Recovery, Renewal, Resilience

COVID-19’s prolonged nature, and the intensity of measures taken to respond to it, have brought major disruptions with lasting consequences. Our relationship to mortality and death has been redefined, not least by disruption to traditional rituals that enable societies to cope with and overcome major trauma. A recent webinar, organised as part of the Manchester Webinar Series, considered how we might collectively remember the COVID-19 pandemic. Our speakers reviewed lessons from the past on building resilience through coproduced commemoration and discussed key considerations for policy makers and communities in planning to recognise and remember the huge losses caused by COVID-19. Consider the key lessons offered by our speakers:

• There is no one way to remember. Unlike most disasters, each individual’s experience of COVID-19 is a personal one and commemoration activities will require careful consideration around ways to bring people together to collectively to remember while also recognising the uniqueness of everyone’s experience
• The co-production of activities can provide a way to ensure commemoration is inclusive of all of those who would like to be involved, to create a collaborative and bottom-up as well as top-down delivery of remembrance, and enable communities to take ownership of their remembrance
• Consideration for who will lead and be involved in these conversation will be really important, to mediate, and to support communities to find ways to compromise on differing views and perspectives on commemoration
• The timing of commemoration is a challenge, considering that COVID-19 is now a long-term chronic problem and we are not at the end of the disaster. The pandemic has seen commemoration since the beginning, demonstrating how communities can begin to create spaces of remembrance even while the crisis persists. Some examples of these commemoration activities can be found in TMB Issue 34 and Issue 29
• Memorials can be political, and grand gestures such as monuments can fade, or be contested. This reinforces the need for co-produced commemoration, enabling the voices of those who will benefit most from commemoration activities to be heard and actively participate
• Education is a good form of remembering, through storytellers or creating spaces (online or in local newspapers) where people can share their individual experiences of the pandemic. Recording those memories now will enable authentic materials to support education in years to come
• Think about how those who have lower agency in communities will remember (e.g. children who have lost grandparents). Commemoration could be done by creating spaces in schools/community youth groups for teachers/youth volunteers to support children

Lockdowns, shielding and school closures have significantly reduced social contact for many people, including older people, children, people with underlying health conditions and those with disabilities. Prolonged isolation from family, friends and social activities poses significant risks to mental health and well-being. To address the impacts of this, consider:

• Establish a community-led mental health and well-being initiative, to support those who may be at risk of more serious distress, to keep people in the community connected and enable socialisation for those who are isolated
• Provide Psychological Frist Aid (PFA) training for those involved in the initiative (see TMB 17)
• Involve local voluntary organisations and groups, and local businesses in establishing and funding the initiative
• Develop a 'check-in' system to build relationships with people in the community and develop an understanding of needs and concerns of those shielding or isolating
• Establish a buddying or be-friending programme to enable local volunteers to support the needs of people in the community by shopping for food, picking up prescriptions or simply just calling virtually/popping by for a chat from the garden:
  • Match a volunteer buddy with up to 10 vulnerable adults/families
  • Buddies can link those who are isolating into existing groups and social activities in the community
• Set up online social activities:
  • Virtual story-telling for children by senior citizens, and vice versa
  • Weekly bingo, book club, quiz night, coffee mornings and kids discos
  • Add humour and prizes for all, such as drawings made by children, to mitigate competitive behaviour in games
  • Online home exercise classes or gardening tutorials
• Recognise that vulnerable people who are isolating may not have access to the internet for virtual activities so also run non-online events:
  • 'Door-step book club', where buddies call to those shielding and discuss books from the person's garden, ensuring they are socially distanced
  • Encourage community donations from businesses/households of unused computers/tablets
  • Develop and deliver local newsletters to include activities such as crosswords/puzzles, and stories written by community members

Important parts of recovery are mourning the loss of loved ones, and remembering those who have tragically lost their lives through the pandemic. Consider opportunities to memorialise, including:

• Develop a website dedicated to those who have died during the pandemic, allowing families to create obituaries, find a network of support, and help those who may feel alone in their grief
• Hold online memorial services to enable people to come together and remember loved ones
• Build and dedicate a memorial to those who have died, e.g. St Paul's Cathedral will build an inner portico at the North Transept and dedicate it as a physical memorial to those who have died due to COVID-19
• Invite those of all faiths and none to join in remembering loved ones to offer a safe and inclusive space of refuge, solace and hope

To ensure appropriate memorialisation, consider:

• coproduction of memorialisation options with communities
• collaboration with partners that specialise in supporting those who have been affected by bereavement
• whether the memorial is to those who have died, those who have been otherwise affected by the crisis, and/or those who have helped in the response to the crisis

Period poverty has increased sharply in the UK since the COVID-19 pandemic. Period poverty is defined as the struggle to pay for basic sanitary products on a monthly basis. Reports from one charity state they have supplied almost six times as many menstrual products compared with before the pandemic started. Around one in five people have experienced period poverty in the UK which has a significant impact on hygiene, health and wellbeing. Period poverty has risen as result of self-isolation, loss of income, and loss of access to services which may have provided free sanitary products. Scotland has become the first country in the world to provide free and universal access to period products, and places a legal duty on local authorities to make period products available for all those who need them. Consider how to:

• Encourage schools, colleges and universities to provide sanitary products for free
• Encourage businesses and places of work to provide sanitary products
• Establish programmes where sanitary products are distributed to low-income households
• Partner with pharmacies to offer free sanitary products to those eligible for free prescriptions
• Raise awareness of trans, non-binary, and genderqueer people's rights to access sanitary products and ensure provision to them

Well-being hubs strategically placed across a location could build on successful initiatives already delivered by the voluntary sector. Such hubs can be used to tackle health inequalities, and help reduce the rise in mental health issues due to the COVID-19 pandemic. Hubs would ideally offer face-to-face support, and would have to ensure COVID-19 safety measures. Hubs may support:

• Health services during the COVID-19 pandemic and relieve pressures on the system through partnership working between healthcare providers, local councils, housing and the voluntary sector e.g. The Hubs in Wakefield, West Yorkshire, relieve pressure on primary care - in six months The Hubs have seen almost 2,000 people including 636 urgent referrals
• Preventative health and wellbeing policies that protect people and reduce potential strains on health and social care services
• Social prescribing, whereby local agencies can refer people to a Link Worker who support people in focusing on 'what matters to me' and taking a holistic approach to health and wellbeing. They connect people to community groups and statutory services for practical and emotional support

Many people may be concerned about the rising cases in some areas and the risks of returning to work. So, the return to workplaces, including the risks this may pose to people’s health, may cause anxiety due to a heightened sense of risk of COVID-19 infection and uncertainty. Consider how new routines may be developed to avoid people becoming overwhelmed. Consider:

• Regular team meetings and debriefs to discuss anxieties about returning to work and any concerns or learning that may arise
• Allocating dedicated ‘buddies’ to support colleagues at work. These people could be from other departments to support confidentiality, and have specific training on helping people to manage their anxieties, on the organisations’ process and plans for safe working, and additional services staff may want to access
• Clear and simple protocols that outline how workplaces will keep employees safe and any workplace adaptations that have taken place
• Accessible ‘Frequently Asked Questions’ sections on organisations’ websites to provide answers to the most common concerns, including signposting to other relevant services such as health and wellbeing support at work
• Providing opportunities for e-learning or training on managing anxiety about returning to work and COVID-safe practices in the workplace
• Surveying staff to understand their enthusiasm for returning to work and addressing concerns raised

University students are beginning to return to communal housing located in residential areas. This, alongside rising COVID-19 infections in younger people and fatigue for COVID-19 restrictions, requires consideration of student welfare, and the management of potential transmission. Consider:

• Who should lead the management of a new community of students in cities (e.g. voluntary sector, universities, local authority) including responsibilities for welfare checks, test and trace, GP registration, and food distribution to student households if they are required to isolate
• Providing a point of local support for students, outside of their academic institution, for students who may have moved away from home. Consider partnership with local voluntary sector to coordinate with the local authority such as the OneSlough project which uses 'Community Champions' to provide information and resources to residents
• How the potential movement of students will be managed e.g. if they become ill and decide to go back home, and the impacts of this on potential transmission in two communities i.e. where they reside as students, and their home
• Targeting local online social media influencers to reach younger audiences to communicate COVID-19 messaging and promote track and trace

With social distancing, limited public transport, and advice on safe working practices, some employers have closed work sites and have required staff to work from home. Many staff report that they work from home diligently, often putting in extra time to support their employer. However, some staff report suspicion that colleagues who are being paid to work from home are not working diligently; for example, logging onto work but not working, failing to attend meetings or provide agreed deliverables, enjoying alternative activities when they should be working, or working reduced hours. In recognition of the disparity between peoples' approaches to working from home, consider:

• how perceived disparity of effort may build resentment across the workforce
• how resentment may manifest itself, create difficult interpersonal working environments, and when intervention from senior staff is needed
• whether this perceived disparity will change work cultures and expectations beyond COVID-19

To address any resentment, consider:

• keeping an open mind on why resentment has developed
• addressing resentment by talking with staff regularly and when resentment is first detected
• identifying how different staff contribute to the organisation in different ways and why these may not always be visible to other colleagues
• communicating justification for work allocation across staff, ensuring fairness at work
• how the organisations may support staff to improve arrangements for working from home
• when conversations are needed to address performance concerns

Extreme fatigue, nausea, chest tightness, severe headaches, "brain fog" and limb pains are among the recurring symptoms described by some sufferers of COVID-19 for weeks/months after their diagnosis. NHS England has developed an online portal for people in England to access tutorials, contact healthcare workers and track their progress called "Your COVID Recovery". Consider development of similar services that include:

• Access to a clinical team including nurses and physiotherapists who can respond online or over the phone to any enquiries from patients
• An online peer-support community for survivors - particularly helpful to those who may be recovering alone
• Exercise tutorials that people can do from home to help them regain muscle strength, and lung function in particular
• Mental health support, which may include a psychologist within the service or referral into other mental health services along with information on what to expect post-COVID
• Face-to-face provision for physical rehabilitation where possible, ensuring the safety of staff and patients
• Support from professionals such as dieticians, speech and language therapists, occupational therapists
• Cultural practices and relationships with rehabilitation needs

There is also an ongoing need for data collection about a nation's health to understand the long-term effects of this disease.

Agoraphobia is an anxiety disorder characterized by symptoms of anxiety in situations where the person perceives their environment to be unsafe with no easy way to escape. People may feel ill, nervous, embarrassed or fearful in public places. With self-isolation and social distancing being a core component of 'living with COVID-19', people may feel trapped or particularly concerned about contamination and infection. Consider the provisions required to support people including:

• Helplines for those wanting to talk over the phone and support lines via live chat, text or email for those who don't wish to call or are unable to
• Webinars for the general public such as: how to be kind & compassionate to yourself', and 'dealing with COVID-19 negative thoughts when you already have anxiety'
• Access to approved therapists able to offer 1:1 support through therapies such as Cognitive Behavioural Therapy (CBT) and counselling

Signposting to supportive apps such as Headspace (www.headspace.com) or Calm (www.calm.com)

Public Health England have adopted a place-based, whole system approach to improving the health of the poorest. This strategy aims to build healthy, resilient, connected and empowered communities on mental health - and sits alongside wider strategies on "Place-Based Approaches for Reducing Health Inequalities". This involves scaling a range of community-centred approaches, addressing community level determinants. Consider addressing the following principles:

1. Scaling: Rolling out a flexible approach rather than applying a standard model using integrated community-centred approaches e.g. integrated wellness services at the local neighbourhood level. Utilise local resources and expertise
2. Involving: Gather community insights and encourage participation to better understand people's health needs
3. Strengthening: Grow local capacity and knowledge through workforce development to build core skills in the community. Encourage a thriving voluntary, community and social enterprise sector
4. Sustaining: Address social determinants of health, as they directly impact on people's resilience and ability to participate. Develop short, medium and long-term indicators about what matters to communities and share between agencies and communities

This week in the UK is Carers Week. Carers Week aims to raise awareness of caring and the challenges carers face. It is also a time to help people who may not identify as having caring responsibilities and to help them recognize this so they can access much-needed support[1]. This is particularly important as an estimated 4.5 million people in the UK have become unpaid carers for elderly, disabled or physically or mentally ill relatives since the COVID-19 pandemic[2]. This is on top of the existing 9.1 million unpaid carers that already provide support in the UK[3].

Around 2.7 million women and 1.8 million men have become new carers, typically helping with food shopping, finances, collecting medication and providing emotional support2. Others may be taking on more intense roles that include helping people with personal hygiene, movement around the home and meal preparation. 62% who have started caring since the outbreak are also juggling paid work alongside their caring responsibilities[4].

Unpaid carers in the UK have described facing mounting anxiety and frustration regarding getting access to vital medication from pharmacies and time spent queuing for medication or food shopping due to social distancing rules[5]. As a result, the following advice has been provided to improve carers’ experiences and ability to access the medicines they need. These include:

• Allowing two people into store when the carer has no choice but to take the person being cared for to the pharmacy with them
• Considering prioritising un-paid carers of vulnerable/shielding people for medicine delivery slots
• Recognising that, for some families, young carers are the only people able to collect medicines in the household

Recognising the role of young carers is extremely important. Of the 13 and a half million unpaid carers in the UK, an estimated 700,000 are children[6]. Evidence suggests that young carers and young adult carers are being disproportionately impacted by COVID-19 and are experiencing high levels of anxiety and isolation as a result of lockdown[7]. Many young carers are under increasing strain while schools remain closed as caring responsibilities increase and time away from these at school decreases[8].

Additionally, other systems used to support and safeguard young carers such as health and social care systems, are struggling under the pressure from COVID-19 impacts[9] as they continue to make changes to accommodate the needs of disabled and vulnerable people[10]. While this is vital, it may draw attention away from the often hidden and marginalised needs of young carers[11], and may miss many new young carers[12]. Where young carers are in contact with local authorities, they are encouraged to discuss with what support or services they need by[13]:

• Thinking about good and bad days being a carer
• Making notes about a typical day helping the person they care for, including their own needs and concerns
• Thinking about things which would help them cope, their aims, hopes, and what is important to them

Although there a huge challenges for unpaid carers, the issue is gaining visibility as a result of the rising numbers of people providing care and has led to calls to government to deliver social care reforms that detail long-term investment into care and support services[14]. This is increasingly important as the timeframes of the pandemic are unknown, and more people may be required to provide care for longer periods of time. Charities supporting carers have called for4:

• An increase in Carer’s Allowance – currently £67.25 a week
• A “one-off coronavirus supplement” in recognition of the role unpaid carers have played in the pandemic and the significant costs associated with caring
• Increased recognition of the vital work unpaid carers provide and the limited support they can currently receive due to COVID-19 restrictions
• Physical and mental support for carers and increased investment in support services
• Carers must be a priority for regular testing and PPE, particularly where they care for the most vulnerable

The government recommends that all carers create an emergency plan with the person they care for to use in circumstances where help from other people to deliver care is needed. This may be from family, friends or another care provider[15]. They advise the following details are provided:

• The name and address and any other contact details of the person you look after
• Who you and the person you look after would like to be contacted in an emergency
• Details of any medication the person you look after is taking

Details of any ongoing treatment they need and any medical appointments they need to take

References:

[1] https://www.carersweek.org/about-us

[2] https://www.carersweek.org/media-and-updates/item/493439-covid-19-pandemic-4-5-million-become-unpaid-carers-in-a-matter-of-weeks

[3] https://www.carersweek.org/media-and-updates/item/493439-covid-19-pandemic-4-5-million-become-unpaid-carers-in-a-matter-of-weeks

[4] https://www.carersweek.org/media-and-updates/item/493439-covid-19-pandemic-4-5-million-become-unpaid-carers-in-a-matter-of-weeks

[5] https://carers.org/news-and-media/news/post/42-organisations-work-together-to-improve-unpaid-carersa-access-to-medicines-during-the-covid-19-pandemic

[6] https://www.bbc.co.uk/news/av/uk-52948236/coronavirus-life-as-a-young-carer-under-lockdown

[7]https://carers.org/what-we-do/our-survey-on-the-impact-of-coronavirus-on-young-carers-and-young-adult-carers-

[8] https://www.bbc.co.uk/news/av/uk-52948236/coronavirus-life-as-a-young-carer-under-lockdown

[9] https://www.uea.ac.uk/about/-/new-project-examines-impact-of-covid-19-on-young-carers

[10] https://www.uea.ac.uk/about/-/new-project-examines-impact-of-covid-19-on-young-carers

[11] https://www.uea.ac.uk/about/-/new-project-examines-impact-of-covid-19-on-young-carers

[12] https://carers.org/what-we-do/our-survey-on-the-impact-of-coronavirus-on-young-carers-and-young-adult-carers-

[13] https://www.southlanarkshire.gov.uk/info/200220/carers_and_caring/505/carers/11

[14] https://www.itv.com/news/2020-06-08/millions-have-become-carers-due-to-covid-crisis-new-research-finds/

[15] https://www.gov.uk/government/publications/coronavirus-covid-19-providing-unpaid-care/guidance-for-those-who-provide-unpaid-care-to-friends-or-family

For example:

• Collect data on the mental health effects of COVID-19 across the population and vulnerable groups
• Monitor and report the rates of anxiety, depression, self-harm, suicide, and other mental health issues
• Determine what psychological support is available to front-line medical/health-care staff and their families
• Determine the best ways to signpost and deliver mental health services for vulnerable groups, including online clinics and community support
• Use health messages to optimise behaviour change and reduce unintended mental health issues
• Design longer-term strategies to address an increased volume of mental health issues and their impacts on service demand
• Target population-level interventions to prevent and treat mental health symptoms (e.g. anxiety) and boost coping and resilience (e.g. exercise)
• Synthesise an evidence base of lessons learned for future pandemics, tailored to specific groups, to motivate and enable people to prepare psychologically and plan for future scenarios

Consider:

• How prayer spaces will be managed for keyworkers- allocate suitable spaces with social distancing requirements in mind, provide adequate notice should a prayer space be closed for cleaning
• Public information regarding Iftar and Eid; the breaking of fasting each day (Iftar) is usually a sociable even. Remind the public that despite its personal religious importance, social distancing measures need to be observed. The same measures also apply to the end of Ramadan (Eid). Eid is on Saturday, 23 May 2020, and even if some lockdown restrictions have been eased, it is important to remind the public that social distancing is still required. Consider working through local leaders, community members and where appropriate the police, to ensure public safety
• These lessons are applicable to other major religious events, or holidays - consider processes to manage events such as Diwali, etc. While later on in the year, it is likely social distancing measures will still need to be observed

Material for those supporting frontline workers has been developed using the latest evidence and drawing on expertise from across the world.

One-page resources are available on issues including: readiness, team dynamics, decision making, leadership, post-traumatic stress disorder (PTSD), resilience. This resource is continually being added to.

Training in psychosocial first aid can help here to increase the network of people who can provide psychosocial support. This can facilitate the population's recovery. This acknowledges that some will need help at a professional level.

Reference: UK County Council

For example: age, gender, and race. In the UK of 2,250 adults surveyed 49% said they had felt more anxious and depressed than normal, 38% said they were having trouble sleeping and, 22% said they were concerned about significant money problems. If current measures are to persist, these figures are likely to rise.

For example, a study in the UK showed that among 24% of 16-24-year-olds said they were finding it extremely difficult to cope with the lockdown. Only 11% of those aged 45 to 75 said they were struggling. While older populations may be more susceptible to the physical impacts of COVID-19, younger people may be impacted more psychologically.