The questions that guide this study are: 1.

Regarding mitigation strategies to respond to disruptions in physiotherapy services during the COVID-19 pandemic, what strategies have been developed and what association exists between the mitigation strategies developed and the country income level of World Physiotherapy member organisations?

The 2022 annual membership census (AMC) of World Physiotherapy was adapted to include additional questions for answering our research questions. In addition to the standard AMC, two multiple choice questions on health emergency response and preparedness were developed (Figure 1). The first question was adapted from the WHO global pulse survey on continuity of essential health services during the COVID-19 pandemic containing similar mitigation strategies for selection (5). The second question was developed with the WHO Rehabilitation Programme and based on core components for health emergency preparedness planning. The response options for the second question contain similar components to the WHO indicator on health emergency preparedness for rehabilitation (15), which contain 8 components and was published after the AMC questions were developed.

Respondents were permitted to select more than one response option for each question. For question 2, an open field box was available to provide more information on any health emergency preparedness component.

AMC questions have not been piloted or cognitively tested prior to inclusion in the census. Questions were written in English and translated into French and Spanish by the authors and checked for conveying the same questions as in the original English version by colleagues that were native French and Spanish speakers. Respondents representing MOs were instructed to contact World Physiotherapy if they needed clarification on any AMC questions.

As per standard procedures, the AMC was sent to the primary contact for each World Physiotherapy MO. World Physiotherapy has only one MO per country/territory. Member organisations are divided into 5 World Physiotherapy regions: Africa, Asia Western Pacific region (AWP), Europe, North America Caribbean region (NACR), and South America region (SAR). Responses to AMC questions may be based on authoritative national data sources or informal sources of information from individuals with deep knowledge of the profession.

Descriptive statistical analyses were conducted for response frequencies on each multiple-choice question on health emergency response and preparedness using Microsoft Excel. Frequencies for each response option were calculated for all participating countries/territories, each region, and by country/territory income level.

Two chi-square tests of independence were conducted. A chi-square test of independence was conducted to examine the relationship between country/territory income level and health emergency components. Another chi-square test of independence was conducted to examine the relationship between regions and mitigation strategies.

24% of all participating MOs reported not adopting any of the listed mitigation strategies to overcome physiotherapy service disruptions in their country/territory during the COVID-19 pandemic. Of the 76% of MOs that reported having mitigation strategies, the most frequently cited strategy was telerehabilitation (57%) to replace or augment in-person services; followed by 42% for provision of home-based care where appropriate; 41% for promotion of self-care interventions where appropriate; 39% for redistribution of physiotherapist roles (task shifting); 24% for an expansion of facility hours; 19% for rapid training mechanisms and job aids for key capacities and new tasks and roles; 12% for integration of patients into alternative care sites; and 9% for catch-up campaigns for missed appointments. 65% of all respondents reported more than one mitigation strategy.

Telerehabilitation was the most frequently reported mitigation strategy in all regions except the Africa region, which reported home-based care as the most frequent mitigation strategy (Table 1).

The result of the chi-square test found no association between region and mitigation strategies (p-value 0.65; chi-square statistic: 28.47, degrees of freedom: 32).

64% of participating MOs (74/116) reported that physiotherapy services were not included in any health emergency preparedness component in their country/territory. The remaining 36% MOs (42/116) reported that physiotherapy was integrated into one or more health emergency preparedness components. The most frequently cited component was training key physiotherapy staff to manage a range of hazards at 18% (21/116); followed by 17% (20/116) for integration of physiotherapy into national and subnational health emergency preparedness plans; 15% (17/116) for having a plan for managing a potential surge of physiotherapy needs in the event of an emergency; 12% (14/116) for having a plan to sustain essential physiotherapy services in the event of an emergency that disrupts or diverts services; 11% (13/116) for mapping of key facilities providing physiotherapy and referral pathways for use in an emergency; and 8% (9/116) for stockpiling of physiotherapy equipment to manage a surge in rehabilitation cases (Table 2).

17% of MOs (20/116) reported having included physiotherapy in more than one health emergency preparedness component in their country/territory (Table 2 and Figure 2); 3 of the 23 MOs in the Africa region, 7 of the 28 MOs in AWP, 7 of the 41 MOs in the Europe region, 2 of the 14 MOs in NACR, and only 1 of the 10 MOs in SAR. Integration of physiotherapy services into (sub)national health emergency preparedness plans was reported in all 3 MOs in the Africa region (Ethiopia, Kenya, Togo) that selected more than one component. In AWP, surge planning and integration of physiotherapy into (sub)national health emergency preparedness plans were most reported in Australia, Fiji, India, New Zealand, Philippines, Saudi Arabia and Yemen. In the Europe region, integration into (sub)national health emergency preparedness plans, stockpiling physiotherapy equipment, and training of key physiotherapy staff were identified as the most frequent components when multiple components were selected in Belgium, Bosnia and Herzegovina, Denmark, France, Palestine, Poland, Slovakia and the United Kingdom. In NACR, having a plan to sustain essential physiotherapy services in the event of an emergency, and mapping of key facilities providing physiotherapy services and referral pathways for use in an emergency were selected for both Guyana and Jamaica. In SAR, Costa Rica reported the inclusion of physiotherapy in all health emergency preparedness components.

In terms of absolute numbers of components for health emergency preparedness planning that included physiotherapy services, 8% (9) of countries have 2 components, 3% (3) of countries have 3 components, 2% (2) of countries have 4 components, 3% (3) of countries have 5 components, and 3% (4) of countries have all 6 components (Table 3).

The most frequently cited health emergency preparedness planning component in high and upper-middle income countries/territories was training of key physiotherapy staff to manage a range of hazards (19%) (Table 4, Figure 3). Training of key physiotherapy staff to manage a range of hazards and integration of physiotherapy services into national and subnational health emergency preparedness plans were equally reported as the most frequent health emergency preparedness component in upper-middle (19%), lower-middle (15%) and low income (18%) countries/territories (Table 4).

The result of the chi-square test found no association between income level and health emergency preparedness measures (p-value 0.98, chi-square statistic:4.13, degrees of freedom: 12).

In terms of mitigation strategies, a key finding of this study is the high percentage of World Physiotherapy MOs that reported mitigation strategies to overcome physiotherapy service disruptions in their country/territory. While this was due to a response to the COVID-19 pandemic, the strategies could be used in other emergency contexts. With no relationship between World Physiotherapy regions and mitigation strategies, the most frequently reported mitigation strategies for physiotherapy services are similar to those reported in the global WHO Pulse Survey 2023 (16). Both AMC respondents and WHO member states representing multiple health sectors reported telerehabilitation/telemedicine, home-based care, and use of self-care interventions among the top strategies implemented in response to the COVID-19 pandemic.

The most commonly adopted mitigation strategy was telerehabilitation to replace or augment in-person services. While telerehabilitation may be a key mitigation strategy, particularly for service disruption due to a pandemic, considerations should be made regarding appropriate device availability and connectivity for future use. Challenges with these likely contributed to the low uptake of telerehabilitation in the Africa region which has the highest percentage of low-income countries and had the lowest telerehabilitation uptake compared with other regions. Moreover, while delivering physiotherapy services via telerehabilitation has evidence to support its effectiveness, it should not be seen as a solution to all emergency related challenges as patient, physiotherapist, and organizational barriers are known to exist (17). It cannot replace inpatient acute and post-acute rehabilitation and is unlikely to be helpful in managing the acute rehabilitation needs created by many emergencies.

Many of the mitigation steps adopted, including task shifting, the formal promotion of self-care, rapid training, expanded service hours and identification of alternative care sites are also critical steps to manage a surge and must be included in emergency preparedness plans to be able to be safely and rapidly implemented.

Future World Physiotherapy AMCs should continue to include questions on mitigation strategies and preparedness measures. Longitudinal analyses should be conducted to monitor change from the baseline provided in this study. This should be complemented with evidence of integration into (sub)national planning and context-specific qualitative information and detailed examples of mitigation strategies and preparedness measures.

Other international rehabilitation organizations should consider developing similar surveys aimed at understanding mitigation strategies and the level of integration of other rehabilitation professions at the (sub)national level. The WHO indicator for health emergency preparedness for rehabilitation can be used to monitor preparedness.

Future studies on mitigation strategies and health emergency preparedness measures in rehabilitation should include a comparison of disaster risk to level of preparedness and document effective strategies and measures.

Validation of data was not confirmed with ministries of health. Responses to the AMC were provided by MO representatives who may not work in a ministry of health or have knowledge of recent or ongoing plans to include rehabilitation into preparedness planning at the government level. As a member's survey, there is also the potential for an advocacy bias in responses.

Response options in the AMC did not allow for in-depth reporting of information regarding the quantity or quality of mitigation strategies or preparedness measures in each country/territory. AMC respondents were not asked to provide data sources or examples of mitigation strategies or preparedness measures for verification.

Further, how well MOs understood the AMC questions is unknown. AMC questions were not cognitively tested, nor was a definition of mitigation strategies or preparedness measures provided. Responses are therefore interpretative of the respondent, and the descriptive nature of the study precludes causal interpretation.