Rehabilitation of vulnerable groups in emergencies and disasters: A systematic review

Hojjat Sheikhbardsiri, Mohammad H. Yarmohammadian, Fatemeh Rezaei, Mohammad Reza Maracy

1 Department of Emergency Operation Center (EOC), Disasters and Emergencies Management Center, Kerman University of Medical Sciences, Kerman, Iran

2 Health Management and Economics Research Center, Faculty of Management and Medical Informatics, Isfahan University of Medical Sciences, Isfahan, Iran

3 Department of Epidemiology & Biostatistics, School of Public Health, Isfahan University of Medical Sciences, Isfahan, Iran

Review Article

Rehabilitation of vulnerable groups in emergencies and disasters: A systematic review

Hojjat Sheikhbardsiri1, Mohammad H. Yarmohammadian2, Fatemeh Rezaei2, Mohammad Reza Maracy3

1Department of Emergency Operation Center (EOC), Disasters and Emergencies Management Center, Kerman University of Medical Sciences, Kerman, Iran

2Health Management and Economics Research Center, Faculty of Management and Medical Informatics, Isfahan University of Medical Sciences, Isfahan, Iran

3Department of Epidemiology & Biostatistics, School of Public Health, Isfahan University of Medical Sciences, Isfahan, Iran

Rehabilitation; Vulnerable group; Emergencies; Disasters

INTRODUCTION

World Health Organization (WHO) defines disasters as a situation that causes inconsistency in social or community performance resulting in extensive humanitarian, economic or environmental damages.[1]Disaster management consists of four phases including prevention and mitigation,preparedness, response and rehabilitation.[2]Rehabilitation is defined as performing health care with the goal of restoring, maintaining or improving routine life skills of individuals with disabilities caused due to disease,accidents or incidents.[3]In disaster situations categories of rehabilitation could be physical, psychological, social,spiritual, and economic.[4]

In general, women, children, elderly and disabled people are more vulnerable when compared with adult men, resulting in a lower capacity of adaptation and survival in emergencies and disasters.[5]National Disaster Response Force (NDRF) reported elderly, children and disable people and emphasized rehabilitation immediately after disasters.[6]When coping with disasters or emergencies conditions, vulnerable people can face several additional problems, which increase their risk for symptoms such as abrupt onset of intense fear, vertigo,insomnia or even psychoses. Therefore, it is necessary for authorities to establish psychological consult clinics to help with adaptation and encourage them to cope with these symptoms.[7]

After emergencies and disasters, the most important economic rehabilitation action will restore vulnerable groups and improve family's livelihoods.[8]Studies conducted years after occurrence of disasters typically show that the society's progress is affected at a largescale, but significant issues are often ignored in relation to vulnerable groups in society.[9]The aim of the study was to perform a systematic review of rehabilitation activities for vulnerable groups during emergencies and disasters, including economical, physical, spiritual,psychological and social activities. The results of the current study may help health field managers better implement standard rehabilitation plans for vulnerable groups.

METHODS

The present study was a systematic review of publications relating to rehabilitation of vulnerable groups in emergencies and disasters. The study performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.[10]

Search strategy

This study conducted during November 2015 reviewed published English papers in the field of vulnerable group's rehabilitation in emergencies and disasters. For this purpose, we studied database including ISI Web of Science, PubMed, Scopus, Science Direct,Ovid, ProQuest, Wiley and Google Scholar from January 1, 2000 to October 22, 2015. The search key words included "recovery", "rehabilitation", "reconstruction","transformation", "transition", "emergency", "disaster","crisis", "hazard", "catastrophe", "tragedy", "mass casualty incident", "women", "female", "children", "pediatric","disable", "handicap", "elder", "old" and "vulnerable".Using OR and AND, key words were combined and written in search box of databases included [(recovery OR rehabilitation OR reconstruction OR transformation OR transition) AND (emergency OR disaster OR crisis OR hazard OR catastrophe OR tragedy OR mass casualty incident) AND (women OR female OR children OR pediatric OR disable OR handicap OR elder OR old OR vulnerable)]. All synonyms of the key words were included using MESH strategies.

Selection of articles and document

Independent reviewers (HS and FR) screened abstracts and titles for eligibility. When the reviewers felt that the abstract or title was potentially useful, full copies of the article were retrieved and considered for eligibility by both reviewers. If discrepancies occurred between reviewers, the reasons were identified and a final decision was made based on third reviewer (MM).Two authors (HS and MY) assessed the methodology quality and grade of evidence of included studies with the Critical Appraisal Skills Program (CASP) tools.[11,12]The CASP tools uses a systematic approach to appraise different study designs from the following domains:study validity, methodology quality, presentation of results, and external validity and each of the items from the checklists were judged with yes (low risk of bias,score 1), no (high risk of bias), or cannot tell (unclear or unknown risk of bias, score 0). Total scores were used to grade the methodologic quality of each study.[11,12]

Inclusion and exclusion criteria

We included papers that had at least one of the rehabilitation categories, at least one the vulnerable groups, and published paper in years of 2000 and after.

Database search

The initial electronic database search of the literature resulted in a total of 11 928 documents. At the next step,duplicated, books, dissertations, presentations were excluded and the number of documents decreased to 632 articles.Based on systematic screening, at the first stage we reviewed the titles and abstracts to find those related to rehabilitation of vulnerable groups in emergencies and disasters and we extracted 63 eligible articles. In the next step, all 63 selected full text papers were considered and finally 25 papers (6 qualitative, 16 cross-sectional and 3 randomized controlled trial studies) which reported rehabilitation of vulnerable groups in emergencies and disasters were selected. Figure 1 shows the search strategy and the selected articles in accordance with the PRISMA guidelines.[10]

Study quality assessment

Quality assessment of the included studies were done using the (CASP) tools.[11,12]The score of qualitative and quantitative studies ranged from 3 to 8 and 2 to 7 respectively. Studies did not report any rehabilitation programs duration after disasters. The majority of quantitative studies did not provide any ethical statement,study design, sampling and reflexivity related to research process. In the cross-sectional studies, only five out of sixteen articles[19,22,26,27,34]used appropriate methods.The majority of them also did not consider important confounding factors. None of the randomized controlled trial articles reported blinding of participants or assessors and two studies[35,36]lacked a control group. More details have shown in Table 1.

Figure 1. Flow diagram showing selection of articles reviewed, in accordance with the PRISMA Guidelines 10.

RESULTS

Demographics

Number of participants of these twenty-five studies were 3 879 in total, which consist of 1 347 females, 145 children, 217 the elderly and 1 517 the disabled. Details of each study and their special features were reported regarding authors, year, study type, vulnerable group,sample size, type of rehabilitation, setting and duration of rehabilitation, disaster type, and main concepts. The studies were mainly conducted in Asian countries and United States, including India,[15,19,20,25–27,31]China,[18,22,23,34,36,37]Pakistan,[16,28,30]Iran,[13,17,21]Indonesia,[29,32]Sri Lanka[35]and United States.[14,24,33]The results of the studies showed that 56% of the studies are about rehabilitation programs for women, 32% is for children, 24% is for elderly, and 16%is for disabled people. Each study included more than onevulnerable group. The mean of the period of physical,psychological, social, and economic rehabilitation programs was about 7.3 months varying from 1 week to 50 months, which were based on the type of the disaster and the countries where the disaster occurred. For instance,psychological rehabilitation period after hurricane Katrina in the USA was about 1 week, and physical and psychological rehabilitation period after an earthquake in China was about 50 months.

Table 1. The quality of the final extracted articles using Critical Appraisal Skills Program (CASP)[11,12]

Among all rehabilitation programs implemented after the disaster, 52% of them were for physical rehabilitation,48% were for psychological rehabilitation, 52% were for social rehabilitation, and 12% of them were for economic rehabilitation. That means each study had more than one type of rehabilitation program. The results of the studies also showed that the countries implemented a wide range of rehabilitation programs for vulnerable groups after the onset of the disasters, but the exact starting time of the programs were not declared. Rehabilitation activities were conducted at different locations such as hospitals,clinics, schools, temporary camps by rehabilitation teams from local (84%) and international (16%) governmental and non-governmental organizations including UNICEF,WHO, and World Bank (IBRD).

Main results

Studies showed no difference between the nature of the implementation of rehabilitation programs and activities based on the type of the disaster and different vulnerable groups. The most important common strategy for vulnerable groups for physical rehabilitation include immediate and early implementation of physical rehabilitation immediately after the response stage and to continue these actions in the society after victims discharge from health centers. Important strategies for psychological rehabilitation include early medical intervention and consultation for all vulnerable groups,focusing on a cooperation approach of the vulnerable groups with the same sex and the same age in order to remove the negative experience and tension especially in women and children.

Strategies for social rehabilitation include emphasis on the participation of the vulnerable groups in the planning and implementation of services and activities from the day after the disaster. These strategies are based on holding proper training courses by local and international organizations especially local media in order to increase the capacity and potency of the people and the society. Strategies for economic rehabilitation include emphasizing the importance of women's role as a financial source in the family by providing them with small businesses, providing families with low-interest loans by international organizations, and providing societies with local businesses based on the culture of the damaged society by the World Bank. Moreover,the summaries of each paper related to rehabilitation of vulnerable groups in emergencies and disasters are shown in Table 2.

DISCUSSION

This systematic review provides an overview of various type of rehabilitation for vulnerable group in emergencies and disasters. This review includes 25 studies (6 qualitative, 16 cross-sectional and 3 randomized controlled trial). Most interventions evaluated in these studies were complex and included more than one active rehabilitation component. The most common kinds of rehabilitation intervention for vulnerable group were physical, social, and psychological activities.

The studies showed that the duration of the implementation of the rehabilitation programs after the onset of the disaster ranged from 1 week to 50 months and the mean of this period is about 7 months. The studies also showed that local public and private organizations performed 84% of the rehabilitation interventions, and international organizations performed 16% of these interventions.These findings are in line with the WHO guideline, which states that the success of the rehabilitation programs after the disaster depends on potential of the damaged area in meeting their needs independent of external aids and supports of non-local organizations.[40]The disaster management experts believe both natural disasters and human-made disasters lead to physical, economic, and social damages,[13,19]and there was no difference in the nature and implementation of rehabilitation programs based on vulnerable groups.

The important result shows physical and psychological rehabilitation programs started immediately after the response phase, which would better preserve function of body organs and cause less psychological signs and symptoms.[36,37]Disaster management experts believe that physical and physiological rehabilitation should be immediately started after response phase to disaster and it should continue in the community over the long term in order to improve and restore function of vulnerable peoples.[13,38,39]

One of the studies emphasized social rehabilitation of vulnerable groups in order to ensure the participation of vulnerable groups in the planning and implementation of services and activities from the day after the onset of the disaster based on the equal time and opportunity to governmental authorities and aid agencies. The strategies that can increase the participation of the vulnerable groups in meeting their needs include: (1) providing services with the cooperation of the people based on the capacity and potency; and (2) dependency of the vulnerable groups to the external services that should be gradually decreased. Reciprocally the use of social sources of the damaged area may be increased.[14,15,18,21,25,28,34]

Studies also emphasized the activity of vulnerable groups especially women in the economic rehabilitation activities in order to meet financial needs by starting small businesses. Supporting the social activity of women leads to ability to direct and organize many active and potent individuals. The most important obstacle for the cooperation of the women in economic rehabilitation activities is the focus of international and local organizations on men as the head of the family and the provider of the financial needs of the family.[15,17,29]Studies also showed that one of the most important approaches in implementation of the rehabilitation processes is the use of local media especially television and radio to provide vital information about rehabilitation procedures such as training courses for the vulnerable groups. Audiovisual tools play an important role in gathering social sources to provide rehabilitation services.[19]

The main barriers for implementing rehabilitations programs reported in some of the studies were lack of detailed information of affected population, lack of trained personnel, structural and non-structural destruction caused by emergencies and disasters, shortage of trained rehabilitation professionals and medical workforce, lack of coordination with other responsible agencies and private volunteer organizations, reduced sensitivity of authorities after a few days from disaster, and lack of comprehensive management plans for disabilities persons after occurrence emergencies and disasters.[13,14,21,28]We did not find any programs related to spiritual rehabilitation for vulnerable groups after emergencies and disasters. Some of reviewed articles did not specify details regarding the duration of rehabilitation period, which was recognized as one of the studies weaknesses.

CONCLUSION

The review of the papers showed different programs of physical, physiological, economic and social rehabilitations for vulnerable groups after emergencies and disasters. These programs may help health field managers better implement correct and timely rehabilitation activities. This review emphasizes comprehensive participation of people affected in all stages of rehabilitation programs and also attention to cultural, social, economic and religious considerations during implementation of rehabilitation actives after emergencies and disasters. The majority of the papers emphasized that the rehabilitation process has different dimensions, in addition, implementation of each of them needs facilities, resources and special approaches that correlate to other domains. Occasionally there are overlaps between the activities related to all domains, so successful rehabilitation process from disasters requires a systemic and holistic viewpoint simultaneously with implementation of specific programs related to each domain.

Funding: None.

Ethical approval: The institutional ethics review board approved the study.

Conflicts of interest: No authors declare any actual or potential conflicts of interest.

Contributors: All authors carried out the design, SH and FR coordinated to the data base search. All authors prepared the manuscript, read and approved the content of the manuscript.

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Mohammad Reza Maracy, Email: mrmaracy@yahoo.co.uk

BACKGROUND:Natural and man-made disasters, especially those occurring in large scales not only result in human mortality, but also cause physical, psychological, and social disabilities.Providing effective rehabilitation services in time can decrease the frequency of such disabilities. The aim of the current study was to perform a systematic review related to rehabilitation of vulnerable groups in emergencies and disasters.

METHODS:The systematic review was conducted according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. The key words "recovery", "rehabilitation","reconstruction", "transformation", "transition", "emergency", "disaster", "crisis", "hazard", "catastrophe","tragedy", "mass casualty incident", "women", "female", "children", "pediatric", "disable", "handicap","elder", "old" and "vulnerable" were used in combination with Boolean operators OR and AND. ISI Web of Science, PubMed, Scopus, Science Direct, Ovid, ProQuest, Wiley, Google Scholar were searched.

RESULTS:In this study a total of 11 928 articles were considered and 25 articles were selected for final review of rehabilitation of vulnerable groups based on the objective of this study. Twenty-five studies including six qualitative, sixteen cross-sectional and three randomized controlled trials were reviewed for rehabilitation of vulnerable groups in emergencies and disasters. Out of the selected papers, 23 were studied based on rehabilitation after natural disasters and the remaining were man-made disasters.Most types of rehabilitation were physical, social, psychological and economic.

CONCLUSION:The review of the papers showed different programs of physical, physiological,economic and social rehabilitations for vulnerable groups after emergencies and disasters. It may help health field managers better implement standard rehabilitation activities for vulnerable groups.

World J Emerg Med 2017;8(4):253–263

10.5847/wjem.j.1920–8642.2017.04.002

December 12, 2016

Accepted after revision July 9, 2017