After removing duplicates, the database searches resulted in 27 included studies (Fig. 1). No further publication was identified through the grey literature search. The grey literature search and the contacting of key organisations focal persons yielded zero additional publications. Of the 16 individuals contacted, 7 replied by either sending their organisation’s global guidelines, or by apologizing that their reports were unpublished and for internal use only. Three national Systematic Assessment of Rehabilitation Situation (STARS) reports were identified from the website searches, but these were excluded as they did not provide information on rehabilitation services in conflict or disaster situations.
Overview of included studies
The included studies were based on events in 11 countries: 9 from China, 4 from the Philippines, 2 each from Bangladesh, Haiti, India, Iran, and Nepal, and 1 each from Brazil, Nigeria, Pakistan and Turkey. Seventeen of the 27 studies described activities related to earthquakes, 6 were not focused on a specific disaster event, 2 were each related to landslides and typhoons. 20 studies described or evaluated response, whilst 7 studies focused on preparedness. Most of the 27 studies were observational studies or case reports and some with data collection years after the event.
When classified according to the six building blocks of health systems, 14 studies focused on service delivery, followed by 6 on health workforce, 4 on health information systems and 3 on the leadership and governance building block (Tables 2–5). No study focused on the financing and assistive technology building blocks, despite these being mentioned in some of the studies that focused on other building blocks.
Service delivery
Most studies (n = 15) focused on rehabilitation service delivery (Table 2). This is an expected finding, considering that rehabilitation need requests service provision, and disaster and conflict situations create demand. Of these, 11 studies were based on earthquakes, with 6 from China alone. Nine studies evaluated service delivery and 6 reported the implementation of services. Most studies made recommendations to develop and integrate rehabilitation into emergency preparedness and response.
Mousavi et al. (2019) (33) iterated what other studies included in this scoping review also emphasized, that the delivery of rehabilitation services during disasters is highly dependent on the existing system, and that, in the absence of a strong rehabilitation system, service delivery during disasters will be inadequate. Taking Iran as an example, Mousavi et al (2019) (33) reported that a lack of policy hindered rehabilitation development with decision makers’ limited knowledge of rehabilitation, a lack of an effective responsible rehabilitation body; weak disaster-related competencies; and under-prioritization of rehabilitation by government to be the greatest barriers towards developing rehabilitation services.
Describing reasons for a lack of rehabilitation services in disasters, Carvalho et al (2019) (34) posed that low demand for services can occur, not because the need does not exist, but because rehabilitation need can be repressed by competing personal needs, financial constraints to pay for services and transport, and lack of access and knowledge of the rehabilitation services available.
Uddin et al. (2021) (35) suggested that a barrier to implementing rehabilitation services for those with traumatic injuries sustained in the 2017 Bangladesh landslide was a lack of rehabilitation professionals and of training to provide rehabilitation services. The authors recommended that rehabilitation capacity be increased with task sharing and rehabilitation technical training integrated into the emergency response structure. Supporting this suggestion, Hotz et al. (2012) (36) recommended a train-the-trainer model to expand workforce capacity and capabilities, based on experiences in Haiti after the 2010 earthquake.
A commonly mentioned consideration for implementing rehabilitation services is that disasters add to the existing unmet need for rehabilitation, with studies in the review reporting a large proportion of individuals with pre-disaster need accessing rehabilitation services set up for disaster victims (3, 10).
Ali et al (2010) (40), Keshkar et al (2014) (38), Li et al (2019) (37), and Mousavi et al (2019) (39) evidenced the long-term need for assistive technology provision for those injured in earthquakes, and emphasized that AT provision, as part of rehabilitation interventions, are associated with outcomes such as better functioning and greater quality of life. The case report from the Philippines by Ganchoon et al (2018) (3) demonstrated that rehabilitation services can be effectively delivered within other relief and medical aid missions. Box 1 summarizes the recommendations from studies focusing on service delivery, with the top four most referenced recommendations being: 1) Early multi-professional rehabilitation (3, 37, 38, 40-43); 2) Assistive technology provision (3, 37-40); 3) Community-based rehabilitation provision (3, 41, 42), and; 4) Psychological support (38, 40, 43).
Box 1 Summary of recommendations from the service delivery studies
Table 2 Summary of the service delivery results
Title
|
Aims
|
Country
|
Disaster
|
Type of study
|
Participant group
|
Findings
|
Philippine academy of rehabilitation medicine emergency basic relief and medical aid mission project (November 2013-february 2014): The role of physiatrists in super typhoon Haiyan (3)
|
To describe the emergency basic relief and medical aid missions performed by physiatrists in response to Super Typhoon Haiyan.
|
Philippines
|
2013 typhoon Haiyan
|
Case report
|
Unknown number of rehabilitation doctors
|
Besides providing medical care, physiatrists functioned as mission team leaders, as community advocates, and other roles. Services included free consultation and treatment; medicines, and wound care supplies to 7255 patients, which included non-disaster related care.
|
Physical rehabilitation in the context of a landslide that occurred in Brazil (34)
|
To investigate the challenges in delivering rehabilitation to those injures in the 2011 landslide disaster.
|
Brazil
|
2011 landslide
|
Cross-sectional mixed method study
|
2326 hospital records and 27 interviews with 11 victims and 16 health professionals
|
Most rehabilitation services didn’t identify a surge in demand post disaster, despite knowing demand existed. This was thought to be because the need was repressed by competing personal needs, financial constraints to pay for rehabilitation and transport, and lack of access and awareness of rehabilitation services, meaning referrals weren’t made.
|
The outcomes and impact of a Post-Earthquake Rehabilitation Program in China: A Qualitative Study (10)
|
To analyze the outcomes and implications for a large-scale, community based, post-earthquake rehabilitation program in Sichuan, China after the program had been operational for 5 years.
|
China
|
2008 Sichuan earthquake
|
Embedded qualitative case study
|
1,471 people who received rehabilitation services between July 2008 and June 2013.
|
75.4% patients sustained injuries related in the earthquake, and the remaining 24.54% were non-earth-quake victims. 88.06% of service users felt the programed helped them achieve their goals. The program achieved favorable results in enhancing functional independence in activities of daily living, physical status and psychosocial well-being of the service users. The program has been transferred to the local partner, with some changes
|
Mobility, prosthesis use and health related quality of life of bilateral lower limb amputees from the 2008 Sichuan earthquake (37)
|
To report the rehabilitation outcomes (mobility, prosthesis use and quality of life) of bilateral lower limb amputees from the Sichuan Earthquake
|
China
|
2008 Sichuan earthquake
|
Observational cross sectional
|
17 bilateral lower limb amputees sustained in the earthquake
|
Results suggested that amputation level and knee joint salvage, prosthesis use and exercise were associated with better rehabilitation outcomes including mobility, adjustment and quality of life 9 amputees (52.9%) used wheel chairs, 2 (11.8%) used crutches,2 (11.8%) used walking sticks and 4 (23.5%) were unaided walkers.
|
Morbidity pattern and impact of rehabilitative services in earthquake victims of Kashmir, India (40)
|
To know the nature of the injuries, magnitude of disability, rehabilitative services provided, and service satisfaction.
|
India
|
2005 Kashmir earthquake
|
Retrospective observational study
|
266 earthquake injured patients needed surgical intervention
|
12.33% of patients had spinal injuries and 32% of all those injured received assistive products, with 90% still in use at 1 year follow up. 97% of patients felt rehabilitation services were beneficial.
|
Epidemiology and the impact of early rehabilitation of spinal trauma after the 2005 earthquake in Kashmir, India (38)
|
To describe the epidemiology of spinal injury in the Kashmir Earthquake and to analyse the impact of 15 days of rehabilitation
|
India
|
2005 Kashmir earthquake
|
Descriptive observational case report
|
38 spinal cord injury patients
|
Provision of free assistive devices was the main rehabilitation intervention to prevent further spinal injuries. Psychotherapy and physiotherapy is important to maintain joint range and prevent contracture, and was deemed beneficial in the sample. 15 days of rehabilitation is not enough.
|
Developing a trauma critical care and rehabilitation hospital in Haiti: A year after the earthquake (36)
|
To describe project Medishare which provides rehabilitation services and training to Haitian healthcare professionals.
|
Haiti
|
2010 earthquake
|
Descriptive observational case report
|
NA
|
Daily patient care has been managed by Haitian medical staff as well as more than 2,400 international volunteers.
Efforts continue for building workforce capacity, and the priority is training and education of the workforce.
|
Amputations of limbs during the 2005 earthquake in Pakistan: A firsthand experience of the author (48)
|
To audit the incidence of amputations of limbs in the 2005 Pakistan earthquake and their rehabilitation management.
|
Pakistan
|
2005 earthquake
|
Retrospective descriptive study
|
112 patients with amputations of upper and lower limbs.
|
Amputations accounted for 0.9 % of total injuries and needed immediate rehabilitation for physical, psychological and occupational challenges which included prosthetic limb fittings.
|
2017 Bangladesh landslides: physical rehabilitation perspective (35)
|
To describe the impact on the population affected by the 2017 landslides in south-eastern Bangladesh
|
Bangladesh
|
2017 landslide
|
Observational
|
Landslide survivors
|
Rehabilitation for traumatic injuries was limited due to a lack of staff trained in rehabilitation. Rehabilitation capacity building requires significant cooperation between academic medical institutions and other emergency response stakeholders.
|
The NHV rehabilitation services program improves long-term physical functioning in survivors of the 2008 Sichuan earthquake: A longitudinal quasi experiment (6)
|
To quantify the effectiveness of the NHV rehabilitation program as measured by the function of earthquake survivors
|
China
|
2008
Sichuan earthquake
|
A longitudinal quasi–experimental design with an intervention group and control group.
|
510 earthquake survivors
|
The NHV rehabilitation services significantly improved estimated Barthel index in both the early and late intervention groups compared to controls, demonstrating benefit from rehabilitation delivered nearly 1.5 years after injury.
|
Functional outcomes and health-related quality of life in fracture victims 27 months after the Sichuan earthquake (41)
|
To evaluate functional outcomes, health-related quality of life and life satisfaction in fracture victims 27 months after the 2008 Sichuan earthquake.
|
China
|
2008
Sichuan earthquake
|
A cross-sectional quasi-experimental study with 2 intervention groups and a control group.
|
390 fracture victims divided into early or late intervention groups, or a routine care control group
|
Activities of daily living and life satisfaction in the intervention groups were significantly improved compared to the control group.
|
Continuous post-disaster physical rehabilitation: a qualitative study on barriers and opportunities in Iran (39)
|
To outline the barriers and opportunities of disaster rehabilitation services in Iran.
|
Iran
|
2003 Bam and 2012 Varzaghan earthquakes
|
Observational
|
16 rehabilitation service providers, users and administration in the affected area of the two earthquakes
|
The main barriers to delivering disaster rehabilitation were found to be: decision makers low knowledge of rehabilitation, a lack of an effective responsible body; weak disaster-related competencies; and under-prioritization by government. Distribution of assistive devices was critical in affected areas.
Rehabilitation specialists could play a role in triage and proper immobilization of injured limbs.
|
Evaluation of functional outcomes of physical rehabilitation and medical complications in spinal cord injury victims of the Sichuan earthquake (42)
|
To characterize spinal cord injuries from the 2008 Sichuan earthquake and evaluate their functional outcomes following rehabilitation
|
China
|
2008
Sichuan earthquake
|
A prospective observational cohort study
|
51 spinal cord injured earthquake victims from 3 hospitals
|
Ambulation, wheelchair mobility and ADL were significantly improved with rehabilitation. 35.3% of patients achieved at least moderate activity of daily living independence and 90.2% regained some self-care ability prior to discharge. The group that began rehabilitation more than 3 months after the earthquake did not show significant functional improvement.
|
Responding to the health and rehabilitation needs of people with disabilities post-Haiyan (46)
|
To describe the activities to increase access to rehabilitation for people with disabilities and with injuries post-Haiyan.
|
Philippines
|
2014 typhoon Haiyan
|
Descriptive field investigation report
|
2998 individuals needing rehabilitation and assistive devices
|
50 prostheses and 320 mobility aids were provided to people with new injuries or pre-existing disabilities. Having detailed pre-disaster data of estimations and profiles of people with disabilities would have improved the response.
|
Factors affecting functional outcome of Sichuan earthquake survivors with tibial shaft fractures: a follow-up study (43)
|
To analyse the functional recovery of earthquake survivors with tibial shaft fractures in Sichuan, China.
|
China
|
2008 Sichuan earthquake
|
Observational
|
174 ambulatory earthquake survivors with tibia shaft fractures
|
Functional recovery was positively associated with rehabilitation intervention (odds ratio 5.3 (95% confidence interval 2.38–11.67)
|
Workforce
Six studies focused on rehabilitation workforce (Table 3) from 6 countries, 1 responding to an earthquake and the others not based on a specific disaster. Overall, the included studies show that the rehabilitation workforce has little experience in disaster preparedness and response due to a lack of training and awareness of professionals in their role in disaster response.
Habib et al (2014) (49) found only three occupational therapists in Bangladesh who had disaster response experience in national or international non-governmental organizations. From the professional organizations register, Ching et al (2019) (50) found only 24 occupational therapists with disaster response experience in the Philippines, who mostly had experience providing mental health support to the pediatric population. These findings by Ching et al (2019) (50) contradict an earlier policy study by Duque et al (2013) (44), classified under the leadership and governance category, describing the process and challenges faced to produce the national Philippines disaster preparedness and response plan for occupational therapists. In the aforementioned plan, key recommendations to support workforce development in disaster preparedness and response were made, which, 5 years on, appeared to have been minimally implemented.
The included articles link the lack of rehabilitation workers’ experience in disasters to little understanding by the workforce of the role they can play. In a Nigerian survey, Ojukwu et al (2019) (7) found that only 68.7% of physiotherapists acknowledged their potential role in disaster management. Conversely, in the only eligible study involving rehabilitation nurses, Kalanlar et al (2021) (45) surveyed nurses in a single hospital in Turkey and found that whilst most respondents felt they had a role to play in disaster response, 72% of the nurses had no experience of disaster work, and 94% felt that they need training in disaster rehabilitation.
He et al (2011) (51) described the implementation of a program to teach basic rehabilitation skills to rapidly increase rehabilitation capacity for earthquake victims, and suggests it could rapidly increase rehabilitation capacity in future emergencies. However, the program outcomes, costs, implementation challenges, and sustainability were not described. Box 2 summarizes recommendations of studies focusing on workforce with the top 3 most referenced recommendations listed foremost: 1) entry level and post graduate practical training to develop disaster management knowledge and skills (50) (7) (45) (51); 2) professionals and their organisations should be involved in shaping disaster policy and advocacy (7, 47, 49), and 3) creating an awareness of the role of rehabilitation disaster among the public and other healthcare professionals (7) (50) (47).
Box 2 Summary of recommendations from the workforce studies
Table 3 Summary of the workforce results
Title
|
Aims
|
Country
|
Disaster
|
Type of study
|
Target group
|
Findings
|
Preparation, roles, and responsibilities of Filipino occupational therapists in disaster preparedness, response, and recovery (50)
|
To describe the roles, responsibilities and work of Filipino occupational therapists in disaster management
|
Philippines
|
Non-specific
|
Descriptive cross-sectional
|
24 occupational therapists with experience working in disasters
|
The roles most frequently performed were encouraging social interactions among survivors, providing mental health services to survivors and attending trainings in disaster response.
|
Knowledge, practices and perceived barriers of physiotherapists involved in disaster management: a cross-sectional survey of Nigeria-based and trained physiotherapists (7)
|
To investigate the knowledge, practices and perceived barriers regarding the role of physiotherapists in disaster management among Nigeria-based and trained physiotherapists.
|
Nigeria
|
Non-specific
|
Descriptive cross-sectional
|
50 registered physiotherapists with at least 1 year of work experience
|
68.7% of physiotherapists acknowledged their potential role in disaster management, but only 6.7% had experience, with 90% citing a lack of established government policies on the integration of physiotherapists into disaster management as a barrier. Involvement of physiotherapy during disasters is limited by financial, workforce, equipment, training, awareness and resource constraints.
|
Rehabilitation nurses’ opinions on disaster rehabilitation services, their training needs and perceptions of preparedness for disasters (45)
|
To assess rehabilitation nurses’ perceptions of disaster preparedness and response, and to identify rehabilitation nurses’ training needs.
|
Turkey
|
Non-Specific
|
Descriptive cross-sectional
|
50 female rehabilitation nurses
|
Participants mostly agreed that rehabilitation nurses have a role in disaster response, but 72% of them had no experience of disaster work and 94% felt that they need training in disaster rehabilitation. 90% were eager to receive training on this topic.
|
Occupational therapy role in disaster management in Bangladesh (49)
|
To investigate the numbers and role of occupational therapists who have worked in disaster management in Bangladesh.
|
Bangladesh
|
Non-specific
|
Observational
|
3 occupational therapists who had disaster response experience
|
There are very few OTs working in disaster management in Bangladesh. The 3 participants who respond reported undertaking preparedness activities such as community risk mapping, advocacy and providing assistive technology.
|
The Urgent Rehabilitation Technique Education Program for Wenchuan earthquake (51)
|
To describe the activities of the specialist forum for the patients injured in the earthquake
|
China
|
Wenchuan 2008 earthquake
|
Case report
|
1500 hospital workers in the most earthquake prone areas
|
The short-term program developed covered the basic clinical technical trainings in physiotherapy, occupational therapy, prosthetics and orthotics to rapidly upscale rehabilitation service capacity for earthquake victims.
|
Physiotherapy in Haiti: A qualitative study exploring local clinicians' perspectives (47)
|
To describe the strengths, weaknesses, opportunities and threats to the development of physiotherapy Haiti after the 2010 earthquake
|
Haiti
|
2010 earthquake
|
Descriptive study
|
4 physiotherapists and 1 rehabilitation technician
|
Respondents identified the lack of funding to be the main the profession's main barrier: funding to create employment opportunities for rehabilitation professionals, and for the population to be able to access affordable physiotherapy services.
|
Health information systems
Three studies from 2 countries fulfilled the criteria for the health information systems category (Table 4), all of them relating to earthquakes. Evidence shows that disasters can result in significant disability (52) and a significant need for rehabilitation, assistive technology, and community modifications due to environmental barriers or earthquake damage (53, 54). Box 3 summarizes recommendations of studies focusing on health information systems with the most referenced recommendation being that provision of early and appropriate rehabilitation, which includes psychological support and assistive technology, is essential.
Box 3 Summary of recommendations from the included health information systems studies
Table 4 Summary of the health information systems results
Title
|
Aims
|
Country
|
Disaster
|
Type of study
|
Target group
|
Findings
|
Function
|
Impairment and functional status of people with disabilities following Nepal earthquake 2015 (52)
|
To investigate the disability status of earthquake survivors a year after the earthquake.
|
Nepal
|
2015 earthquake
|
Observational cross-sectional survey
|
29 persons with disability in the Bahunepati area
|
The average percentage score of disability, calculated by the WHODAS 2.O scoring guidelines was an average of 56%. One year after the earthquake, the number of people with disabilities was few, but the level of disability among them was high.
|
Evaluation
|
Epidemiological analysis of trauma patients following the Lushan earthquake (53)
|
To analyze the earthquake injury characteristics and treatments.
|
China
|
2013 Lushan earthquake
|
Observational study
|
2010 patients admitted to hospitals with earthquake related injuries
|
70.5% patients had limb dysfunction. For 60% of these, rehabilitation records could be found and the median time to start rehabilitation was 1 week and the median duration was 3 weeks. 508 patients required assistive technology devices
|
Implementation
|
Rehabilitation needs of the survivors of the 2013 Ya'an earthquake in China (54)
|
To determine the physical, functional and psychosocial rehabilitation needs of those injured
|
China
|
2013 Ya’an earthquake
|
Observational survey
|
143 survivors with lower limb and spinal fractures
|
74.8% required rehabilitation, 44.8% needed splints and 45.5% needed home modifications. There was a high need for assistive devices and home and community modifications due to environmental barriers or earthquake damage.
|
Implementation
|
Leadership and governance
Three policy studies from Iran, Nepal and the Philippines were categorized under leadership and governance (Table 5), all documenting professional organisations’ attempts to develop national rehabilitation disaster preparedness plans. These studies suggest that disaster preparedness and response activities are likely driven from the ‘bottom up’ in the absence of policy, and indicate a possible lack of awareness of rehabilitation in disasters at national coordination levels.
Ardalan et al (2016) (55) described the process of developing a comprehensive disaster preparedness plan for rehabilitation in Iran and identified that information sharing, advocacy in the media, workforce education, and availability of funding were the best methods for improving stakeholders’ participation and collaboration in formulating a rehabilitation disaster plan. Inadequate basic services provided by unqualified staff had the greatest negative impact on formulating a rehabilitation disaster response plan. Reflecting on the 2015 earthquake, the Nepal physiotherapy association (8) made recommendations for future disaster response planning and concluded that the immediate activation of the pre-established rehabilitation subcluster played a key role in coordinating the earthquake response and then implementing a long-term rehabilitation strategy that included community services for those in remote locations or who had lost their homes. They emphasized that coordination and strong leadership are essential for effective response, and that professional associations should be consulted. Box 4 summarizes recommendations of studies focusing on leadership and governance with the most referenced recommendations listed being: 1) Advocacy on the role of rehabilitation professionals (44) (55) (8) and 2) rehabilitation professionals and community health workers should be involved in drafting of disaster response plans (8, 44, 55).
Box 4 Summary of recommendations from the leadership and governance results
Table 5 Summary of the leadership and governance results
Title
|
Aims
|
Country
|
Event
|
Type of study
|
Participants
|
Findings
|
Function
|
Responding to physical and psychological health impacts of disasters: case study of the Iranian disaster rehabilitation plan (55)
|
To report the process of developing a comprehensive pre-disaster plan for physical and psychological rehabilitation Iran.
|
Iran
|
Non-specific
|
Case report
|
80 health disaster experts working in 34 governmental and nongovernmental organizations.
|
Sharing information, education, workforce training and funding were identified as the best methods of improving stakeholders’ participation and collaboration in formulating a disaster plan.
Inadequate basic services with unqualified staff had
the greatest negative impact.
|
Policy
|
The role of physical therapists in the medical response team following a natural disaster: Our experience in Nepal (8)
|
To describe the PT role in the response, and recommendations for future planning.
|
Nepal
|
2015 earthquake
|
Case report
|
Nepal Physiotherapy Association
|
The immediate activation of the pre-established rehabilitation subcluster played a key role in coordinating the earthquake response and implementing a long-term rehabilitation strategy that included community services for those in remote locations, or who had lost their homes. Coordination and strong leadership are essential at all levels. National associations are well placed to support both national and local planning.
|
Policy
|
Development of a national occupational therapy disaster preparedness and response plan: the Philippine experience (44)
|
To describe the process to produce the national occupational therapy Philippine disaster preparedness and response plan and to document the challenges of the task.
|
Philippines
|
Non-specific
|
Descriptive report
|
Occupational therapists, community development workers and organizations of persons with disabilities.
|
A national workshop took place and a disaster response plan and framework were produced to highlight the role occupational therapists should play in disaster response, and plans made to incorporate them into disaster response and to build up workforce capacity.
|
Policy
|