homes that required changing some part of the home, for example, relocating a toilet to be closer to the participant’s living area. In Group 3 modifications weren’t possible in the homes for various reasons, therefore newer quarters needed to be built. In Group 4 home modifications were necessary, but only to ensure safety and security for the participant, rather than to improve the enabling environment, for example replacing a new roof or filling a specific piece of land to prevent flooding. The number of homes in each group, the cost of modifications and the duration of the construction for each group is presented in Table 1.

Table 1

Quality of life scores before and after home modifications, Thailand, 2013

Type of home modifications	No. (%) of homes	Duration of construction, days	Average cost of modifications, US$	EQ-5D-5L baseline score	EQ-5D-5L after modifications score	Net score change
Group 1: Modifications with minimum changes	12 (29)	2–15	697	0.337	0.495	0.158
Group 2: Modifications in some part of the home	20 (47)	3–20	1384	0.410	0.574	0.164
Group 3: New quarters built	9 (20)	11–30	2130	0.198	0.546	0.348
Group 4: Modifications to ensure safety and security	2 (4)	5 and 14	744	0.184	0.511	0.327
All	43 (100)	NA	NA	0.346	0.549	0.203

NA: not applicable; US$: United States dollars.

Note: EQ-5D-5L is a standardized instrument measuring quality of life, using five dimensions: mobility, self-care, usual activities, pain and discomfort and, anxiety and depression. Each dimension contains an additional five levels: no problem, slight problem, moderate problem, severe problem and extreme problem. EQ-5D-5L scores range from −1 to 1, with −1 being the lowest quality of life score and 1 being the highest quality of life score.

Financing the modifications

In addition to the government subsidies, provincial rehabilitation and subdistrict administrative organizations’ funds and donations from participants’ families were used to pay for home modifications. Volunteers from the local community, for example, family members, Buddhist monks, soldiers and other villagers worked on the modifications. In the areas where volunteers were unavailable, local professional builders were hired. On-site coordination and management were done by district hospital staff. The government subsidies and the provincial rehabilitation funds covered approximately 70% of the modification costs, and were used mostly to buy building material. The remaining 30% was mobilized from subdistrict administrative organizations and households and was used to cover labour cost, including meals for volunteers.

Relevant changes

Of the 77 persons with disabilities we identified, we recruited 62 persons to participate in the project. Six participants died before the home modifications started, two others died later during the modifications and eleven were still waiting for funding when the project started. Therefore, only 43 participants were included in the project and their 43 homes were successfully modified.

The level of difficulty experienced by the participants when performing daily activities was assessed before and after the home modifications. When compared with the baseline assessment, this had decreased after the modifications. At the baseline assessment, the most frequently reported activities performed with difficulties by the 43 participants were, walking 97.7% (42), getting up from the floor 88.4% (38), getting up from a chair/bed 62.8% (27), moving around inside the home 30.2% (13), moving around outside the home using equipment 39.5% (17) and climbing stairs 23.3% (10). After the modifications, the level of difficulties decreased for 23.8% (10/42) of the participants who had reported having difficulties walking and 29.6% (8/27) of those who had reported having difficulties getting up from a chair/bed. The decrease for other activities was 44.7% (17/38) for getting up from the floor, 38.5% (5/13) for moving around inside the home and 11.8% (2/17) for moving around outside the home using equipment. As shown in Table 2, after the home modifications, the number of participants reporting that their difficulties were reduced had increased in all function areas except for participants with severe degrees of difficulties, such as those reporting themselves as unable to walk (d450) and unable to get up from the floor (d4101), indicating that home modifications cannot improve functions for those with severe degrees of difficulties. The average EQ-5D-5L score had also increased by 0.203 from 0.346 at baseline to 0.549, indicating that in general the quality of life of persons with disabilities participating in the programme was improved (Table 1).

Table 2

Level of difficulty in performing activities, before and after home modifications, Thailand, 2013

Type and level of difficulty based on ICF code	No. (%) of persons with disabilities (n = 43)
	Before home modifications	After homemodifications
Walking (d450)
Walk independently	1 (2.3)	3 (7.0)
Walk with abnormal gait	9 (20.9)	10 (23.3)
Walk with assistive device	14 (32.6)	10 (23.3)
Walk with assistive device and personal assistance	7 (16.3)	4 (9.3)
Cannot walk at all	12 (27.9)	16 (37.2)
Getting up from floor (d4101)
Getting up independently	5 (11.6)	8 (18.6)
Getting up with assistive device	15 (34.9)	8 (18.6)
Getting up with assistive device and minimal personal assistance	2 (4.7)	2 (4.7)
Getting up with assistive device and maximal personal assistance	11 (25.6)	4 (9.3)
Cannot get up at all	10 (23.3)	21 (48.8)
Getting up from chair or bed (d4103)
Getting up independently	12 (27.9)	12 (27.9)
Getting up with assistive device	11 (25.6)	14 (32.6)
Getting up with assistive device and minimal personal assistance	4 (9.3)	0 (0.0)
Getting up with assistive device and maximal personal assistance	3 (7.0)	2 (4.7)
Cannot get up at all	9 (20.9)	9 (20.9)
Not relevant	4 (9.3)	6 (14.0)
Moving around (d460)
Moving independently	29 (67.4)	29 (67.4)
Moving under supervision	3 (7.0)	4 (9.3)
Moving with minimal personal assistance	2 (4.7)	3 (7.0)
Moving with maximal personal assistance	7 (16.3)	4 (9.3)
Cannot move at all	1 (2.3)	2 (4.7)
Not relevant	1 (2.3)	1 (2.3)
Climbing (d4551)
Climbing independently	0 (0.0)	7 (16.3)
Climbing with personal assistance	10 (23.3)	4 (9.3)
Cannot climb at all	0 (0.0)	1 (2.3)
Not relevant	33 (76.7)	31 (72.1)
Moving around using equipment (d465)
Moving independently	26 (60.5)	27 (62.8)
Moving with personal assistance	10 (23.3)	9 (20.9)
Cannot move at all	7 (16.3)	7 (16.3)

ICF: International classification of functioning, disability and health.

Lessons learnt

Box 1 summarizes the main lessons learnt. The programme demonstrated that home modifications in low-resourced settings are technically and financially feasible and can lead to a reduction in functioning difficulty and improvement in the quality of life of persons with disabilities. Technical expertise for home assessment and modification design can be mobilized and supported locally, especially in areas where local training institutions, such as vocational colleges, are available. A multidisciplinary team consisting of medical and nonmedical practitioners, as well as volunteers from the community can be convened either by local government organizations or district hospitals to support a home modification programme. Local government’s ownership and leadership of the programme is critical to mobilize local resources.

An effective national policy that entitles home environment modifications for persons with disabilities needs local funding and implementation capacity to show improvement in the quality of life of persons with disabilities.

To scale up a home environment modifications programme beyond the project site, increased government subsidies in line with the different types of modifications, additional financial and technical resources from local government and communities and technical guidelines on home modifications and training for provincial staff is needed.

Intersectoral and multidisciplinary approach from project planning to implementation is important for successful implementation.