Treatment Considerations in Disasters and Conflicts

Original Editors - Naomi O'Reilly

Top Contributors - Naomi O'Reilly, Kim Jackson, Jess Bell and Rucha Gadgil      

Introduction[edit | edit source]

Rehabilitation is “a set of measures that assist individuals who experience, or are likely to experience disability to achieve and maintain optimal functioning in interaction with their environments”, and when provided in a timely fashion can: result in better health outcomes; reduce hospital stays and the probability of long-term disability; prevent further loss of function; and can improve an individual’s ability to function within environment.[1][2][3] From the first world war to more recent disasters, such as the 2015 Nepal Earthquake and the 2020 explosion in Beirut, Lebanon, the importance of integrating rehabilitation into emergency responses in disasters and conflicts has become more clear. The World Health Organization emergency medical team standards and recommendations for rehabilitation, launched in 2016, signalled significant progress in recognising the role that rehabilitation professionals play and the necessity of early access to rehabilitation services.[4]

Rehabilitation professionals face unique challenges associated with complex trauma, injury surge and resource scarcity that many have never encountered before. Practical guidance to deliver quality rehabilitation in these contexts is essential if disaster and conflict response is to evolve beyond its life- and limb-saving mandate and deliver care that maximises patient outcomes. Rehabilitation professionals need to be equipped with the knowledge and skills to meet patient needs and navigate the demands of emergency medical response. In humanitarian emergency situations, such as during or post sudden onset disaster and conflict situations, the need for basic functional rehabilitation services is overwhelming and critical to preventing disability and improving the lives of people with disabilities.

Rehabilitation is now recognised as being an integral part of a patient’s recovery in disaster and conflict situations. Starting in acute care, access to rehabilitation has been shown to help prevent complications, speed up recovery, enable early discharge and help ensure continuity of care. Rehabilitation professionals working in rehabilitation need skills across a wide range of clinical areas, and in disasters and conflicts need to be able to manage challenges including large surges in patient numbers, limited equipment, and complex clinical presentations. They also need to be aware of the impact of these factors when considering treatment options and prioritisation of interventions used.[5]

As such, it is vital to see beyond specific treatment methods such as range of movement, or strength training , and consider the broader elements of treatment that should underpin all that we do. It must also be recognised that in disaster and conflict situations, the impact of trauma must be considered. The Trauma-Informed Care Model is a framework that involves understanding the impact of trauma on the individuals and their support structures. It incorporates ways to respond to the trauma by enhancing the physical, psychological and emotional safety of patients and their caregivers while providing them with opportunities to rebuild self-control and empowerment. Applying the principles of trauma-informed care to your treatment approach is about recognising the many ways in which a traumatic experience can impact all aspects of care, from communication to clinical reasoning.

The basic principles of trauma-informed care can be summarised as follows:

  1. Safety
  2. Trustworthiness and Transparency
  3. Peer Support
  4. Collaboration and Mutuality
  5. Empowerment, Voice and Choice
  6. Cultural, Historical, Gender and Disability Issues[6]

Education and Self-Management[edit | edit source]

Patient education has been defined as, "any set of planned activities designed to improve a patient's health behaviours, health status, or both."[7] These activities aim to facilitate the patient's knowledge base in order to help them make sense of their condition and guide them towards effective, ongoing self-management by developing skills such as problem solving, decision making, resource utilisation, action planning, self-tailoring, and self-monitoring, which all require a positive patient-rehabilitation professional partnership.

Self-management is a model of care in which patients are active participants in their own healthcare and are encouraged to use strategies and learn skills to manage their own health needs, and take responsibility for their own health care behaviours.[8] [9] The World Health Organization (WHO) define self- management as “the ability of individuals, families and communities to promote health, prevent disease, and maintain health to cope with illness and disability with or without the support of a health-care provider.”[1] Self-management, incorporating active involvement of the patient and their support networks in decisions about treatment and shared responsibility, has become a recognised aspect of all rehabilitation. It is a vital aspect of treatment in disaster and conflict settings given that patients often have reduced access to or time with rehabilitation professionals, and follow-up is often limited or delayed secondary to constrained health systems and damaged health and community infrastructure.[10][11][12]

Educating patients and caregivers on self-management is hugely important in disaster and conflict settings. Also important are: providing patients and caregivers with clear guidance on any restrictions and signs of complications; advice and exercises; explaining how to progress exercise; discussion what to do if they don’t make progress. This education can be even more important when patients are awaiting definitive management, as pre-operative education can make post-operative care much easier.

Promoting Independence[edit | edit source]

After a traumatic injury, people need rehabilitation assessment and interventions that take account of any pre-existing conditions and focus on helping them regain optimum function and independence as quickly as possible within the environment to which they will be discharged. A person’s ability to participate in everyday activities in their home and community environments may be significantly disrupted as a result of the disaster or conflict (i.e. damaged and destroyed infrastructure, poor access to essential services and crowded living conditions) or as a result of the specific injury, which may require them to change their routines or daily activities. These may have to be relearned or managed differently. Alternatively, the individual may require assistance from others for personal tasks such as showering, dressing and grooming, as well as domestic and community tasks. What is considered best practice may be different given the impact of the setting on the individual. Thus, you need to ensure you always consider not only a client's specific injuries, but the environment in which they have to live.

Psychological Support[edit | edit source]

During and following disasters and conflicts, many people experience strong emotional or physical reactions. For most, these reactions subside over a few days or weeks, but for some this may take significantly longer. People may be worried about practical issues, or require simple guidance on topics like talking with children about the disaster or conflict, or supporting friends and family members who have been affected. They tend to respond well to support, reassurance and problem solving.

Psychological first aid describes a humane, supportive response to a fellow human being who is suffering and who may need support.[13][14] It might be the first thing that you do with individuals or families following a disaster. Typically, it is most widely used in the first hours, days and weeks following an event. It is based on an understanding that people affected by disasters will experience a range of early reactions (physical, psychological, emotional), which are all normal reactions and understandable given people’s experiences. However, they have the potential to interfere with a person's ability to cope.[15] An important aim of psychological first aid is to build people’s capacity to recover by helping them to identify their immediate needs and their strengths and abilities to meet these needs.

Psychological first aid involves the following themes[13][14]:

  • Providing practical care and support, which does not intrude;
  • Assessing needs and concerns;
  • Helping people to address basic needs (for example, food and water, information);
  • Listening to people, but not pressuring them to talk;
  • Comforting people and helping them to feel calm;
  • Helping people connect to information, services and social supports;
  • Protecting people from further harm.

You can read more about Psychological First Aid in:

Psychosocial Support[edit | edit source]

Disasters and conflict put significant psychological and social stress on individuals, families and communities, and can impose significant stress and hardship. The term ‘psychosocial’ refers to the dynamic relationship between the psychological dimension of a person, including their internal, emotional and thought processes, feelings and reactions, and the social dimension of a person, which includes their relationships, family and community network, social values and cultural practices.

According to UNICEF, psychosocial well-being can be seen as the state of being or doing well of an individual in different aspects of life, including having supportive social relationships, access to basic survival needs and economic and environmental resources. Physical, intellectual, emotional and development needs will also be addressed.[18]

‘Psychosocial support’ then refers to the actions that address both the psychological and the social needs of individuals, families and communities, and helps them to deal with the situation in which they find themselves. It helps them to build resilience, and rebuild their life. It involves a range of care and support interventions offered by caregivers, family members, friends, teachers, rehabilitation workers, and community members on a daily basis, and may include the care and support offered by specialised psychological and social services where required.

The role of the psychosocial assessment in the medical interview should never be underestimated. A thorough psychosocial evaluation will provide a holistic view of the patient, as well as his/her condition and assist the clinician in devising an all-encompassing management plan. Also, proper focus on the psychosocial aspects of the patient enhances the therapeutic alliance and improves patient compliance as an active participant in the process of treatment and rehabilitation.

Peer Support[edit | edit source]

Peer support occurs when people share their personal knowledge, experience, emotional, social or practical help with each other. Peer support comes from people who have faced the same kind of experience, trauma or injury. Peer support offers an environment where a person can feel that they are being listened to as a person and not as a patient and can offer a different and unique perspective to the medics and rehabilitation professionals. Peers have that “lived experience”, so they can relate to the person in a way that only someone who has “been there and done that” can.

Peer support is commonly used in situations where a person has undergone a life-changing injury such as a spinal cord injury, traumatic brain injury or amputation and can take a number of forms including peer mentoring, reflective listening (reflecting content and/or feelings), or counselling. It can be provided face to face, individually or in a group based setting, and in some instances, it has also been provided through telehealth.[14] Peer support can be utilised not only for the person who has had the injury, but can also include peer support for family members and caregivers.

Summary[edit | edit source]

As a rehabilitation professional, you need to consider a wide range of factors when deciding which treatment to use in disaster and conflict situations. You need to be aware of the implications of the disaster and conflict on the health systems, access to health services, the patient and their support structures.

  • Ensure you establish an environment where the client feels safe, connected, valued, informed, empowered and hopeful of recovery.
  • Always apply the knowledge of trauma and paths to recovery to practices, policies and procedures.
  • Recognise the signs and symptoms of trauma in patients, caregivers, multi-disciplinary team members and others involved in the system.
  • Work purposefully with individuals, caregivers and other agencies to promote and protect the autonomy of the client.
  • Understand the concept of re-traumatisation and apply that knowledge to your services at the level of practices, policies and procedures.
  • Ensure you are aware of the environment in which you work and practice culturally competent and non-discriminatory policies, procedures and practices.

Resources[edit | edit source]

Early Rehabilitation in Conflicts and Disasters, Humanity and Inclusion

Rehabilitation in Sudden Onset Disasters, Humanity and Inclusion

IASC Guidelines on the Inclusion of Persons with Disabilities in Humanitarian Action, Inter-Agency Standing Committee

References [edit | edit source]

  1. 1.0 1.1 World Health Organization. World Report on Disability. 2011 Available from: https://www.who.int/teams/noncommunicable-diseases/sensory-functions-disability-and-rehabilitation/world-report-on-disability [Accessed: 03/03/2022]
  2. von Groote PM, Bickenbach JE, Gutenbrunner C. The World Report on Disability–implications, perspectives and opportunities for physical and rehabilitation medicine (PRM). Journal of Rehabilitation Medicine. 2011 Oct 1;43(10):869-75.
  3. Mousavi G, Ardalan A, Khankeh H, Kamali M, Ostadtaghizadeh A. Physical rehabilitation services in disasters and emergencies: A systematic review. Iranian Journal of Public Health. 2019 May;48(5):808.
  4. Lathia C, Skelton P, Clift Z. Early rehabilitation in conflicts and disasters. HI. Accessed from Humanity--Inclusion-Clinical-Handbook.
  5. WHO. Early rehabilitation in conflict and disasters
  6. Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration,2014.
  7. Louw, A, Puentedura, E. (2013). Therapeutic Neuroscience Education. Teaching patients about pain. A guide for clinicians. Minneapolis. Orthopedic Physical Therapy Products.
  8. Oliveira VC, Ferreira PH, Maher CG, Pinto RZ, Refshauge KM, Ferreira ML. Effectiveness of self‐management of low back pain: Systematic review with meta‐analysis. Arthritis care & research. 2012 Nov;64(11):1739-48.
  9. Harding V, Watson PJ. Increasing activity and improving function in chronic pain management. Physiotherapy. 2000 Dec 1;86(12):619-30.
  10. Mudge, S. et al, Who is in Control? Clinicians’ View on their Role in Self-management Approaches: A Qualitative Metasynthesis , BMJ Open, 2015
  11. Jones, F. Chapter 19: Self-management , in Stokes, M. &s Stack, E., Physical Management for Neurological Conditions, Churchill Livingstone, 2013.
  12. Lorig KR, Holman HR. Self-management education: history, definition, outcomes, and mechanisms. Annals of behavioral medicine. 2003 Aug 1;26(1):1-7.
  13. 13.0 13.1 International Federation of Red Cross and Red Crescent Societies (IFRC) 2009, Psychosocial Handbook, International Reference Centre for Psychosocial Support, Copenhagen, Denmark.
  14. 14.0 14.1 14.2 Inter-Agency Standing Committee (IASC), IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings, IASC (2007), Geneva, Switzerland.
  15. Brymer, M, Jacobs, A, Layne, C, Pynoos, R, Ruzek, J, Steinberg, A, Vernberg, E & Watson, P 2006, Psychological First Aid – Field Operations Guide, 2nd edn, National Child Traumatic Stress Network & National Center for PTSD, USA.
  16. Australian Psychological Society . The Recovery - Helping After Natural Disasters. Available from: https://youtu.be/a4uoGr1P_hQ[last accessed 10/03/22]
  17. svenskarodakorset. Psychological first aid - look, listen, link. Available from: https://youtu.be/kly45u9ml_A[last accessed 10/03/]
  18. UNICEF. Key Practice: Psychosocial Support. Available from: https://www.unicef.org/uganda/key-practice-psychosocial-support (Accessed 2 March 2022).
  19. British Red Cross. Understanding Psychosocial Support #PowerOfKindness Available from: https://youtu.be/h8PHvxVmC0I[last accessed 28/02/22]
  20. Hamanitarian Capacity Building..Psychosocial Support. Available from: https://youtu.be/_h0L6u68tbI[last accessed 28/02/22]