COVID-19 Rehabilitation in Vulnerable Populations

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Original Editor - Jess Bell Top Contributors - Jess Bell, Kim Jackson, Tarina van der Stockt and Lucinda hampton

Introduction

COVID-19 poses a severe threat to all communities, but there are several vulnerable communities that are particularly affected and face even greater challenges[1]. Prior to COVID-19 many people relied on rehabilitation services to improve function and quality of life. According to the World Health Organisation (WHO) rehabilitation is 'a set of interventions designed to reduce disability and optimize function in individuals with health conditions in interaction with their environment’[2] For some access to services was already limited by resources, socio-economic factors and location. For others rehabilitation has been disrupted as rehabilitation is seen as a non-essential service by many healthcare providers, although people who need access would not agree as rehabilitation is essential to their daily health and well-being[3]. It has been recommended by the WHO where there has been a reduction in rehabilitation services it is necessary to identify patients who are a priority for services. The needs of service users should, where possible, be addressed by other means, such as Telehealth Services, with policies in place to direct the reintegration of services as soon as possible.[2] Vulnerable groups affected include:

  • People living with disabilities
  • People with existing conditions
  • Older People
  • People living in Low Resource settings
  • Refugees/displaced people

Physiotherapy and rehabilitation is a vital component of recovery post COVID-19 as people transition from the acute to post-actue phase after infection[3]. This has resulted in a redistribution of the workforce, with physiotherapist being redeployed to areas such as acute and critical care to deal with the immediate respiratory symptoms of COVID patients. Where possible some rehabilitation services have managed to adapt service delivery to limit face to face contact, this is not always possible for vulnerable people as their access to technology may be limited by such factors as:[3]

  • Availability of technology, including devices and the internet
  • Inability to use technology efficiently due to disability and cognitive deficits
  • Unaware of how to use technology, especially important to consider in the older population
  • Location particularly relevant to refugees and displaced persons

The other consideration when looking at vulnerable communities is the stigma that surrounds COVID-19. Many people do not want to access services, especially those in LMICs for fear of reprisal and ostracisation.[4]

People Living with Disabilities

People with disabilities will face higher health risks as a result of COVID-19 - they may be more susceptible to getting the virus and having significant sequelae.[5] They also face various challenges due to changes in their environment, including reductions in services, such as social support, rehabilitation or protection service. These changes further exacerbate the impact of COVID-19 on these individuals, leading to poorer health outcomes, including permanent impairments and reduced function. Thus, it is essential that both people with disabilities and their relevant support organisations are actively involved in COVID-19 planning to ensure that their needs are considered.[5] People with disability may be impacted both directly and indirectly and have a higher risk of infection or severe illness COVID-19 because of[6]:

  • Underlying medical conditions
  • Barriers to implementing hand hygiene.
  • Difficulty in enacting social distancing.
  • The need to touch things to obtain information from the environment or for physical support.
  • Barriers to accessing public health information.
  • Barriers to accessing healthcare.

This WHO document, Disability considerations during the COVID-19 outbreak, outlines actions for authorities, healthcare workers, disability service providers, the community, people with disability and their household.

It is important to note that COVID-19 presents even greater risks for refugees/displaced people living with disabilities. It is estimated that 15% of the world’s population have disabilities. However, these figures may be higher in areas where there is a conflict or humanitarian crises. For instance, it is estimated that 30% of the population aged 12 and above in Syria are people with disabilities.[5]

People with Existing Conditions

With advances in medical technology there are has been an increase in life expectancy of people living with non-communicable diseases (NCDs) such as COPD, Diabetes, cancer, HIV/AIDs[7] The existence of an underlying condition and weakened immune system has been shown to be a factor in determining the severity of complications and death from COVID-19. Because of this, people in this group have been classified as vulnerable and therefore extra care and strict protocols have been put in place. This has resulted in a reduction of regular rehabilitation services which are needed to cope with the daily demands of their condition.[8] The fear of exposure to COVID-19 has meant that people with underlying health issues are avoiding contact with others and also their attendance at local clinics and hospitals which may lead of functional decline and increased risk of complications

Older People

Evidence suggests that older people (those of 60 years and older), and in particular those living with NCDs, have an increased risk of developing a severe form of the disease.[9][8] Individuals over 60 who contract COVID-19 have been found to have increased functional decline and need rehabilitation on discharge from acute care.[10]But it is not only the symptoms of COVID-19 that can impact older people. The protocols introduced to protect them such as social distancing and isolation may make them feel excluded and also limit their social and physical interactions. This may lead to inactivity and deconditioning which may influence their quality of life and their return to normal every day activities. With rehabilitation being redirected to other services and the lack of face to face interactions within this vulnerable group there will be less access, not only from health professionals but friends and family, to support and assist in maintaining their physical and mental wellbeing.

People Living in Low Resource Settings

Physiotherapy and rehabilitation services were already poorly supported in Low Middle Income Countries (LMIC) before COVID-19 leaving people at an even greater disadvantage. Rehabilitation professionals are under-represented due to a shortage of professional education and funding.[3]

It has been established that rehabilitation needs in LMICs are much higher in women but the difficulties experienced in accessing services impacts them negatively.[11] and this may be even more of an issue during the COVID-19 pandemic where services have been affected not only by COVID-19 but also by travel restrictions and many volunteer organisations being told to return home[3]. Another vulnerable group in LMICs are older people, who have to deal with additional social and environmental factors such as:

  • poverty
  • poor transportation
  • difficult terrains
  • poor sanitation
  • shifting geo-political dynamics

The link between mortality and health care resources in the COVID-19 pandemic may cause concerns for LMICs due to[12]:

  • Inability to afford large-scale diagnostics.
  • ICU beds and personnel trained in critical care may be limited.
  • Inability to fund the additional cost of critical care units from limited health budgets.
  • Disruption of supply chains and depletion of stock, such as medical supplies, equipment and PPE.
  • High numbers of internally displaced people and displace refugees who often have co-morbidities and reside in large-scale camps[13]

Refugees/Displaced People

  • The United Nations High Commission for Refugees found that in 2018, over 70.8 million people worldwide were forcibly displaced, which is the highest figure of population displacement ever recorded.[14] 41.3 million of these individuals were internally displaced people (ie they remain within their country’s borders), 3.5 million were asylum seekers (ie have crossed international borders but are awaiting decisions to determine their refugee status) and 25.9 million were refugees (ie have fled their home, but been granted refugee status in another country).[14]
  • Because of their past experiences, these individuals often present with various complex health issues[14] and have a greater prevalence of comorbidities, including both non-communicable and communicable diseases.[15] However, they generally face administrative, financial, legal and language barriers which impact on their ability to access health services.[16] For example, in Greece a recent study reports that around 62% of the 80,000 undocumented migrants living in over-crowded camps have unmet health needs. 53% had major difficulty accessing health services due to barriers such as cost and long waiting lists.[17]

Moreover, refugees/displaced people are often living in camps or camp-like settings where living conditions are inadequate. They are:

  • Often overcrowded
  • Lack of basic amenities, including clean running water and soap
  • Have insufficient access to healthcare professionals and poor access to health information.[14] For instance, in Greece, there is only one public physiotherapist available for every 12,852 people and many people report that they queue for hours to access medical services at both public and NGO clinics, only to be turned away unseen at the end of the day.[17]

Thus, basic prevention measures like social distancing, hand hygiene and self-isolation are more difficult to implement in these settings.[16] These individuals may, therefore, be more heavily impacted by COVID-19.[15]

[18]

It is important to note that while these groups are more vulnerable to COVID-19, evidence suggests that they have a low risk of transmitting communicable diseases to host countries[16] as they are effectively isolated from the wider community.[19] Aid workers who visit the camps are the most likely vectors for transmission of COVID-19 into camps.[19] The World Health Organisation highlights the importance of communicating to communities that migrants and refugees do not pose an increased risk in comparison to other travellers, but they are more vulnerable and need additional support, particularly in relation to preventive and care services.[20]

Impact of COVID-19 on Refugees/Displaced People

There are three key reasons why COVID-19 will likely have an even greater impact on refugees/displaced people:[15]

  1. There will likely be a higher transmission of COVID-19 in camps/camp-like settings due to larger household sizes and overcrowding in camps, as well as certain cultural/religious practices such as mass prayer gatherings, large weddings and funerals.
  2. There will be higher infection-to-case ratios and progression to severe disease due to COVID-19’s interaction with comorbidities, including non-communicable diseases, under-nutrition, tuberculosis and HIV.
  3. There is also a lack of intensive care capacity in these settings, which will lead to higher fatality rates. The extreme pressure on health services can reduce access to other services, thus adversely affecting health outcomes related to other conditions.[21][15]

Addressing Rehabilitation Needs

In an attempt to prevent COVID-19 from spreading, many measures including border closures, social distancing and quarantine measures have been introduced to protect these vulnerable populations. These measures are, however, resource-intensive, and it is argued that they are not easily replicated in lower-income/crisis settings. This is because it is more difficult to introduce adequate surveillance and testing in these areas. Thus, it is harder to determine levels of community transmission of COVID-19.[15]

In order to reduce the transmission of COVID-19 in the community, it has been found that most non-essential workers need to work from home. However, this strategy is not well suited to many low-income settings. Moreover, it needs to be sustained long term until either vaccination or treatment (or both) is available.[1]

Measures such as travel restrictions can be harmful to export-dependent economies. This quickly has an impact on individuals’ livelihoods, which reduces the likelihood a community will adhere to control measures. Thus, these strategies may work for a limited time and provide a window to prepare a response to COVID-19 but may fail long term.[1]

As mentioned, COVID-19 appears to have a more significant impact on individuals with certain comorbidities. Thus, one measure to reduce the impact of this virus could be to maintain existing health services that focus on non-communicable disease, TB and HIV detection and management. Non-essential services can also be postponed to free up health service capacity.[1]

It is unlikely in low-income or camp-like settings that intensive care services can be increased to the levels required if there is a large outbreak of COVID-19. Similarly, isolating patients with COVID-19 in general wards may not be clinically beneficial or reduce transmission of the virus. Without adequate training and infection control supplies, these sorts of facilities could generate increased risk for health workers - this is significant as there is often a scarcity of workers in low income and crisis settings.[15]

[22]

Shielding

Because of these issues, a report by Favas[15] for the London School of Hygiene and Tropical Medicine/Health in Humanitarian Crisis Centre have suggested that a more targeted approach focused on “shielding” high-risk individuals may be an option in these settings[15] - it should be noted that this is not the only approach and may not be adopted in all areas.

Shielding in the context of COVID-19 is, essentially, a reversal of the approach taken in Ebola epidemics where unwell individuals are isolated into contaminated ‘red zones’, so that healthy individuals are protected. In COVID-19, a green zone is created for at-risk individuals. In this zone, these individuals can be shielded from the transmission of COVID-19 and cared for if they need to isolate.[15]

While there is no one approach that will fit all settings, shielding aims to protect those who are most vulnerable from infection by helping them to live safely, but away from their families and neighbours for an extended period of time, until treatment or vaccinations are available.[15]

Who Should Be Shielded?

The risk from COVID-19 appears to increase with age, particularly those aged over 70 and/or those who have non-communicable diseases and other immuno-suppressing conditions. It has been suggested that in low-income/crisis-affected settings, the high-risk definition should be extended to include:[1][15]

  • Individuals aged 60 and above
  • Individuals  living with TB or HIV
  • Malnourished adults

Types of Shielding

There are three main shielding options

  1. Household-level shielding (where a room/area in a house is demarcated as a green zone).
  2. Street or extended family level shielding (a specific shelter/group of shelters within a small camp area - for a maximum of 5-10 households)
  3. Neighbourhood or sector level isolation (eg in displaced persons’/refugee camps - ideally located at the periphery of camps, comprising of a specific group of shelters in a camp for up to 50 high-risk individuals, with infection control/social distancing)[1][15]

Implementation of Shielding

Ideally, the selection of shielding measures should be community-led (although this may not always be possible). Decisions to consider include:

  • Deciding which household members meet the inclusion criteria for shielding
  • Who should be moved to each green zone
  • Which shelters should be vacated/swapped
  • What provisions (such as beds and supplies) need to be transferred[15]

Managing Symptomatic Residents of the Green Zone

It is essential that there is an alert system, so that if/when an individual develops symptoms of COVID-19, s/he will be immediately isolated (and tested where possible). Isolation measures will vary depending on the context.[15]

Health Service Provision

Where possible, it is important that health services are as close as possible to the green zones. This will reduce the amount of movement of individuals outside of the green zone. There are various options to provide these services, including the use of mobile clinics.[1][15]

Rehabilitation Planning

Many people in the groups discussed above have limited access to digital services so such as Telehealth and Social Media, which has been used to share information and promote health and disease prevention, which puts them at a huge disadvantage. The need to limit face to face contact and follow social distancing has brought to the fore the importance of digital services. The next barrier to overcome is making this universally available and acceptable to all age groups regardless of location. This will also require a period of education so that equally opportunity and value is experienced by all.

Specific community rehabilitation for COVID-19 is discussed here. Shortages of PPE have been highlighted elsewhere in all settings,[23] so it is important to ensure that you are aware of local requirements/standards for infection control. Standard infection control practices are discussed here. Read more about the mental health challenges in COVID and f refugees here. However, there are some considerations, which are specific to working with refugees/displaced people.

Healthcare for refugees and displaced people often takes place in difficult social, political, and economic contexts and no universal rehabilitation model exists to meet their needs. However, certain key points should be considered when planning rehabilitation services:[24]

  • Each individual should be individually evaluated and their rehabilitation needs should be considered.
  • Management should be holistic and consider physical, psychological, social and cultural dimensions.[24] Some interventions, such as manual therapy, may not be appropriate for all cultures.[25] Similarly, some communities may be more collectivist in nature, so group interventions of those that engage family members may be more beneficial for some individuals.[25] However, it is important to note that all management plans and modifications based on culture should be considered an individual basis to avoid cultural stereotyping.[25]
  • Barriers, including cultural differences, language and limited information available contribute to poor outcomes.[24] WHO advises that refugees and migrants should be involved in the creation of readiness/response plans/strategies, which may help to address some of these issues.[20]
  • When assessing children, it is important to remember that they are at increased risk of various physical, behavioural and developmental health issues. Understanding each child's immigration history will enable the healthcare team to carry out appropriate screening for infectious diseases and determine any other exposure risks (including trauma).[26]
  • A lack of understanding of the complexities of health issues faced by vulnerable people on the part of the health provider will also contribute to poor outcomes.[24] Disparities in health outcomes for patients from different cultural/linguistic backgrounds have also been documented.[25] Physiotherapists must, therefore, have an understanding of the special needs of different groups to be able to provide appropriate care based on their individual needs and, social and cultural backgrounds.[27] This goes beyond the use of an interpreter; physiotherapists need to be familiar with the common beliefs and practices held by the communities they work with. They must be able to recognise that there is always intra- and inter-cultural variation. Moreover, they must reflect on their own personal/professional culture and any associated biases.

Summary

  • Vulnerable people have differing needs but all will benefit from rehabilitation services
  • Lack of technology and digital skills lead to a disparity of care and service provision
  • Refugees/displaced people and those living in low-income areas will face significant additional challenges during the COVID-19 pandemic.
  • Individuals may require a different community response to ensure it meets their needs.
  • Many people are living with significant long-term, pre-existing health conditions which may increase their vulnerability to COVID-19 and the related alterations/reductions in existing healthcare services.
  • It is important that rehabilitation services are holistic and all domains are considered.

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Dahab M, van Zandvoort K, Flasche S, Warsame A, Spiegel PB, Waldman RJ et al. COVID-19 control in low-income settings and displaced populations: what can realistically be done? London: London School of Hygiene and Tropical Medicine. 2020. Available from https://www.lshtm.ac.uk/newsevents/news/2020/covid-19-control-low-income-settings-and-displaced-populations-what-can
  2. 2.0 2.1 World Health Organization 2017. Rehabilitation in health systems. Geneva, Swtizerland: WHO. [last accessed 10 December 2020]
  3. 3.0 3.1 3.2 3.3 3.4 World Physiotherapy. World Physiotherapy Response to COVID-19 (Briefing Paper 5). The Impact of COVID-19 on Fragile Health Systems and Vulnerable Communities, And the Role of Physiotherapists in theDelivery of Rehabilitation [Last accessed 10 December 2020]
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  10. World Health Organization 2020. Clinical management of COVID-19. Interim guidance 27 May 2020. Geneva, Switzerland: WHO.
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  12. Hopman J, Allegranzi B, Mehtar S. Managing COVID-19 in Low-and Middle-Income Countries. JAMA. 2020 Mar 16.
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  21. Lau LS, Samari G, Moresky RT, Casey SE, Kachur SP, Roberts LF et al. COVID-19 in humanitarian settings and lessons learned from past epidemics. Nat Med 26, 647–648 (2020). 
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