Disability and COVID-19
Several organisations have already published guidelines for eye health services during this pandemic. However, most of them neglect the needs of people with disabilities, including people who are blind or partially sighted.
People with disabilities are at greater risk of having difficulties when performing essential hygiene measures (for example, accessing water pumps for handwashing), following recommendations for physical distancing, and/or accessing health information material.1 This increases the risk that people with visual impairment and other disabilities may contract SARS-CoV-2.2 Here are a few practical recommendations for eye health professionals.
Involve people with disabilities in decision making
Reach out to local organisations of persons with disabilities (OPD), also known as disabled people’s organisations (DPOs), and involve their representatives in adapting eye health services for people with diﬀerent types of impairments during the pandemic. If these organisations do not exist, there are very helpful web-based resources available, for example from the International Disability Alliance webpage (International Disability Alliance).3
Make communication accessible
Make any mass media communication as accessible as possible by using captioning, sign language translation, high contrast, Braille, and so on.3 Short and simple toolkits to improve the accessibility of documents for people with low vision are readily available, for example from the webpage of the World Blind Union.4 It is also important to secure a budget for more costly resources, such as sign language translation. The use of face masks, and recommendations to talk as little as possible during slit lamp examinations, significantly reduce verbal and non-verbal communication. It is important to explain the need for these adaptations to patients ahead of an examination.
Face masks might intimidate older patients as well as individuals with hearing, cognitive or psychosocial impairments, and conveying medical information in an encouraging manner is more difficult if patients cannot rely on non-verbal information sources such as facial expression. This can aggravate the general fear and anxiety caused by the pandemic. Be very patient, take additional eﬀorts to repeat information as needed, and try to use transparent masks, if available.
A helpful “ABC mnemonic” was recently published to improve non-verbal communication when wearing facemasks, especially during communication with older patients or those with cognitive impairments: “Attend mindfully – Behave calmly – Communicate clearly.”5 Use plain language and clear illustrations to convey health information messages.6
Provide inclusive guidance for people with disabilities
General COVID-19 guidance may not be feasible for people with disabilities. For example, people may not be able to stay 1–2 metres away from others (as recommended by the World Health Organization) if they rely on carers or family members for help with their daily tasks. To “cover your mouth with the elbow when coughing” can be impossible for people with spinal cord injuries or muscular-skeletal conditions. Health information material should inform people about possible modifications and tailored recommendations.7 For example, if individuals with cognitive disabilities are not able to avoid touching their eyes, the people supporting them could help them to wash their hands more often. Service providers should make sure that equipment used by people with physical impairments, such as wheelchairs, handrails, and crutches, are frequently cleaned and disinfected, and that people with disabilities have access to water, sanitation and hygiene facilities that do not pose a risk to them.
Some conditions, such as Down’s syndrome, are associated with other health conditions which increase the risk of those aﬀected becoming seriously ill from COVID-19. If possible, proactively test them, and the people supporting and caring for them, for SARS-CoV-2 infection. Carers should also write down who they have been in contact with; this supports contact tracing in communities with lower levels of SARS-CoV-2 infection.
It is very important to consider those patients who are hard of hearing and in need of eye health services, as well as the large number of patients with combined visual and hearing impairments. Results from a population-based study in Telangana state, India, suggested that 25% of people with visual impairment also had an additional moderate or severe hearing impairment.8 It is easy to imagine how difficult it might be for them to get information and to communicate with health workers during the COVID pandemic, and all the stress this brings. Recommendations for medical personnel to facilitate communication with patients who are deaf, hard of hearing or deafblind9 include the following:
• Integrate accessible communication in pandemic preparedness plans. During a pandemic, health systems are overwhelmed. It is essential that medical facilities optimise accessible communication with patients with all types of impairments before a pandemic, so that they are prepared accordingly.
• Every hospital should have pen and paper, or whiteboards and markers, so that people with hearing impairments can communicate with health care workers.
• Transparent (see-through) face masks oﬀers speech reading (lip reading) advantages for listeners with severe-to-profound hearing losses, especially in noisy hospital settings.10 Instructions for self-made transparent masks are circulating in social media; however, these masks have not been tested against common safety standards, so the level of protection they provide may be no greater than that of a fabric mask.
An eye hospital’s humanitarian response to COVID-19
NIRPHAD (Naujhil Integrated Rural Project for Health and Development) Rural Eye Hospital is a secondary eye hospital in the state of Uttar Pradesh, Northern India. It focuses mainly on eye patients from vulnerable populations and has strong links to community-based rehabilitation services, as well as organisations of people with disabilities.
Since the declaration of the COVID-19 pandemic, the eye hospital oﬀered services to emergency patients only. At the same time, staﬀ members decided to organise humanitarian response activities. NIRPHAD Rural Eye Hospital is located next to one of the main national highways in India, and the sudden announcement of a national lockdown in India at the end of March resulted in thousands of migrant workers passing by on their way back to their homes in rural villages. Hospital staﬀ members handed out around 1,500 sanitisation kits and food packs in this time (Figure 1).
Eye hospital personnel also started to distribute soap, masks and food to poor and vulnerable people in Mathura town, focusing on people with disabilities (Figures 2 and 3). This targeted humanitarian response was possible because the health workers already had access to information about people with disabilities in the community, including where they live, thanks to a disability disaggregated community survey that was conducted before the pandemic.
Personnel trained in disability-inclusive development supported the district authorities to provide accessible health information, for example by using plain language that is understood easily by everybody, including people with cognitive disabilities.
We would like to acknowledge Mr Shashikant Mishra and Mr Jeetesh Lavanya from the Naujhil Integrated Rural Project for Health and Development, as well as Mr Shakeeb Khan and Mr Nirad Bag from the CBM India Trust.
1 World Health Organization. Disability considerations during the COVID-19 outbreak. WHO/2019-nCoV/Disability/2020.1 Available from bit.ly/ Cov19disability
2 Kuper H, Banks LM, Bright T et al. Disability-inclusive COVID-19 response: What it is, why it is important and what we can learn from the United Kingdom’s response [version 1; peer review: 2 approved] Wellcome Open Research 2020, 5:79 https:// doi.org/10.12688/wellcomeopenres.15833.1
3 International Disability Alliance: Toward a Disability-Inclusive COVID-19 Response: 10 recommendations from the International Disability Alliance. Available from https://bit.ly/DisabilityCOV
4 World Blind Union. Examples of making documents accessible.bit.ly/WBUaccess
5 Schlögl M, Jones C. Maintaining Our Humanity Through the Mask: Mindful Communication During COVID-19. JAGS 68:E12-E13, 2020. DOI: 10.1111/ jgs.16488. Available from:https://onlinelibrary.wiley.com/doi/pdf/10.1111/jgs.16488
6 Ellison EW. Reaching out to patients with intellectual disabilities. Comm Eye Health Vol. 26 No. 81 2013: 13. Available from https://www.cehjournal.org/article/reaching-out-to-patientswith-intellectualdisabilities/
7 Sightsavers. Including people with disabilities in response to the COVID-19 pandemic.May 2020. Available from:bit.ly/Sightcov
8 Mactaggart I et al. A population-based survey of visual impairment and its correlates in Mahabubnagar district, Telangana State, India. Ophthal Epidemiol 2017;25:238-245. https://doi.org/10.1080/0928658 6.2017.1418386
9 COVID-19: Deaf and Hard of Hearing Communication Access Recommendations for the Hospital. https://bit.ly/deafCOV
10 Atcherson S et al. The eﬀect of conventional and transparent surgical masks on speech understanding in individuals with and without hearing loss. J Am Acad Audiol. 2017 Jan;28(1):58- 67. doi: 10.3766/jaaa.15151