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      Impact of the societal response to COVID-19 on access to healthcare for non-COVID-19 health issues in slum communities of Bangladesh, Kenya, Nigeria and Pakistan: results of pre-COVID and COVID-19 lockdown stakeholder engagements

      research-article
      1 , 2 , 3 , 4 ,   5 , 1 , 6 , 5 , 7 , , 5 , 4 , 8 , 9 , 3 , 8 , 5 , 5 , 8 , 5 , 10 , 5 , 3 , 11 , 5 , 3 , 4 , 4 , 4 , 12 , 4 , 4 , 5 , 3 , 13 , 14 , 15 , 5 , 10 , 16 , 3 , 17 , 10 , 5 , 1 , On behalf of the Improving Health in Slums Collaborative
      BMJ Global Health
      BMJ Publishing Group
      health policy, health systems, public health, other infection, disease, disorder, or injury, qualitative study

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          Abstract

          Introduction

          With COVID-19, there is urgency for policymakers to understand and respond to the health needs of slum communities. Lockdowns for pandemic control have health, social and economic consequences. We consider access to healthcare before and during COVID-19 with those working and living in slum communities.

          Methods

          In seven slums in Bangladesh, Kenya, Nigeria and Pakistan, we explored stakeholder perspectives and experiences of healthcare access for non-COVID-19 conditions in two periods: pre-COVID-19 and during COVID-19 lockdowns.

          Results

          Between March 2018 and May 2020, we engaged with 860 community leaders, residents, health workers and local authority representatives. Perceived common illnesses in all sites included respiratory, gastric, waterborne and mosquitoborne illnesses and hypertension. Pre-COVID, stakeholders described various preventive, diagnostic and treatment services, including well-used antenatal and immunisation programmes and some screening for hypertension, tuberculosis, HIV and vectorborne disease. In all sites, pharmacists and patent medicine vendors were key providers of treatment and advice for minor illnesses. Mental health services and those addressing gender-based violence were perceived to be limited or unavailable. With COVID-19, a reduction in access to healthcare services was reported in all sites, including preventive services. Cost of healthcare increased while household income reduced. Residents had difficulty reaching healthcare facilities. Fear of being diagnosed with COVID-19 discouraged healthcare seeking. Alleviators included provision of healthcare by phone, pharmacists/drug vendors extending credit and residents receiving philanthropic or government support; these were inconsistent and inadequate.

          Conclusion

          Slum residents’ ability to seek healthcare for non-COVID-19 conditions has been reduced during lockdowns. To encourage healthcare seeking, clear communication is needed about what is available and whether infection control is in place. Policymakers need to ensure that costs do not escalate and unfairly disadvantage slum communities. Remote consulting to reduce face-to-face contact and provision of mental health and gender-based violence services should be considered.

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          Most cited references34

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          COVID-19 and mental health: A review of the existing literature

          Highlights • Subsyndromal mental health concerns are a common response to the COVID-19 outbreak. • These responses affect both the general public and healthcare workers. • Depressive and anxiety symptoms have been reported in 16–28% of subjects screened. • Novel methods of consultation, such as online services, can be helpful for these patients. • There is a need for further long-term research in this area, especially from other countries
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            Psychosocial impact of COVID-19

            Background Along with its high infectivity and fatality rates, the 2019 Corona Virus Disease (COVID-19) has caused universal psychosocial impact by causing mass hysteria, economic burden and financial losses. Mass fear of COVID-19, termed as “coronaphobia”, has generated a plethora of psychiatric manifestations across the different strata of the society. So, this review has been undertaken to define psychosocial impact of COVID-19. Methods Pubmed and GoogleScholar are searched with the following key terms- “COVID-19”, “SARS-CoV2”, “Pandemic”, “Psychology”, “Psychosocial”, “Psychitry”, “marginalized”, “telemedicine”, “mental health”, “quarantine”, “infodemic”, “social media” and” “internet”. Few news paper reports related to COVID-19 and psychosocial impacts have also been added as per context. Results Disease itself multitude by forced quarantine to combat COVID-19 applied by nationwide lockdowns can produce acute panic, anxiety, obsessive behaviors, hoarding, paranoia, and depression, and post-traumatic stress disorder (PTSD) in the long run. These have been fueled by an “infodemic” spread via different platforms social media. Outbursts of racism, stigmatization, and xenophobia against particular communities are also being widely reported. Nevertheless, frontline healthcare workers are at higher-risk of contracting the disease as well as experiencing adverse psychological outcomes in form of burnout, anxiety, fear of transmitting infection, feeling of incompatibility, depression, increased substance-dependence, and PTSD. Community-based mitigation programs to combat COVID-19 will disrupt children's usual lifestyle and may cause florid mental distress. The psychosocial aspects of older people, their caregivers, psychiatric patients and marginalized communities are affected by this pandemic in different ways and need special attention. Conclusion For better dealing with these psychosocial issues of different strata of the society, psychosocial crisis prevention and intervention models should be urgently developed by the government, health care personnel and other stakeholders. Apt application of internet services, technology and social media to curb both pandemic and infodemic needs to be instigated. Psychosocial preparedness by setting up mental organizations specific for future pandemics is certainly necessary.
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              Prevention and control of non-communicable diseases in the COVID-19 response

              Moving towards universal health coverage, promoting health and wellbeing, and protecting against health emergencies are the WHO global priorities 1 that are shared by the proposed WHO European Programme of Work 2020–25. 2 The coronavirus disease 2019 (COVID-19) pandemic has underlined the importance of interconnecting these strategic priorities. Of the six WHO regions, the European region is the most affected by non-communicable disease (NCD)-related morbidity and mortality 3 and the growth of the NCDs is concerning. Cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes are among the leading causes of death and disability in the region, 3 and an increasing proportion of children and adults are living with overweight or obesity, 4 one of the major risk factors for NCDs. Prevention and control of NCDs are important during this pandemic because NCDs are major risk factors for patients with COVID-19. 5 Additionally, some of the restrictive measures such as lockdowns, social distancing, and travel restrictions to reduce the spread of infection in many countries impact specifically on people living with NCDs by limiting their activity, ability to secure healthy foods, and access to preventive or health promotion services. 6 The COVID-19 pandemic has had widespread health impacts, revealing the particular vulnerability of those with underlying conditions. In Italy, a recent report revealed that the majority (96·2%) of patients who have died in-hospital from COVID-19 had comorbidities, primarily NCDs; the most prevalent NCDs among these patients were hypertension (69·2%), type 2 diabetes (31·8%), ischaemic heart disease (28·2%), chronic obstructive pulmonary disease (16·9%), and cancer (16·3%). 7 An association between COVID-19 severity and NCDs has also been reported in Spain, 8 China, 9 and the USA. 10 However, many COVID-19 deaths also occur in older people who often have existing comorbidities. 11 Body-mass index (BMI) might also be associated with the severity of COVID-19; in China, patients with severe COVID-19 and non-survivors typically had a high BMI (>25 kg/m2). 12 The impact of COVID-19 response measures on NCDs is multifaceted. Physical distancing or quarantine can lead to poor management of NCD behavioural risk factors, including unhealthy diet, physical inactivity, tobacco use, and harmful use of alcohol. 13 Evidence from this and previous pandemics suggests that without proper management, chronic conditions can worsen due to stressful situations resulting from restrictions, insecure economic situations, and changes in normal health behaviours. As with other health service and preventive programmes, the postponement of routine medical appointments and tests can delay NCD management, while physical distancing, restricted access to primary health care units, pharmacies, and community services, alongside a reduction of transport links, all disrupt continuity of care for NCD patients. This disruption of routine health services and medical supplies risks increasing morbidity, disability, and avoidable mortality over time in NCD patients. Additionally, patients with severe obesity who require intensive care have increased patient management needs. 6 The prevention and control of NCDs have a crucial role in the COVID-19 response and an adaptive response is required to account for the needs of people with NCDs. Prevention of NCDs is important since the true scale of at-risk groups is probably underestimated, given that many cases of hypertension and diabetes are undiagnosed.14, 15 Communities and health systems need to be adaptive to both support and manage the increased risks of people with known NCDs and exercise sensitivity about the vulnerability of the large population with undiagnosed NCDs and those at increased risk of NCDs. The COVID-19 response and continued and strengthened focus on NCD prevention and management are key and interlinked aspects of public health at the present time. If the COVID-19 response is not adapted to encompass prevention and management of NCD risks, we will fail many people at a time when their vulnerability is heightened. What steps should be taken to adapt the COVID-19 response? The WHO Regional Office for Europe has started to develop a list of actions that could be adapted by countries to address the needs of those at risk of NCDs or who are already living with NCDs, together with practical considerations for teams developing COVID-19 response plans at local or national levels (table ). Table Responses and risks related to NCD prevention and control during the COVID-19 pandemic NCD-specific responses Associated risks Community transmission with containment measures such as physical distancing and public service and institution closures or restrictions Lengthened time spent indoors Use technology to provide knowledge and support for management of NCDs, online information on exercise and mental health self-management classes, healthy recipes for home preparation, and online delivery of healthy foods, among other responses Reduced physical activity and increased strain on mental health might result in greater consumption of unhealthy foods and harmful use of tobacco and alcohol Family members at home Provide special arrangements for families with NCD patients to self-isolate Risk of increased contact with younger family members at home Inadequate access to medicines Use telemedicine more, allow local or community doctors and pharmacists to renew or extend drug prescriptions, deliver essential NCD drugs to home Shortage of essential medicines such as insulin and other NCD-specific medications Transport and other services restricted Prioritise and ensure continued community level services in a safe way to cater for NCD patients' needs Restricted transport facilities and family support for continued NCD care Infection control Early detection and laboratory testing Prioritise NCD patients for COVID-19 testing; triaging should take account of whether patients have NCDs and are immunocompromised Those NCD patients for whom visits to health facilities are essential could be at greater risk of getting exposed to COVID-19 Contact tracing Focus especially on those with increased risk factors for NCDs and NCD patients (ie, patients living with obesity) and alert and follow up closely any possible contacts for NCD patients NCD patients might be unaware of the additional risks posed on them Extensive testing Prioritise NCD patients for testing when possible and promote the need for testing NCD patients might be less motivated or able to actively seek testing (in a safe, physically distanced manner) Health-care settings (infection control) Provide NCD patients and health-care staff working in NCD services with special training and personal protective equipment, as well as health-care professionals at increased risk of NCDs NCD patients with comorbidities are at increased risk of infection; health-care staff working in NCD clinics are therefore also at increased risk of infection NCD=non-communicable disease. COVID-19=coronavirus disease 2019. Patients living with obesity and NCDs are at increased risk of the health impacts of emergencies such as COVID-19. 16 NCD health-care staff and associated workers and volunteers should be centrally involved in the planning of COVID-19 response strategies to ensure that the needs of patients and caregivers are addressed. Specific advice should be made available nationally and locally for patients living with NCDs, their families, and their caregivers. Prevention and control of obesity and NCDs are crucial in preparedness for this and future public health threats. A streamlined response to COVID-19 in the context of NCDs is important to optimise public health outcomes and reduce the impacts of this pandemic on individuals, vulnerable groups, key workers, and society.
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                Author and article information

                Journal
                BMJ Glob Health
                BMJ Glob Health
                bmjgh
                bmjgh
                BMJ Global Health
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2059-7908
                2020
                20 August 2020
                : 5
                : 8
                : e003042
                Affiliations
                [1 ]departmentCentre for Health, Population and Development , Independent University Bangladesh , Dhaka, Bangladesh
                [2 ]departmentNational Institute for Health Research Project , University of Ibadan , Ibadan, Oyo State, Nigeria
                [3 ]departmentCommunity Health Sciences Department , Aga Khan University , Karachi, Pakistan
                [4 ]African Population and Health Research Center , Nairobi, Kenya
                [5 ]departmentDivision of Health Sciences, Warwick Medical School , University of Warwick , Coventry, UK
                [6 ]departmentDepartment of Sociology, Faculty of Social Sciences , University of Ibadan , Ibadan, Oyo State, Nigeria
                [7 ]departmentCentre for Health Policy, School of Public Health , University of the Witwatersrand , Johannesburg, South Africa
                [8 ]departmentInstitute of Applied Health Research, College of Medical and Dental Sciences , University of Birmingham , Birmingham, UK
                [9 ]departmentDepartment of Obstetrics and Gynaecology, Faculty of Clinical Sciences, College of Medicine , University of Ibadan , Ibadan, Oyo State, Nigeria
                [10 ]departmentInstitute for Global Sustainable Development , University of Warwick , Coventry, UK
                [11 ]departmentLancaster Medical School , Lancaster University , Lancaster, UK
                [12 ]departmentWarwick Clinical Trials Unit, Warwick Medical School , University of Warwick , Coventry, UK
                [13 ]Nigerian Academy of Science , Lagos, Nigeria
                [14 ]departmentDepartment of Periodontology and Community Dentistry, Faculty of Dentistry, College of Medicine , University of Ibadan , Ibadan, Oyo State, Nigeria
                [15 ]departmentDepartment of Community Medicine, Faculty of Public Health, College of Medicine , University of Ibadan , Ibadan, Oyo State, Nigeria
                [16 ]University of Liberal Arts Bangladesh , Dhaka, Bangladesh
                [17 ]departmentDepartment of Geography, Faculty of Social Sciences , University of Ibadan , Ibadan, Oyo State, Nigeria
                Author notes
                [Correspondence to ] Professor Frances Griffiths; f.e.griffiths@ 123456warwick.ac.uk
                Author information
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                https://orcid.org/0000-0002-1704-0944
                https://orcid.org/0000-0001-7097-5450
                https://orcid.org/0000-0002-9446-2761
                https://orcid.org/0000-0002-4173-1438
                https://orcid.org/0000-0003-4695-008X
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                https://orcid.org/0000-0002-0151-9571
                Article
                bmjgh-2020-003042
                10.1136/bmjgh-2020-003042
                7443197
                32819917
                4b74b17e-fd4c-4903-9f1e-0e2cc3fd0fac
                © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/.

                History
                : 01 June 2020
                : 27 July 2020
                : 29 July 2020
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100000272, National Institute for Health Research;
                Award ID: 16/136/87
                Categories
                Original Research
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                health policy,health systems,public health,other infection,disease,disorder,or injury,qualitative study

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