Vision rehabilitation workforce in Italy: a country-level analysis

Abstract

Background

Research and monitoring of human resources available for vision rehabilitation services has been a neglected area of work in the past. This study aims to offer an overview of the vision rehabilitation workforce available in Italy, in order to profile the distribution and number of human resources for vision rehabilitation.

Methods

Data on the available vision rehabilitation professionals were collected from the yearly report on the state of implementation of policies relating to the prevention of blindness, education and vision rehabilitation, according to a law which was passed by the Italian Ministry of Health, Department of Health Prevention. The report presents a review of all professional workers dealing with low vision rehabilitation centers in Italy between January 2005 and December 2019. Data on the distribution and type of services of government-supported low vision centers across the country were also obtained and examined.

Results

Of the 289 low vision rehabilitation workers in 2019, 28% were ophthalmologists, 31% orthoptists, 19% psychologists, 17% nurses and 5% social workers.

The health workforce densities across the Italian regions ranged from 1.62 to 0.12 per 100.000. The density of vision rehabilitation workers showed a no growing trend from 2006 to 2015. During the study period, it was found a weak but statistically significant association of workforce density with the number of government-supported low vision centers across the Italian territory (r² = 0.3, p < 0.05). The vision rehabilitation workforce was not associated with the number of low vision patients who accessed to a vision rehabilitation center (r² = 0.05, p < 0.0001).

Discussion

A critical review has identified the following national situation: need-based shortages of workers in the vision rehabilitation service sector, as well as deficiencies in data sources. Based on our results, we would recommend increasing the development of human resources trained and dedicated to vision rehabilitation and improve data collection and analysis; provide structural enhancements, across all service levels. These considerations may contribute to the enhancement of policy decisions in order to guarantee an adequate vision rehabilitation workforce and meet national rehabilitation needs. Furthermore, this analysis should be used as a lesson learned by other countries, as low-income ones, in order to develop vision rehabilitation services.

Introduction

Globally, it is estimated that approximately 1.3 billion people live with some form of distance or near vision impairment [1]. With regard to distance vision, 188.5 million have a mild vision impairment, 217 million have moderate to severe vision impairment, and 36 million people are blind. In terms of near vision, 826 million people live with a near vision impairment. Population growth and aging will likely increase the number of people who may develop some form of vision impairment during their lives [1, 2]. Therefore, the prevalence of people experiencing vision disabilities is expected to grow, also due to increased treatment opportunities that are transforming permanently blinding conditions into low vision ones [3,4,5,6,7]. Disabled people can also experience secondary health conditions resulting from their impairments [8,9,10,11]. An adequate and well-distributed low vision rehabilitation workforce¹is crucial for achieving the principles of Universal Health Coverage (UHC). The ambition of UHC implies the estimation of the number, type and distribution of health workers in order to content the population needs regarding health services. Therefore, it requires continuing political commitment and leadership to equally distribute human resources for health (HRH). The World Health Organization (WHO) and Global Health Workforce Alliance are clear that there can be no health care delivery without a capable healthcare workforce [12]. Moreover, evidence in human resources for eye health and vision rehabilitation has been consistently recognized as central to eye health service delivery in global initiatives, reports and resolutions on visual impairment over the last two decades [13,14,15,16,17]. Italy’s healthcare system is based on the secondary and tertiary healthcare model, with services delivered through a network of tertiary level hospitals and district hospitals. Low vision services in Italy are mostly provided by government-supported institutions, with a for profit sector growing at a modest rate. The vision rehabilitation workforce involves many different professional profiles, in both public and private sector. These include ophthalmologists, psychologists, orthoptist-ophthalmology assistants, and nurses among a wide array of other health workers providing the visually impaired with the rehabilitation services they need. Provisions for the prevention of blindness, vision rehabilitation and the social and occupational integration of the severely visually impaired and blind in public sector, are referred to the Law 284 of 1997 (https://www.gazzettaufficiale.it/eli/id/1998/02/18/098A1210/sg).

The health sector is organized in such a way that the functions of the national government include the formulation of health policy and the management of national referral structures, while the functions of the regions include the facilitation of the delivery of health services at the regions’ own health facilities. The regulatory bodies of the regions register both the number of health workers and the description of their activities and then transfer this information to the Ministry of Health (MoH). Specifically, Italian regions may set up centers or services for permanent education and experimentation for work and occupational activities in order to promote the social, educational and working integration of visually impaired people who present further sensory, motor, intellectual impairments. The Law also determines the equipment needed by centers to deliver those services, regulates their organigram, the human resources required and their function and management structure, as well as the method to evaluate the results achieved every year. Pursuant to the above-mentioned Law, data on low vision services provided at regional level are included in a report, which is published by the MoH. As the MoH transfers the responsibility for the provision of health services to the regions, it is crucial to understand their capacity in terms of health workers and to examine the distribution of this capacity. In addition, perhaps for the first time, information on available human resources makes it possible to examine the relationship between the density of visual rehabilitation workforce and key health indicators in Italy. The study and monitoring of vision rehabilitation teams has been mostly neglected so far, despite a more in-depth understanding of the health and social workforce, would allow a more appropriate definition of the investments needed to achieve efficient, effective, resilient and sustainable health systems. This study aims to analyze the vision rehabilitation workforce in Italy, in order to provide a general overview of the last 15 years, which can offer support for further analysis to verify whether the number and type of human resources match with both the demand for staffing and the population need for vision rehabilitation. More in depth, the research, provides an analysis of the geographical distribution and evolution characteristics of human resources engaged in vision rehabilitation centers at national level from 2005 to 2019.

Methods

Design

This is a retrospective study of the workforce involved in Italian low vision centers over a 15-year period. The authors have conducted an observational analysis of data collected by the Italian MoH.

Research strategy and data collection

The staffing requirements for Italian low vision centers according to the Law (284/97) include: ophthalmologist, psychologist, orthoptist-assistant in ophthalmology, professional nurse, and social worker. It also follows from the Law, that each vision rehabilitation center must have at least one professional figure in each category above-mentioned. Therefore, these professionals’ categories are the only mandated by the Law 284/97.

The annual MoH reports were accessed between March 2021 and December 2021 to retrieve data on human resources used in this analysis. The covering period was from January 2005 to December 2019, and the terms “Ophthalmologist”, “Psychologist”, “Orthoptist-Ophthalmology Assistant”, “Social worker”, and “Nurse” were used for searching strategy. Specifically, the data concerning vision rehabilitation professionals by the public sector are based on the annual declarations of activities of rehabilitation centers transmitted to the MoH by the regional administrations. Therefore, yearly data were processed and published in the Italian MoH’s reports available on the website www.salute.gov.it. Data regarding vision rehabilitation operators (workers/professionals) included the number of workers at each low vision center as described in the MoH report. All analysis concerns the vision care workforce provision in the public sector, both in health facilities and other settings, which directly support health service delivery. Data on vision rehabilitation professionals do not include personal details such as gender and age. Data on personnel involved in the non-public sector are not transmitted and therefore not considered for this study.

Then, citation-tracking and consulting references lists were also carried out. Further analysis of forms filled in by low vision centers nationwide was conducted to integrate all available information. These steps were taken with the aim to identify existing strengths and weaknesses, with the overall objective to define a data platform to advance the study, monitoring and development of the vision rehabilitation workforce. Data on vision rehabilitation staff underwent a cleaning process, by matching the information from the MoH reports and the regionally filled-in forms, to avoid duplication and to provide the best available evidence on the current vision rehabilitation workforce. The WHO World Report on Disability and the World Report on Vision were also consulted, both as informative material and as a source for references [3, 18].

Data management and analysis

For consistency, all MoH reports data were reviewed by a single researcher as they were published. Data were then entered directly in an ad-hoc created database and divided into specific categories, in order to answer to the study objectives. Descriptive statistics were calculated for all variables collected. Means with standard deviations were used to describe continuous variables, and aggregates and percentages were used for categorical data.

Density of rehabilitation professionals was used to analyze the distribution of human resources. This density represents the number of staff in low vision centers divided by population and multiplied by 100.000 (unit: persons per 100.000 population).

Moreover, we examined the distribution of the public sector vision rehabilitation workforce and low vision rehabilitation centers using linear regression, and by using correlation analysis. Also, we explored the relationship between staff distribution and key indicators, such as the number of visually impaired people who had access to vision rehabilitation centers, identified as cases. Information and data on ophthalmologists, orthoptists-assistant in ophthalmology, psychologists, nurses and social workers workforce capacity at national level were obtained from the professional associations websites (psychologists at https//www.psy.it; nurses at https://www.fnopi.it/associazioni-infermieristiche/; social workers at https://cnoas.org/numeri-della-professione/). Using this information, the professionals’ ratio was calculated for each category and year of analysis. The correlations were analyzed using linear regression in the Excel database. Furthermore, multiple linear regression analysis was used to explain the relationship between dependent variables as professionals and independent variables as number of low vision centers, cases who had access to vision rehabilitation centers and health services provided. Correlations of r² < 0.05 were considered weak. Scatter plots with fitted trend lines provided a visual representation of the linear association between human resources involved in vision rehabilitation and the factors mentioned above (centers, cases and health services).

Results

Data published by the MoH in the 2019 about the Law 284/97 activities report showed 289 vision rehabilitation workers engaged in the public sector. Other employees were non-clinical support staff, administrators and non-clinical managers. Specifically, the vision rehabilitation workers categories included ophthalmologists, psychologists, orthoptist-assistants in ophthalmology, nurses and social workers. No data about gender and age were available. Of the 289 workers, 80 (28%) were ophthalmologists, 89 (31%) orthoptists, 53 (19%) psychologists, 51 (17%) nurses and 16 (5%) social workers.

The national public vision rehabilitation workforce to population density was 0.15 for ophthalmologists, 0.17 for orthoptists, 0.09 for psychologists, 0.08 for nurses and 0.02 for social workers per 100.000, respectively. When data were pooled across the national sample, the ophthalmologist ratio involved in low vision rehabilitation settings was 1.2%, the orthoptist ratio was 2.6% and the psychologist was 0.05%. When all Italian nurses and social workers were considered, the practitioners working in low vision centers were 0.01% respectively. Although the number of social workers is increasing nationwide (social workers at https://cnoas.org/numeri-della-professione/), those working in visual rehabilitation centers seems to be decreasing. Density for ophthalmologists, psychologists, orthoptist-assistants in ophthalmology, nurses, and social workers from 2005 to 2019 are shown in Fig. 1. Generally, the density of vision rehabilitation professionals showed a no growing trend from 2006 to 2015. Moreover, during the last years of analysis a decreasing trend was registered.

Fig. 1

Process-tracing of human resources for vision rehabilitation in relation to the number of population (2005–2019)

Therefore, considering the total number for each category of health workers, at national level, it can be assumed that on average 86.8 (SD: 19.9) ophthalmologists, 81.2 (SD: 15.6) orthoptists, 43.5 (SD: 6.8) psychologists, 41.4 (SD: 6.8) nurses and 22.1 (SD: 7.1) social workers worked in national low vision centers during the 15 years of reference. During the study period, there were vacancies in three worker categories: the highest were for psychologists, followed by nurses and social workers in relevant order. Considering the ratio between vision rehabilitation centers and vision rehabilitation staff from 2005 to 2019, a shortage of professional health figures such as psychologists (ratio = 0.7), nurses (ratio = 0.7) and social workers (ratio = 0.4) was identified. The ratio for ophthalmologists and orthoptists was 1.5 and 1.4, respectively.

Cross-region analysis

The density of the visual rehabilitation workforce in different regions ranges from 1.62 per 100,000 to a low of 0.12 per 100,000 (Fig. 2). These results highlight how there is, in the Italian context, a high variation in the workforce to population ratios across regions within the country. In particular, the analysis underlines how health worker densities are highest in regions with more than one vision rehabilitation center and lowest in regional districts with only one vision rehabilitation center (see supplementary data).

Fig. 2

Public vision rehabilitation workforce to population density by region. The public sector vision rehabilitation workforce per 100.000 population across the regions (n = 20). The colors indicate different range of values of vision rehabilitation staff densities for the regions

Actually, in 2019 Lombardia, with 16% of Italy’s population and a total of 15 low vision rehabilitation centers, was home to 25 (31%, density: 0.25) ophthalmologists, 24 (27%, density: 0.24) orthoptists, 12 (23%, density: 0.12) psychologists, 10 (20%, density: 0.10) nurses and 6 (38%, density: 0.06) social workers, whilst Campania, with 10% of the population, had 3 (4%, density: 0.05) ophthalmologists, 2 (2%, density: 0.03) orthoptists, 1 (2%, density: 0.01) psychologist, 1 (2%, density: 0.01) nurse and 0 social workers. Moreover, Friuli Venezia Giulia, with 2% of Italy’s population and 2 vision rehabilitation centers, had 4 (5%: density: 0.32) ophthalmologists, 4 (4%, density: 0.32) orthoptists, 5 (9%, density: 0.40) psychologists, 5 (14%, density: 0.40) nurses and 2 (13%, density: 0.16) social workers (Table 1).

Table 1 Density of vision rehabilitation health workers (per 100.000 population) in Italy per national region in 2019

Coverage of health workers in vision rehabilitation

Every year a mean of 1,543.4 (SD: 2,259.2) patients had access to national vision rehabilitation centers. In addition, an average of 8,665.8 (SD: 11,537.1) healthcare services of vision rehabilitation were provided. The ratio between the whole number of vision rehabilitation workforce and visually impaired patients was 1:128. Specifically, the ratio between the number of patients who had access to a national low vision center and the number of vision rehabilitation workforce, between 2015 and 2019, was 1:398 for ophthalmologists and 1:483 for orthoptists. Particularly, a weak ratio was found for psychologists (1:706), nurses (1:863) and social workers (1:1,535). Moreover, when comparing the number of vision rehabilitation workforce with the number of visually impaired patients who had access to a low vision center, no relationship between variables (r² = 0.03, p < 0.05) was found. This finding demonstrated that the number of available human resources in vision rehabilitation centers is inadequate to the number of visually impaired people who accessed to the centers (Fig. 3).

Fig. 3

Scatter-plot graph indicating no correlation between the number of human resources involved in vision rehabilitation centers (dependent variable) and the number of visually impaired people who had access to low vision centers between 2005 and 2019

The lowest association was observed for nurses and it was particularly critical for psychologists, orthoptists and social workers (Fig. 4).

Fig. 4

Associations between vision rehabilitation workforce and both low vision centers and cases for Italian region

In addition, the data analysis showed that, among the available low vision centers activity indicators (centers, cases and health services), correlation coefficients imply statistically significant associations of the professionals involved in vision rehabilitation with healthcare services. All the professional workers seem to be associated to the number of healthcare services provided (ophthalmologists: r² = 0.27, p < 0.05; orthoptists: r² = 0.20, p < 0.05; psychologists r² = 0.3, p < 0.05; nurses (r² = 0.18, p < 0.05). In particular, social workers had the minor impact (r² = 0.04, p < 0.05).

Discussion

Here we report for the first time, to the best of our knowledge, the results of the analysis based on MoH reports on vision rehabilitation in Italy regarding: the geographical distribution and number of low vision centers; health professionals²; individuals accessing vision rehabilitation centers and healthcare services provided, over a 15-year period. The results of the study underline, coherently with the trend of the health workforce in Italy [19], that there is probably a general shortage of visual rehabilitation workers throughout the country. Although it was not possible to include and analyze data from the private rehabilitation sector, it is unlikely that the inclusion of much smaller numbers of health personnel would bridge the apparently large gap between the actual workforce densities in visual rehabilitation centers in the various regions and the minimum density of health personnel as recommended by the WHO. Moreover, of particular note, it is that the data analyzed indicate a high variation in the ratio of visual rehabilitation health workers/population between the regions of the country. As Italian MoH devolves the provision of healthcare for the visually impaired to these regions, this poor distribution is a major concern. Therefore, the first element notable is about densities of professional workers across Italian regions that seem to be significantly low in some areas, suggesting an unfavorable skewing in this setting.

The analysis also showed how more than half of human resources working in low vision centers in Italy are ophthalmologists and orthoptists (59%). Moreover, the study shows that, in Italy, the numbers of ophthalmologists and orthoptists per visually impaired individuals who had access to national vision rehabilitation centers were 1:398 and 1:483 respectively, between 2005 and 2019, which is considered to be below the standard set by the Italian Law. The study results highlight, also, a shortage of some specific categories of professional workers that are required by the Law, such as psychologists, nurses and social workers. At this regard it is necessary to highlight that, although some Authors reported that low vision condition produces a state of emotional uncertainty with a negative impact in everyday life, also generating depression and anxiety, less than 20% of all the human resources registered was represented by psychologists [20,21,22,23]. This observation is consistent with previous reports that adjustment disorders and depression are also pervasive among the visually impaired persons. Vision rehabilitation centers often do not offer psychological healthcare services as part of a comprehensive set of services on site [24,25,26]. This contrasts with vision rehabilitation models where the psychologist is a key member of the multidisciplinary team. Another relevant finding concerns nurses and social workers, who are even less represented. These professionals may play an important role in providing vision rehabilitation healthcare services and in promoting eye health, yet there is no evidence of the extent of their contribution to the vision rehabilitation agenda. Disparity in the distribution of the different low vision center operators, with a significant majority of ophthalmologists and orthoptists, might indicate an inadequacy of human resources dealing with vision rehabilitation in Italy. Bearing in mind the importance of a multidisciplinary rehabilitation approach, including psychologists, together with orthoptists and ophthalmologists, it is necessary to consider that visual rehabilitation encompasses a holistic method aimed at enhancing the quality of life and independence of individuals with visual impairments. This comprehensive strategy should encompass activities not only to improve visual function but also to address other essential aspects of daily life, such as Daily Living Skills Training (which includes cooking, grooming, direction-finding) and transportation and household management services to facilitate mobility of visually impairs. While not mandatory, according to Italian Law, the involvement of relevant rehabilitation professionals, such as physiotherapists, occupational therapists and orientation and mobility instructors should be recommended. Involving professionals with specific competences in rehabilitation can contribute significantly to areas like mobility enhancement, fall prevention, and functional capacity improvement. These aspects have been already investigated and reported by WHO within the “International Vision Rehabilitation Standards” [27]. As the life expectancy of populations increases and vision rehabilitation services are mainly related to the number of people in the older age group and the rise in chronic eye diseases, most countries should envisage for an increase in the number of people living with low vision. Importantly, in relation to results of WHO global estimates, low vision population is increasing, but from our findings, focused on the Italian context, there is not a significant growth in vision rehabilitation-workforce capacity [28]. The human resources in the regions that have a low number of low vision centers, such as Sardegna, is predicted to increase only very slightly, whilst the number of visually impaired is likely to remain high and even increase. To date, the workforce for vision rehabilitation centers seems to be not in line and it does not follow the growth trend of low vision condition. Moreover, our findings indicate a disparity in distribution of low vision centers with significant skewing favoring some regions. The densities seem to be not associated to territorial needs. This uneven distribution also highlights how the poverty level of an area, investigated on the basis of median household income, is also a barrier for high-income countries to accessing health care (http://dati.istat.it/Index.aspx?QueryId=22919#). Nevertheless, the data relating to the extremely low percentages of each professional category with respect to the total at national level remains impressive: 0.05% and 0.01% for psychologists, social workers and nurses, respectively. In the future, integrated low vision and rehabilitation services for the elderly will become increasingly more important. Optimizing the management of the health workforce is necessary for the progressive attainment of UHC [29,30,31,32].

According to regression analysis, the results indicate that the relationship between professional figures as ophthalmologists, orthoptists and psychologists were quite adequate to the density of low vision rehabilitation centers. On the other hand, it was not found a strong association with the number of subjects (cases) who had access to vision rehabilitation centers.

Then, our analysis based on Italy’s workforce for vision rehabilitation data system indicates that there is an overall shortage of professionals such as psychologists, nurses and social workers in the public sector nationwide and that there is an inadequate relationship between the number of low vision centers and the number of visually impaired people who could access them. Italy may face an array of different challenges relating to addressing its specific staff shortages and upgrading the training status of available professional workers. There is evidence that adequate numbers of health workers, which must be defined on the basis of epidemiological and demographic trends characteristic of the context, are associated with positive health outcomes [33]. A shortage of a workforce in low vision centers could contribute to missing the target for universal health coverage for basic rehabilitation [34,35,36]. It could be suggested that an analysis of the policy and governance and mechanisms for health workforce development and implementation is required, which could, in turn, guide the identification of the most relevant and appropriate levels of intervention to respond to needs. It is necessary to refine and increase the number of health staff in low vision services and create awareness amongst all medical, social and rehabilitation services, to ensure that low vision patients can receive adequate care. The shortage of professional health workers in vision rehabilitation centers could also constitute a barrier to accessing services [37, 38]. Increasing human resources in low vision rehabilitation could significantly improve the quality of care and living standards of patients [39]. Furthermore, a lack of professional workers is likely to have an adverse effect on the ability of the health system to provide equitable and accessible care. The disparity in the distribution of workers in low vision rehabilitation centers should be addressed as a matter of priority in order to achieve universal access to healthcare. For an optimally functioning health system, all vision rehabilitation health operators must be employed both adequately and appropriately, in accordance with the health needs of the population, new technologies and medical innovations, and the geographical distribution of the population. Our analysis suggests that decision makers of various countries should address the shortages and the disparity underlined within the study, as fundamental aspects to guarantee of the country’s economic and social well-being.

Our study, unfortunately, also highlights the difficulty of collecting human resources data in eye care sector. The major limitation of the study was the incompleteness and inaccuracy of the data, which made it difficult to get a reliable estimate of the quantities, densities and distribution of health eye care workers. An undefined number of health professionals were not specifically included in the MoH report for each year covered by the study. None of the databases provided accurate information on health workers in other sectors of the health system, such as the for-profit sector and non-governmental organizations. Considering ophthalmologists and orthoptists, we need to highlight the difficulty of collecting data at national level. This was due to the fact that professional ophthalmologists and orthoptists societies were unable to support data collection on practitioners in the active workforce. It may also be due to the fact that a percentage of ophthalmologists are not registered to the national society that is not always able to monitor professionals’ number to national level. Therefore, these data seem to be insufficient to understand the actual complete dynamics of this particular low vision rehabilitation workforce; more in-depth field studies may instead be needed in some cadres. Another relevant problem revealed is that data and distribution of eye care professionals was not centralized and easily available. It is troubling that it is difficult to access this type of data. Therefore, an accurate estimation of the total ophthalmologists and orthoptists density is not possible. Although the data span from 2005 to 2019, they are not adequate to calculate trends in human resources for eye care. Nevertheless, this study provides information on the current national status of human resources for vision rehabilitation, and it could act as a key element for improving the future supply of and demand for quality evidence and research on this important topic. Improving the availability and use of timely, comprehensive, and reliable data on the various health professions associated with Vision Rehabilitation is the first step toward evidence-based workforce development strategies in low vision rehabilitation. In addition, continued and improved efforts should be made to collect workforce data to enable monitoring of progress in addressing low vision rehabilitation human resource challenges. In fact, in order to more adequately define policy solutions to address the major challenges of appropriate labor market modeling to best meet current and future national needs, further specific studies will be required to investigate the trends and forces influencing education, training and employment of health care workers [40]. However, despite such considerations, in our opinion, this analysis represents the starting point for a critical review of political and management approaches, since it clearly illustrates the value of planning the development of efficient human resources and improved health information systems at a national level. Italy is a highly developed country hence there is an urgent need to establish a global information system on the healthcare workforce, which is updated in real-time thanks to adequate resources and that is accessible to all interested parties. Data on human resources should also be differentiated according to the various levels of low vision rehabilitation centers and disaggregated by the level of the healthcare facility [40, 41]. Human resources for low vision information systems are necessary for generating, managing, and disseminating knowledge of the national healthcare workforce, and providing a platform for decision-making for healthcare managers, local and national policy-makers, and global organizations [42, 43].

Conclusion

In conclusion, as recommended by WHO, one of the main goal to accelerate progress towards UHC is to optimize performance, quality and impact of the health workforce through evidence informed policies on human resources for health, contributing to healthy lives and well-being, effective universal health coverage, resilience and strengthened health systems at all level [38]. This will require greater and sustained investment from national authorities in order to identify appropriate tools that can be integrated into national information systems. In order to monitor trends in health workforce situation and performance, or for countries to share experiences and best practices, it is necessary to know how workers in vision rehabilitation are defined and classified in the original information source.