A path toward disability-inclusive health in Zimbabwe Part 2: A qualitative study on the national response to COVID-19.

Background: People with disabilities are at higher risk of adverse coronavirus disease 2019 (COVID-19) outcomes. Additionally, measures to mitigate COVID-19 transmission have impacted health service provision and access, which may particularly disadvantage people with disabilities. Objectives: To explore the perspectives and experiences of people with disabilities in accessing health services in Zimbabwe during the pandemic, to identify perceived challenges and facilitators to inclusive health and key actions to improve accessibility. Methods: We used in-depth interviews with 24 people with disabilities (identified through purposive sampling) and with 10 key informants (from expert recommendation) to explore the impact of COVID-19 on access to health care. Interviews were transcribed, coded and thematically analysed. We used the disability-inclusive health 'Missing Billion' framework to map and inform barriers to inclusive health care during COVID-19 and disparities in outcomes faced by people with disabilities. Results: People with disabilities demonstrated good awareness of COVID-19 mitigation strategies, but faced difficulties accessing COVID-19 information and health services. Challenges to the implementation of COVID-19 guidelines related to a person's functional impairment and financial ability to do so. A key supply-side constraint was the perceived de-prioritisation of rehabilitation services. Further restrictions on access to health services and rehabilitation decreased an individual's functional ability and exacerbated pre-existing conditions. Conclusion: The immediate health and financial impacts of the COVID-19 pandemic on people with disabilities in Zimbabwe were severe. Government departments should include people with disabilities in all communications and activities related to the pandemic through a twin-track approach, meaning inclusion in mainstream activities and targeting with specific interventions where necessary.

A path toward disability-inclusive health in Zimbabwe Part 1: A qualitative study on access to healthcare.

Background: On average, people with disabilities have greater healthcare needs, yet face a range of barriers in accessing care. Objectives: Our objectives were to explore the experiences of people with disabilities in accessing care and identify opportunities for the health system to be designed for inclusion in Zimbabwe. Methods: In-depth qualitative interviews were conducted between May and June 2021 with 24 people with disabilities (identified through purposive sampling) and with 10 key informants from local and national health authorities (identified through expert recommendations). Interviews explored the experience of accessing healthcare prior to the coronavirus disease 2019 (COVID-19) pandemic. Interviews were transcribed, coded and thematically analysed. We used the disability-inclusive health 'Missing Billion' framework to map and inform barriers to inclusive healthcare and disparities in outcomes faced by people with disabilities. Results: People with disabilities experienced difficulties accessing health services in Zimbabwe prior to COVID-19. These experiences were shaped by health literacy, self-stigma and affordability of services, which limited demand. Supply of health services was constrained by the perceived poor capacity of health workers to treat people with disabilities and discrimination. Inclusion was facilitated by clinic staff support of people with disabilities' access to medication through referral to mission hospitals and private clinics, and the lobbying of organisations of people with disabilities. Conclusion: Strategies to promote disability inclusion in healthcare include meaningfully engaging people with disabilities, investing in organisations of people with disabilities, protecting funding for disability inclusion, collecting and analysing disability-disaggregated data and strengthening a twin-track approach to health service provision.

Should disability-inclusive health be a priority in low-income countries? A case-study from Zimbabwe.

The National Disability Policy was launched in Zimbabwe in June 2021 and includes a range of commitments for the provision of disability-inclusive health services and rehabilitation. Fulfilment of these pledges is important, as at least 7% of the population have disabilities, and people with disabilities face greater challenges accessing healthcare services and experience worse health outcomes. However, it will require financial investment which is challenging as the needs of people with disabilities are set against a background of widespread health systems failures in Zimbabwe, exacerbated by the COVID-19 pandemic. Zimbabwe currently faces an epidemic of TB and HIV and a growing burden of non-communicable diseases (NCDs) with a lack of investment, healthcare staff or infrastructure to provide the necessary care. Urgent action is therefore needed to strengthen the health system and 'build back better' after both the pandemic and the regime change. The Zimbabwean government may face the dilemma, common in many low-resource settings, of whether to focus on disability or to wait until the health system has been strengthened for the majority. This paper proposed four complementary arguments why it is important to focus on people with disabilities. First, this focus respects the rights of people with disabilities, including those specified in the new National Disability Policy. Second, it will be challenging to reach the Sustainable Development Goals, including those on health and other global health targets, without including people with disabilities. Third, there is a growing rationale that disability-inclusive health systems will work better for all, and fourth, that they will create cost savings. Everyone will therefore benefit when the health systems are designed for inclusion. In conclusion, a focus on disability may help to strengthen health systems for all as well as helping to achieve human rights and global development goals.

Deaths involving COVID-19 by self-reported disability status during the first two waves of the COVID-19 pandemic in England: a retrospective, population-based cohort study.

BACKGROUND: People with learning disabilities are at substantially increased risk of COVID-19 mortality, but evidence on risks of COVID-19 mortality for disabled people more generally is limited. We aimed to use population-level data to estimate the association between self-reported disability and death involving COVID-19 during the first two waves of the COVID-19 pandemic in England. METHODS: We conducted a retrospective, population-based cohort study of adults aged 30-100 years living in private households or communal establishments in England, using data from the Office for National Statistics Public Health Data Asset. Participants were present at the 2011 Census and alive on Jan 24, 2020. Participants reported being limited a lot in their daily activities, limited a little, or not limited at all, in response to a question from the 2011 Census. The outcome was death involving COVID-19, occurring between Jan 24, 2020, and Feb 28, 2021. We used Cox proportional hazards regression to calculate hazard ratios (HRs) for the association between disability and death involving COVID-19, sequentially adjusting for age, residence type (private household, care home, or other communal establishment), geographical characteristics (local authority district and population density), sociodemographic characteristics (ethnicity, highest qualification, Index of Multiple Deprivation decile, household characteristics [National Statistics Socio-economic Classification of the household reference person, tenure of household, household size, family status, household composition, and key worker in household], key worker type, individual and household exposure to disease, and individual and household proximity to others), and health status (pre-existing health conditions, body-mass index, and number of admissions to hospital and days spent in hospital over the previous 3 years). FINDINGS: 29 293 845 adults were included in the study (13 806 623 [47%] men, 15 487 222 [53%] women), of whom 3 038 772 (10%) reported being limited a little and 2 011 576 (7%) reported being limited a lot. During follow-up, 105 213 people died from causes involving COVID-19 in England, 61 416 (58%) of whom were disabled. Age-adjusted analyses showed higher mortality involving COVID-19 among disabled people who were limited a lot (HR 3·05 [95% CI 2·98-3·11] for men; 3·48 [3·41-3·56] for women) and disabled people who were limited a little (HR 1·88 [1·84-1·92] for men; 2·03 [1·98-2·08] for women) than among non-disabled people. Adjustment for residence type, geography, sociodemographics, and health conditions reduced but did not eliminate the associations between disability and death involving COVID-19 (HR 1·35 [1·32-1·38] for men who were limited a lot; 1·21 [1·18-1·23] for men who were limited a little; 1·55 [1·51-1·59] for women who were limited a lot; and 1·28 [1·25-1·31] for women who were limited a little). INTERPRETATION: Given the association between disability and mortality involving COVID-19, verification of these findings and consideration of recommendations for protective measures are now required. FUNDING: None.

Risks of covid-19 hospital admission and death for people with learning disability: population based cohort study using the OpenSAFELY platform.

OBJECTIVE: To assess the association between learning disability and risk of hospital admission and death from covid-19 in England among adults and children. DESIGN: Population based cohort study on behalf of NHS England using the OpenSAFELY platform. SETTING: Patient level data were obtained for more than 17 million people registered with a general practice in England that uses TPP software. Electronic health records were linked with death data from the Office for National Statistics and hospital admission data from NHS Secondary Uses Service. PARTICIPANTS: Adults (aged 16-105 years) and children (<16 years) from two cohorts: wave 1 (registered with a TPP practice as of 1 March 2020 and followed until 31 August 2020); and wave 2 (registered 1 September 2020 and followed until 8 February 2021). The main exposure group consisted of people on a general practice learning disability register; a subgroup was defined as those having profound or severe learning disability. People with Down's syndrome and cerebral palsy were identified (whether or not they were on the learning disability register). MAIN OUTCOME MEASURE: Covid-19 related hospital admission and covid-19 related death. Non-covid-19 deaths were also explored. RESULTS: For wave 1, 14 312 023 adults aged ≥16 years were included, and 90 307 (0.63%) were on the learning disability register. Among adults on the register, 538 (0.6%) had a covid-19 related hospital admission; there were 222 (0.25%) covid-19 related deaths and 602 (0.7%) non-covid deaths. Among adults not on the register, 29 781 (0.2%) had a covid-19 related hospital admission; there were 13 737 (0.1%) covid-19 related deaths and 69 837 (0.5%) non-covid deaths. Wave 1 hazard ratios for adults on the learning disability register (adjusted for age, sex, ethnicity, and geographical location) were 5.3 (95% confidence interval 4.9 to 5.8) for covid-19 related hospital admission and 8.2 (7.2 to 9.4) for covid-19 related death. Wave 2 produced similar estimates. Associations were stronger among those classified as having severe to profound learning disability, and among those in residential care. For both waves, Down's syndrome and cerebral palsy were associated with increased hazards for both events; Down's syndrome to a greater extent. Hazard ratios for non-covid deaths followed similar patterns with weaker associations. Similar patterns of increased relative risk were seen for children, but covid-19 related deaths and hospital admissions were rare, reflecting low event rates among children. CONCLUSIONS: People with learning disability have markedly increased risks of hospital admission and death from covid-19, over and above the risks observed for non-covid causes of death. Prompt access to covid-19 testing and healthcare is warranted for this vulnerable group, and prioritisation for covid-19 vaccination and other targeted preventive measures should be considered.

The promise and pitfalls of social science research in an emergency: lessons from studying the Zika epidemic in Brazil, 2015-2016.

Social science generates evidence necessary to control epidemics. It can help to craft appropriate public health responses, develop solutions to the epidemic impacts and improve understanding of why the epidemic occurred. Yet, there are practical constraints in undertaking this international research in a way that produces quality, ethical and appropriate data, and that values all voices and experiences, especially those of local researchers and research participants. In this paper, we reflected on the experience of undertaking social science research during the 2015/2016 Zika epidemic in Brazil. This experience was considered from the perspective of this paper's authors: three Brazilian academics, two UK academics and two mothers of children affected by congenital Zika syndrome. This group came together through the conduct of the Social and Economic Impact of Zika study, a mixed-methods social science study. The key findings highlight practical issues in the achievement of three goals: the conduct of high-quality social science in emergencies and efforts towards the decolonisation of global health in terms of levelling the power between Brazilian and UK researchers and optimising the role of patients within research. From our perspective, the information collected through social science was valuable, providing detailed insight into the programmatic needs of mothers and their affected children (eg, economic and social support and mental health services). Social science was considered a low priority within the Zika epidemic despite its potential importance. There were logistical challenges in conducting social science research, foremost of which are the difficulties in developing a trusting and balanced power relationship between the UK and Brazilian researchers in a short time frame. When these issues were overcome, each partner brought unique qualities, making the research stronger. The mothers of affected children expressed dissatisfaction with research, as they were involved in many studies which were not coordinated, and from which they did not see a benefit. In conclusion, the importance of social science in epidemics must continue to be promoted by funders. Funders can also set in place mechanisms to help equalise the power dynamics between foreign and local researchers, researchers and participants, both to promote justice and to create best quality data.

Disability among Older People: Analysis of Data from Disability Surveys in Six Low- and Middle-Income Countries.

This analysis of surveys from six low- and middle-income countries (LMICs) aimed to (i) estimate the prevalence of disability among older adults and (ii) compare experiences and participation in key life areas among older people with and without disabilities which may show vulnerability during the COVID-19 pandemic. Data were analysed from district-level or national surveys in Cameroon, Guatemala, Haiti, India, Nepal and the Maldives, which across the six databases totalled 3499 participants aged 60 years and above including 691 people with disabilities. Disability was common among adults 60+, ranging from 9.7% (8.0-11.8) in Nepal to 39.2% in India (95% CI 34.1-44.5%). Mobility was the most commonly reported functional difficulty. In each setting, older people with disabilities were significantly less likely to be working and reported greater participation restrictions and environmental barriers in key life areas compared to people in the same age categories without disabilities (p < 0.05). Disability is common in this population, and older people with disabilities may have greater difficulties participating in COVID-19 responses and have high economic vulnerabilities. It is imperative to prioritise the needs of older people with disabilities in the COVID-19 pandemic, including ensuring accessibility of both health services and the community in general.

Shifting the focus to functioning: essential for achieving Sustainable Development Goal 3, inclusive Universal Health Coverage and supporting COVID-19 survivors.

If Sustainable Developmental Goal 3 and Universal Health Coverage are to be achieved, functioning is a third health indicator which must be assessed and integrated into global health population-based metrics alongside mortality and morbidity. In this paper, we define functioning according to the International Classification of Functioning, Disability and Health (ICF) and present why functioning is important to measure, especially when considering the need for, and outcome of, rehabilitation and assistive technology. We discuss examples of tools that measure components of functioning through clinical assessment and self-report methodologies, and present the development of a comprehensive population level tool which aligns with the ICF and combines self-report and clinical measurement methods to measure functioning and the need for rehabilitation and AT. Throughout the paper a survivor of Coronavirus 2019 (COVID-19) is given as an example to illustrate functioning according to the ICF and how access to the interventions of rehabilitation and assistive technology might be of benefit to improve and optimise his/her functioning. We argue that the Global Health community must take action and ensure that the measurement of functioning is well established, accepted and integrated as the third health indicator following the COVID-19 pandemic.

Prevalence of depression, anxiety and post-traumatic stress disorder in health care workers during the COVID-19 pandemic: A systematic review and meta-analysis.

OBJECTIVE: The COVID-19 pandemic has placed health care workers under psychological stress. Previous reviews show a high prevalence of mental disorders among health care workers, but these need updating and inclusion of studies written in Chinese. The aim of this systematic review and meta-analysis was to provide updated prevalence estimates for depression, anxiety and post-traumatic stress disorder (PTSD) among health care workers during the COVID-19 pandemic, benefitting from the inclusion of studies published in Chinese. METHODS: Systematic search of EMBASE, MEDLINE, PsycINFO, Global Health, Web of Science, CINAHL, Google Scholar and the Chinese databases SinoMed, WanfangMed, CNKI and CQVIP, for studies conducted between December 2019 and August 2020 on the prevalence of depression, anxiety and PTSD in health care workers during the COVID-19 pandemic. Studies published in both English and Chinese were included. RESULTS: Data on the prevalence of moderate depression, anxiety and PTSD was pooled across 65 studies involving 97,333 health care workers across 21 countries. The pooled prevalence of depression was 21.7% (95% CI, 18.3%-25.2%), of anxiety 22.1% (95% CI, 18.2%-26.3%), and of PTSD 21.5% (95% CI, 10.5%-34.9%). Prevalence estimates are also provided for a mild classification of each disorder. Pooled prevalence estimates of depression and anxiety were highest in studies conducted in the Middle-East (34.6%; 28.9%). Subgroup and meta-regression analyses were conducted across covariates, including sampling method and outcome measure. CONCLUSIONS: This systematic review and meta-analysis has identified a high prevalence of moderate depression, anxiety and PTSD among health care workers during the COVID-19 pandemic. Appropriate support is urgently needed. The response would benefit from additional research on which interventions are effective at mitigating these risks.

Disability-inclusive responses to COVID-19: Lessons learnt from research on social protection in low- and middle-income countries.

The one billion people living with disabilities globally already face a heightened risk of poverty, which will likely be exacerbated by the COVID-19 pandemic unless interventions to address its economic impacts are disability-inclusive. This paper draws on the literature on disability, poverty and social protection in low- and middle-income countries to explore the pathways through which the current pandemic may increase the risk of poverty amongst people with disabilities, such as loss of income from disruptions to work, particularly in the informal sector, and higher future spending and productivity losses from disruptions to healthcare and other key services (e.g. rehabilitation, assistive devices). It also explores how social protection and other initiatives to mitigate the economic impacts of the pandemic should consider the needs of people with disabilities, with recommendations for disability-inclusive actions in the design and implementation of eligibility criteria and application procedures, as well as the delivery and content of benefits. Across recommendations, meaningful consultations with people with disabilities, leadership at the program and policy level, appropriate budgeting and monitoring of progress through routine collection of data on disability are key for improving access to and impact of economic responses amongst people with disabilities.

Disability-inclusive COVID-19 response: What it is, why it is important and what we can learn from the United Kingdom's response.

All too often, disabled people are left behind in emergencies, and this is a risk in the ongoing COVID-19 pandemic. This is an important issue, as globally there are approximately one billion people with disabilities. This number includes one in three people aged over 60, who are the group at greatest risk from COVID-19. The COVID-19 pandemic in the UK has highlighted additional difficulties that disabled people may face. Complying with preventative measures, like social distancing, can be challenging, particular for people who rely on carers. Disabled people may also be at greater risk of morbidity and mortality if they contract the virus, yet in danger of being de-prioritised for care. Many people with disabilities have ongoing healthcare needs, and these need to still be supported during the pandemic. Furthermore, people may become newly disabled as a result of the pandemic, and therefore require appropriate care. Good practice examples have emerged for meeting these challenges, such as guidance for healthcare professionals on treating people with dementia, but these need to be scaled up further and adapted for other settings. In conclusion, it is clear that a disability-inclusive COVID-19 response is needed, both in the UK and as the pandemic unfolds globally. This response will require inclusion of disability measures within data collection, consulting with disabled people, and tailoring responses to be appropriate for this group.