COVID-19 Rehabilitation in Vulnerable Populations

Introduction

COVID-19 poses a serious threat to all communities, but several vulnerable communities have been disproportionately affected and face greater challenges [1]. Before COVID-19, many people relied on rehabilitation services to improve function and quality of life. According to the World Health Organization Organization (WHO) rehabilitation is “a set of interventions aimed at reducing disability and optimizing functioning in individuals with health problems as they interact with their environment”[2] For some access to services has been influenced by resource socioeconomic Place. For others, recovery has been disrupted because many healthcare providers view rehabilitation as a non-essential service, although those who need access to services would not agree because recovery is essential to their day-to-day health and well-being [3]. where it has been recommended by the World Health Organization Rehabilitation services have been reduced, making it necessary to identify priority patients. Service user needs should be addressed by other means as much as possible, such as telehealth services, and policies in place to guide service reintegration as quickly as possible as much 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

Physical therapy and rehabilitation are important components of post-COVID-19 recovery as people transition from acute to post-acute after infection [3]. This has led to a reallocation of the workforce, with physical therapists being redeployed into areas such as emergency and critical care to cope with Have immediate respiratory symptoms in a patient with COVID. Where possible, some rehabilitation services have sought to adapt service delivery to limit face-to-face contact, which is not always possible for vulnerable populations whose access to technology may be limited by:[3]

• Availability of technology, including equipment and the Internet
• Inability to use technology effectively due to disabilities and cognitive deficits
• Not knowing how to use technology is especially important among older adults
• Locations of particular relevance to refugees and displaced persons

Another consideration when focusing on vulnerable communities is the stigma surrounding COVID-19. Many people, especially those in low- and middle-income countries, do not want to access services due to fear of reprisal and ostracism. [4]

People Living with Disabilities

People with disabilities face heightened health risks due to COVID-19—they may be more susceptible to contracting the virus and developing severe sequelae. [5] They also face challenges due to changing circumstances, including reduced services such as social support Rehabilitation or protective services. These changes further exacerbate the impact of COVID-19 on these individuals, leading to worse health outcomes, including permanent impairment and decreased function. Therefore, people with disabilities and their associated support organizations must Actively participate in COVID-19 planning to ensure their needs are considered. [5] Individuals with disabilities may be directly or indirectly affected and at higher risk of contracting or becoming seriously ill from COVID-19 due to [6]:

• Underlying medical conditions
• Barriers to implementing hand hygiene.
• Difficulty maintaining social distance.
• Need to touch things to get information from the environment or to get 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, health care workers, disability service providers, people with disabilities in the community and their families.

It is important to note that refugees/displaced persons with disabilities are at increased risk from COVID-19. An estimated 15% of the world’s population has a disability. However, these figures may be higher in areas of conflict or humanitarian crisis. for For example, it is estimated that 30% of the Syrian population aged 12 and over are disabled. [5]

People with Existing Conditions

Increased life expectancy of people with non-communicable diseases (NCDs) such as COPD, diabetes, cancer, HIV/AIDS due to advances in medical technology[7] is a factor in the decision Severity of complications and deaths from COVID-19. Because these individuals in this group are classified as vulnerable, extra care and strict protocols have been put in place. This has resulted in a reduction in the regular rehabilitation services needed to cope with the illness. the daily needs of their condition. [8] Fear of exposure to COVID-19 means that people with underlying health conditions are avoiding contact with others and local clinics and hospitals, which can lead to reduced functioning and increased risk of complications

Older People

Evidence suggests that older adults (age 60 and over), especially those with non-communicable diseases, are at increased risk of developing severe forms of the disease. [9][8] People over 60 years of age infected with COVID-19 have been found to have increased functional decline requiring rehabilitation [10] However, it is not only the symptoms of COVID-19 that affect older adults. Protocols introduced to protect them, such as social distancing and quarantine, can make them feel excluded and limit their social and physical interactions. this may cause inactivity and de-indications, which may affect their quality of life and their return to normal daily activities. As rehabilitation is diverted to other services and there is a lack of face-to-face interaction within this vulnerable population, opportunities will decrease, not only from health professionals But friends and family will support and help maintain their physical and mental health.

People Living in Low Resource Settings

Exercise and rehabilitation were already well supported in Middle-Income Countries (LMIC) before COVID-19 left people in even greater trouble. Rehabilitation professionals are underrepresented due to lack of professional education and funding.[3]

Rehabilitation needs in LMICs have been shown to be higher among women but they are negatively impacted by difficulties in accessing services.[11] and this could be an even bigger issue in the context of the COVID-19 pandemic where businesses are not only affected by COVID-19 but by travel restrictions and many voluntary organizations asking them to return home[3]. Another vulnerable group in LMICs is the older population who have to deal with additional social and environmental issues such as:

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

The relationship between mortality and health factors during the COVID-19 pandemic may raise concerns among LMICs due to[12]:

• If they cannot afford the high cost of diagnosis.
• ICU beds and personnel trained in critical care may be limited.
• Additional costs in intensive care units cannot be paid from limited health budgets.
• Supply chain disruptions and depleted stocks, such as medical supplies, equipment and PPE.
• Large numbers of IDPs and displaced refugees often suffer from comorbidities and live in large camps [13]

Refugees/Displaced People

• The United Nations High Commissioner for Refugees found that more than 70.8 million people were forcibly displaced globally in 2018, the highest number of people displaced on record. [14] 41.3 million of these people were internally displaced (i.e. 3.5 million are asylum seekers (i.e. have crossed an international border but are awaiting a decision to determine their refugee status) and 25.9 million are refugees (i.e. have fled their homeland but gained refugee status in another country). [14]
• Due to their past experiences, these individuals often present with a variety of complex health problems [14] and have a higher prevalence of comorbidities, including noncommunicable and communicable diseases. [15] However, they often face administrative financial legal and language barriers This affects their ability to access health care. [16] In Greece, for example, a recent study reported that some 62 percent of 80,000 undocumented immigrants living in overcrowded camps had unmet health needs. 53% have difficulty accessing healthcare due to barriers such as cost and length of time waiting list. [17]

In addition, refugees/displaced persons often live in camps or camp-like settings with poor living conditions. they are:

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

Consequently, it is more difficult to implement basic preventive measures such as socially distanced hand hygiene and self-isolation in these settings. [16] Therefore, these individuals may be more vulnerable to COVID-19. [15]

[18]

It is important to note that while these groups are more susceptible to COVID-19, there is evidence that they are at lower risk of transmitting infectious disease to host countries [16] because they are effectively isolated from the wider community . [19] Aid workers who visit camps are most likely to Vectors for spreading COVID-19 into camps. [19] The World Health Organization emphasizes the importance of communicating with communities that migrants and refugees are not at increased risk compared to other travellers, but they are more vulnerable and require additional support Especially in prevention and care services. [20]

Impact of COVID-19 on Refugees/Displaced Persons

There are three main reasons that COVID-19 is likely to have an even greater impact on refugees/IDPs:[15]

1. There is likely to be an increase in COVID-19 in camps/camp-like facilities due to large houses and overcrowding in camps as well as certain cultural/religious practices such as mass prayers, large weddings and funerals . . . .
2. Increased association of infection with infection and progression to severe disease due to COVID-19’s association with co-morbidities including non-communicable diseases and malnutrition and HIV.
3. In addition, intensive care units do not have these facilities which would increase mortality. Excessive pressure on health services may reduce access to other services thereby negatively affecting health outcomes related to other conditions.[21][15]

Addressing Rehabilitation Needs

In an effort to prevent the spread of COVID-19, many measures including border closures, social distancing and quarantine measures have been introduced to protect these vulnerable people. However this design takes a lot of resources and is shown not to be easily replicated in situations of low income/distress. This is because it is more difficult to introduce appropriate research and testing in these areas. It is therefore difficult to quantify local transmission of COVID-19.[15]

In order to reduce the spread of COVID-19 in the community, it has been found that most of the essential workers need to work from home. But this approach is not well suited for many low-income situations. Additionally it should be maintained indefinitely until vaccination or treatment (or both) . is available.[1]

Measures such as travel restrictions could be detrimental to export-dependent economies. This can quickly have an impact on the livelihoods of individuals, reducing the likelihood that communities will comply with control measures. Therefore, these strategies may work for a limited time and provide a window to prepare Response to COVID-19, but likely to fail in the long run. [1]

As noted previously, COVID-19 appears to have a more significant impact on individuals with certain comorbidities. Therefore, one measure to reduce the impact of this virus may be to maintain existing health services that focus on the testing and management of the noncommunicable diseases TB and HIV. Non-essential Services may also be postponed to free up healthcare delivery capacity. [1]

In low-income or camp-like settings, critical care services are unlikely to increase to the levels needed in a large-scale COVID-19 outbreak. Likewise, isolating COVID-19 patients in general wards may not be clinically beneficial or reduce viral transmission. No Adequate training and infection control supplies These types of facilities can put health workers at increased risk—important because workers are often scarce 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/Humanitarian Crisis Center for Health suggests that in these settings a more targeted approach may be chosen, focusing on “protection” High-risk groups [15] – it should be noted that This is not the only approach and may not be employed in all areas.

Shielding in the context of COVID-19 is essentially a reversal of the approach taken to the Ebola epidemic, in which the unwell were quarantined into contaminated “red zones” to protect the healthy . In COVID-19, a green zone has been created for high-risk groups. in this area These people are protected from the spread of COVID-19 and cared for if they need to isolate. [15]

While there is no one-size-fits-all approach, shielding aims to protect those most vulnerable from infection by helping them live safely but away from family and neighbors for an extended period of time until treatment or vaccination is available . [15] ]

Who Should Be Shielded?

The risk of COVID-19 appears to increase with age, especially those over the age of 70 and/or those with noncommunicable and other immunosuppressive diseases. It has been suggested that, in low-income/crisis-affected settings, the high-risk definition should be extended to Including:[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. Home-level shielding (one room/area in the house is zoned as a green zone).
2. Shielding at the street or extended family level (specific shelters/shelter groups within small camp areas – maximum 5-10 families)
3. Segregated community or section level (for example, in displaced persons/refugee camps – it is best in camps with a specific accommodation category in camp for individuals at risk size up to 50 with infection control/life distance) [15] .

Implementation of Shielding

Ideally, local communities should choose the options for protection (although this may not always be possible). Decisions to consider include:

• Determine which family members meet inclusion criteria for shielding
• Who should be moved to each green zone
• Which shelters should be vacated/swapped
• What supplies (e.g. beds and supplies) need to be moved[15]

Management of Green Zone Residents with Signs

It is important to have an alert system in place so that if/when an individual develops symptoms of COVID-19, he or she is promptly isolated (and tested where possible). The isolation measures will vary depending on the context.[15]

Health Service Provision

Where possible it is important that healthcare facilities are as close as possible to green spaces. This will reduce movement of individuals outside the green space. There are various ways of providing this service including the use of mobile hospitals.[1][15]

Rehabilitation Planning

Many people in the above mentioned groups have limited access to digital hence such as Telehealth and Social Media which they have used to share information and promote health and disease prevention putting them at greater risk . . . . The need to limit face-to-face contact and pursue association remote control has highlighted the importance of digital services. The next hurdle 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 everyone has equal opportunities and benefits.

Specific community-based rehabilitation for COVID-19 is discussed here. PPE shortages have been highlighted elsewhere in all settings [23] so it is important to ensure you are aware of local infection control requirements/standards. Standard infection control practices are discussed here. read More on COVID and f refugee mental health challenges. However, there are some considerations specific to working with refugees/displaced persons.

Healthcare for refugees and displaced persons often occurs in difficult sociopolitical 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 assessed individually and their rehabilitation needs considered.
  • In such cases, measures such as the International Classification of Functioning and Health (ICF) and the use of a biopsychosocial approach may be useful. [24][25]
• Management should be holistic and consider physical psychosocial and cultural aspects. [24] Some interventions, such as manual therapy, may not be appropriate for all cultures. [25] Likewise, some communities may be more collectivist in nature, so group interventions of people involved Family members may be more beneficial to some people. [25] However, it is important to note that all culture-based management plans and modifications should be considered on an individual basis to avoid cultural stereotypes. [25]
• Barriers including cultural differences, language and limited information available contributed to poor outcomes. [24] WHO recommends that refugees and migrants should be involved in developing preparedness/response plans/strategies, which may help address some of these issues. [20]
• When evaluating children, it is important to remember that they are at increased risk for a variety of physical behavioral and developmental health problems. Knowing each child’s immigration history will allow the medical team to conduct appropriate screening and Identify any other exposure risks (including trauma). [26]
• A lack of understanding by healthcare providers of the complexities of health issues faced by vulnerable populations can also lead to poor outcomes. [24] also documented differences in health outcomes among patients from different cultural/linguistic backgrounds. [25] It is therefore imperative that physiotherapists understand the particular needs of different groups in order to be able to provide appropriate care according to their individual needs as well as their social and cultural context. [27] This goes beyond the use of an interpreter; the physiotherapist needs to be familiar with Shared beliefs and practices held by the communities with whom they work. They must be able to recognize that there are always differences within and between cultures. Additionally, they must reflect on their own personal/professional culture and any associated biases.

Summary

• Vulnerable groups have different needs, but all benefit from rehabilitation services
• Lack of technology and digital skills lead to disparities in care and service delivery
• Refugees/displaced persons and those living in low-income areas will face additional significant challenges during the COVID-19 pandemic.
• Individuals may require different community responses to ensure their needs are met.
• Many people have long-standing serious health conditions that may increase their vulnerability to COVID-19 and associated changes/decreases in existing healthcare services.
• It is important that rehabilitation services are comprehensive and that all areas are considered.