COVID-19 and community health services for dependent older people in Fortaleza, Brazil
9 November 2021
It can be taken for granted that the COVID-19 pandemic has reduced older people’s access to essential health and social care services. However, collecting specific data on these effects has been challenging. Health workers have been overwhelmed with crisis management and researchers have been unable to go into the field due to the risks of infection. Over the past four years, we have been part of a larger team in a project assessing interventions to address the health and social care needs of poor older people in Brazil. This has involved fieldwork and data collection in two different cities: Belo Horizonte and Fortaleza. Our plans were made before the COVID-19 pandemic and so we have had to adjust to the new challenges this has posed.
One part of the project required us to interview vulnerable, care dependent older people about their needs and use of health services. This work was due to begin in early 2020 when the pandemic hit Brazil and we were forced to put it on hold for more than a year. Three months ago, we were able to resume. This had required us to adapt our data collection strategy to the new situation, ensuring that it was safe, ethical and that the questions we were asking were still relevant.
One key challenge we faced was that neither of us could travel to Brazil. This meant we had to develop a close working partnership with local Community Health Agents (known in Brazil as Agentes Comunitários de Saúde or ACSs). These ACSs are based in local health posts and provide a range of community services, such as vaccinations, home visits, collecting patients’ histories and assessing their general wellbeing. A small number of ACSs in Fortaleza agreed to help us identify and recruit older people for our study and to facilitate the interviews, which we conducted remotely using Zoom.
This has not been a perfect process. On one hand, having the ACSs present in the interview was often useful as they could clarify any question which the older person or his/her carer could not answer. On the other, the presence of the ACS may have discouraged informants from making any criticisms about the quality of care they were receiving, as well as raising other conflicts of interest. For example, after one interview it emerged that the ACS and older person were in fact neighbours and had known each other for a long time.
The interviews are ongoing, due to the limited free time of ACSs and other health professionals who are still dealing with the overwhelming challenges of the pandemic. But the testimonies we have collected to date are starting to reveal the degree to which these vulnerable older people have been cut adrift.
Even before the pandemic, many health and social care needs of our informants were not being properly met. But in from early 2020 almost all other health services previously provided to older patients were suspended, as the system focused exclusively on COVID-19. Despite the personal risks they faced, ACSs have continued to make home visits during most of the pandemic. However, they have usually avoided meeting older people in person, due to their elevated risk of death, if infected. Instead, ACSs have usually relied on doorstep discussions with family members, although some families refused to have any face-to-face contact with the ACS due to fears of infection. There were significant challenges for the ACSs to support frail and dependent older people in the community during the pandemic. In one of the ‘postos de saúde’ (health centres), the main medical doctor interrupted his work as he himself was in the high-risk group for contracting COVID-19. The health service in this particular posto de saude was reduced to a nurse with the support of ACSs in monitoring patients who presented signs of COVID infection, including older people, and when necessary, instructing patients or their families to seek the hospital services if their health deteriorated. Apart from emergencies, any other health conditions were deferred to until the health service could resume normal activities.
Having the ACS rely on family members’ accounts and communicating with the older patient added an extra barrier for the ACS to support this population. Additionally, many families tried to avoid as much as possible seeking hospital care, resulting in many older people dying in their homes or arriving at the hospital when it was too late.
The case of one 89 year-old informant gives a powerful illustration of how the pandemic has affected the oldest old. Dona Olicia (not her real name) already had a number of health problems dating back several years and had limited mobility after breaking her hip in a fall in 2016. In early February 2020, she broke her leg in another fall and spent some time in hospital. In terms of the timing of this event, she might be considered fortunate -by March and April the city’s hospitals had been overwhelmed with acute COVID-19 cases. A few days after her discharge, Dona Olicia made an outpatient visit for preliminary rehabilitation, but following that all health support was suspended. Her follow-up treatment was interrupted for 7 months – a period which could have been used for her to regain mobility in her leg. Her carers tried to speak with the doctor for further instructions but had no reply. No other support or instruction was given to Dona Olicia from March to July. During this time, she kept her leg immobile, preventing her rehabilitation at short and long term. Over time, Doña Olicia has become less mobile and now experiences chronic pain. She has been prescribed stronger pain medication and told that she needs to visit the local health post in order to resume treatment. However, she says she is in too much pain to walk there.
The lack of health services dedicated to looking after older people in their own homes can play a major role in unnecessary hospitalisations. Dona Lucia is bedbound and a wheelchair user. She requires round the clock care which is provided by her daughter. Dona Lucia’s mental capacity fluctuates through the day and she has a speech impairment. She sleeps in a special bed which is elevated to facilitate lifting her in and out. In April 2020 she had a fall from this bed and sustained a cut to the head that bled profusely. She was taken to hospital where the cut was treated. In hospital, she had several tests including a CT scan to check if the fall had caused any internal damage. Dona Lucia spent 2 days at the hospital waiting for the necessary tests which all came back clear. The doctor who looked after Dona Lucia recommended fitting a bed guard in Dona Lucia’s home to prevent any further accidents. However, the family did not fit the guard because they could find any in the local shops. Instead, Dona Lucia’s daughter placed the wheelchair next to bed hoping this would prevent her mother having a second fall. In July 2020 Dona Lucia had another fall and broke her nose as she hit her face against the wheel of the wheelchair. Dona Lucia was taken to hospital for 3 days for the necessary treatment and tests. After this incident, a friend of the family found a website which sells bed guards. The cost of the bed guard was around 120 Brazilian Reais (25 American Dollars). Dona Lucia did not experience further falls since using the guard bed.
Despite the challenges of remotely collecting data in the field, the testimonies of these older people and their carers are able to reveal the extent to which they have suffered the effects of health service disruption. Once we have the full set of interviews and have been able to analyse them systematically, we hope to develop them into an academic paper.
 This project is funded by a partnership between the UK’s Medical Research Council/Newton Fund (Grant Number: MR/R024219/1) and the Confederation of Foundations for Brazilian Research Support, with the participation of FAPEMIG (Grant Number: APQ-01141-18) and FUNCAP/CE (Grant Number: 0133-00003.01.00/18).