The Impact of COVID-19 on Individuals with Hearing and Visual Disabilities during the First Pandemic Wave in Italy

Background. The COVID-19 pandemic has imposed radical behavioral and social changes in the general population, significantly impacting the lives of individuals affected by disabilities. The aim of this study was to investigate the impact of COVID-19 on non-institutionalized subjects with sensorineural disabilities during the first COVID-19 wave in Italy. Methods. A 39-item online national survey was disseminated from 1 April 2020 to 31 June 2020 via social media throughout Italy to communities of individuals with proven severe sensorineural disabilities, affiliated to five national patient associations. The survey collected extensive information on the socio-demographic profile, health, everyday activities, and lifestyle of individuals with hearing and visual disabilities. Results. One hundred and sixty-three respondents with hearing (66.9%) and visual (33.1%) disabilities returned a usable questionnaire. The mean age of interviewees was 38.4 ± 20.2 years and 56.3% of them were females. Despite the vast majority of respondents (77.9%) perceiving their health status as unchanged (68.8% of interviewees with hearing deficits vs. 96.3% of those with visual impairments), about half the interviewees reported sleep disorders during lock-down, more likely those with visual deficits. Remote services were seemingly more effective for business than school activities. Furthermore, although just 18.8% of respondents rated remote rehabilitation care unsatisfactory, only 12.8% of interviewees felt supported by health and social services during the COVID-19 emergency. The vast majority of respondents were concerned about the future and the risk of SARS-CoV-2 contagion, particularly individuals with hearing impairments. Among the various risk mitigation measures, facemasks caused the greatest discomfort due to communication barriers, particularly among interviewees affected by hearing disabilities (92.2% vs. 45.7%). The most common request (46.5%) of respondents to reduce the inconveniences of the COVID-19 emergency country lock-down was improving the access to and delivery of health and social services for individuals with sensorineural disabilities (19.3%), followed by the use of transparent masks (17.5%). Conclusions. Although health protection measures such as face masks and social distancing play a key role in preventing and controlling the spread of SARS-CoV-2, the unmet needs of disabled individuals should be carefully considered, especially those affected by sensory disabilities. Tailored access to health and social services for individuals affected by sensorineural disabilities should be implemented. Additional actions should include the use of to face masks to reduce communication barriers linked to hearing-impairment, as well as the improvement of remote services, especially distance learning at school.


Background
In January 2020, the Chinese government announced the outbreak of COVID-19, a respiratory disease caused by a novel beta-coronavirus subsequently called SARS-CoV-2. On 11th March 2020, COVID-19 was declared a pandemic by the World Health Organization (WHO) [1,2], and a country lock-down was enforced in Italy. Risk mitigation measures against the spread of COVID-19 immediately focused on identifying, treating, and isolating active cases of the disease and introducing health protection measures such as social distancing, frequent hand washing, and use of face masks, even outdoors [3].
Social restrictions against the spread of SARS-CoV-2 inevitably impacted the everyday and professional lives of all individuals, compromising inter-personal physical contacts and communications between people [4]. The health impact of COVID-19, the fear of SARS-CoV-2 contagion, and the unpredictable trend of the epidemic generated a strong emotional influence in the general population worldwide. Psychological distress such as anxiety, depression, and post-traumatic stress disorders have already been experienced in populations hit by the H1N1 influenza, MERS-CoV, and Ebola epidemics [5,6].
According to the United Nations, the psychological impact of COVID-19 has been even worse than the physical consequence of the disease [7]. For instance, in the UK, patients suffering from mental health problems increased by around 50% during country lock-down [8]. Furthermore, sleep disorders emerged as one of the main health problems associated with the COVID-19 emergency, increasing by 57.1% in Italy during country lock-down [9]. Sleep disorders have already been identified as one of the most common health problems and an early health indicator of the general population [10].
Some subgroups, such as those affected by disabilities, are inevitably more vulnerable to COVID-19 and less resilient to the respective social restrictions. Disabled individuals in fact typically experience economic hardships, have lower educational levels, have lower employment rates, and experience more barriers in accessing health and social care services than the general healthy population do [11,12]. The risk of death for COVID-19 during the first two months of the pandemic in England and Wales was 11 times higher among individuals with disabilities [13]. If, on the one hand, disabilities associated with poverty may create precarious social conditions, making it difficult to observe physical distancing and personal hygiene [12], on the other hand, COVID-19 may also increase social isolation, psychological distress, and difficulties in the interpersonal relationships of disabled individuals, who have a higher demand of health and social care support. Indeed, a recent nationwide survey reported that the psychological distress associated with COVID-19 was significantly higher among subjects affected by pre-existing conditions or disabilities in Italy [14]. Disability affects 1 billion individuals worldwide [12], 5.2% of the Italian general population (over 3.1 million people) [15].
By interfering with their capacity of accessing health and social care, habilitation, and rehabilitation services, communication barriers can play a major role in the vulnerability of subjects affected by sensorineural disabilities. These difficulties may be amplified by the lack of accessible information on the pandemic, as not all governments have provided sign language interpretation during COVID-19 briefings [11].
In view of the above, as the impact of COVID-19 on individuals affected by sensorineural disabilities has been almost neglected thus far, we conducted a survey on disabled individuals affected by hearing and visual impairments during the first COVID-19 pandemic wave in Italy, with the goal of understanding the effect of social restrictions on these particular social categories and their unmet needs, thus assisting policy makers to design tailored public health policies [16].

Materials and Methods
This observational survey was conducted through a specific 39-item online questionnaire, disseminated in Italy from 1 April 2020 to 31 June 2020 via social media to communities of individuals with proven severe sensorineural disabilities and affiliated with five national patient associations. The online version of the questionnaire was created through the "Survey Administration App" on the Google Forms web platform and circulated through multiple web channels (Facebook and Instagram). Furthermore, the survey tool was also shared within the mailing lists of the main dedicated Italian patients' associations: "Lega filo d' oro" ("Golden thread league"), "Italian blind union," "Italian families associated for the defense of the rights of the deaf people," "Umbria Onlus," "Let's face deafness together," and "Association of cochlear implant bearers" Onlus.

Inclusion Criteria
A convenience snow-balling sample was employed to recruit as many subjects with sensorineural disabilities as possible. Participation in the study was voluntary and there was no control on the number of study participants. All questionnaires returned were considered, but only subjects with hearing or visual impairments were included in this study.
Severe visual impairment is defined by the WHO [17] as a best corrected visual acuity of 3/60-6/60, whereas the term blindness implies full or almost full vision loss (corrected visual acuity <3/60).
By residual visus < 3/10 in both eyes or in the best eye, even with refractory correction; -binocular perimetric residue <30%.

The Questionnaire
The questionnaire used for the survey (Supplementary File S1) was designed by an interdisciplinary team composed by an otolaryngologist, a public health consultant, a psychologist, and a sociologist, with the support of patients' associations. The same four experts and an ophthalmologist reviewed the survey instrument, contributing also to improve its quality and reducing the initial number of questions from 45 to 39. As the survey was conducted in an emergency situation, during the first COVID-19 pandemic wave, a pilot test was conducted only on 3 sensorineural disabled patients.
The questionnaire investigated the impact of lock-down and various health protection measures on various aspects of participants' behavior, including health status, lifestyle, education, smart working, access to health and social care services, evaluation of remote rehabilitation services, use of personal protective equipment (PPE), and other risk mitigation measures.
The survey questionnaire was broken down into four sections: • The first collected demographic data of study subjects: sex, age, type of disability, and geographical area of residence.

•
In the second, the impact of the COVID-19 pandemic on education and working activities and on any changes in social relationships was delved into.

•
The third dealt with aspects of health/social care, rehabilitation care, use of PPE, and their eventual side-effects.

•
The last part of the questionnaire analyzed eventual repercussions of the COVID-19 pandemic on patients' quality of life in terms of sleep disorders, concentration difficulties, and use of symptomatic drugs. Further free answers provided understanding and insights.
For each answer to items of Sections 2-4, a 4-point scale (unsatisfactory, fair, good, and excellent) was used.
Questionnaires not fully completed were ruled out. This study was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained by the Italian National Institute for Deaf People. Informed consent was obtained from study participants before starting the survey online. Collection, storage, management, and analysis of survey data were conducted anonymously.

Lifestyle, Stress Management, and Related Stressors
In order to assess the impact of lock-down, risk and protective factors for psychological distress, including changes in routine activities and daily behaviors, were examined. Based on previous literature related to the COVID-19 pandemic [6,14,19,20], lifestyle and stress management items (e.g., 29-What were your daily life habits during lock-down?) and 6 stressors terms (e.g., 35-Have you experienced sleep disturbances during lock-down?; 36 Are you worried about the future?) were arranged.
Data analysis was performed using Stata 14.3 (Stata corporation, College station, Texas, USA). Descriptive statistics was performed, reporting frequencies and percentages. Univariable logistic analysis was also employed to contrast disability type (visual vs. hearing) by each explanatory factor. A p-value < 0.05 was considered statistically significant.

Results
After the exclusion of 25 questionnaires not fully completed, 163 study subjects with hearing and visual disabilities met the inclusion criteria.
The mean age of study participants (56.5% being females) was 38.4 ± 20.2 years. Sociodemographic and clinical features of respondents are summarized in Table 1. As can be seen, the vast majority of interviewees (86.9%) were living at least with one family member (partner, parent, or child) and 77.4% were living in a building with an open space (garden or terrace).

Lifehabits and Perceived Well-Being
As can be seen from Table 1, 85.9% (=122/163) of disabled interviewees had meals at regular time schedules during lock-down, and 44.8% (=73/163) reported weight gain. Moreover, whilst 75.5% of respondents were dedicated to recreational activities before the COVID-19 pandemic, this proportion reduced to 36.3% during lock-down (Table 2).

Education
As can be seen from Table 3, school activities continued during lock-down for 84.6% (=33/39) of student respondents. However, distance learning was rated unsatisfactory by

Education
As can be seen from Table 3, school activities continued during lock-down for 84.6% (=33/39) of student respondents. However, distance learning was rated unsatisfactory by 43.6% (=17/39) of students, of whom 65.0% were individuals affected by visual disabilities and 37.5% by hearing impairments (Figure 3).

Education
As can be seen from Table 3, school activities continued during lock-down for 84.6% (=33/39) of student respondents. However, distance learning was rated unsatisfactory by 43.6% (=17/39) of students, of whom 65.0% were individuals affected by visual disabilities and 37.5% by hearing impairments (Figure 3).   A support teacher, available to 68.4% (=26/38) of students before the pandemic, was no longer available to 61.5% (=16/26) of them during country lock-down, particularly to those affected by visual disabilities. Social relationships with classmates were also significantly compromised by the COVID-19 emergency, worsening for 37.3% (=19/39) of interviewees as compared to before the emergency (Table 3 and Figure 4). A support teacher, available to 68.4% (=26/38) of students before the pandemic, was no longer available to 61.5% (=16/26) of them during country lock-down, particularly to those affected by visual disabilities. Social relationships with classmates were also significantly compromised by the COVID-19 emergency, worsening for 37.3% (=19/39) of interviewees as compared to before the emergency (Table 3 and Figure 4).

Work
The majority of workers (84.9% = 62/73) continued their job during the COVID-19 emergency, with 66.7% (=46/79) of them being equipped with remote services by the respective employer. As can be seen from Table 3 and Figure 5, although the relative estimates were not statistically significant, individuals affected by visual disabilities appreciated remote working more than those with hearing impairments.
The rating of work relationships was similar between those affected by visual and hearing impairments, with most of both groups predominantly classifying their relationship with colleagues as unchanged as compared to before the COVID-19 emergency (Figure 6).

Health, Social and Rehabilitation Services
As can be seen from Table 4, most respondents (87.3% = 130/163) reported unsatisfactory support from health and social care services during the COVID-19 emergency,

Work
The majority of workers (84.9% = 62/73) continued their job during the COVID-19 emergency, with 66.7% (=46/79) of them being equipped with remote services by the respective employer. As can be seen from Table 3 and Figure 5, although the relative estimates were not statistically significant, individuals affected by visual disabilities appreciated remote working more than those with hearing impairments.  The rating of work relationships was similar between those affected by visual and hearing impairments, with most of both groups predominantly classifying their relationship with colleagues as unchanged as compared to before the COVID-19 emergency ( Figure 6).

Rating of work relationships
Hearing disability Vsual disability Figure 6. Answers to question: "How do you rate your current work relationships as compared to before the COVID-19 emergency?".

Discussion
This online survey investigated the impact of health protection measures against the spread of SARS-CoV-2 on a sample of individuals affected by sensorineural disabilities during the first COVID-19 pandemic wave in Italy. Social media proved to be a valuable, quick, and low-cost instrument to distribute the survey in a relatively short time. However, access to social media may be hampered for some disabled individuals, who therefore may have been excluded from participating in this study. Despite a relatively limited statistical power and low representativeness of the sample, the findings of this survey are still useful to obtain indications of the health and psychological stress suffered by individuals affected by hearing and visual disabilities during the COVID-19 emergency in Italy.
In particular, the pandemic seemingly had a negative influence on the everyday life of disabled individuals affected by sensorineural impairments. Among the most relevant issues experienced by study subjects were a fear of SARS-CoV-2 contagion and concern about the future, especially among individuals affected by hearing deficits, who were also more likely to be worried about communication barriers caused by the mandatory use of face masks. Furthermore, most interviewees expressed dissatisfaction about the access/delivery of health and social care services during the emergency. Whilst remote services Finally, improved health and social care (19.3% = 2/114) and the use of transparent masks (17.5% = 20/114) were the most suggested solutions to reduce the burden of risk mitigation measures against the spread of SARS-CoV-2. Individuals affected by visual disabilities were less likely to propose transparent masks (OR = 0.09; 95%CI: 0.02; 0.50) than those with hearing impairments (Table 4).

Discussion
This online survey investigated the impact of health protection measures against the spread of SARS-CoV-2 on a sample of individuals affected by sensorineural disabilities during the first COVID-19 pandemic wave in Italy. Social media proved to be a valuable, quick, and low-cost instrument to distribute the survey in a relatively short time. However, access to social media may be hampered for some disabled individuals, who therefore may have been excluded from participating in this study. Despite a relatively limited statistical power and low representativeness of the sample, the findings of this survey are still useful to obtain indications of the health and psychological stress suffered by individuals affected by hearing and visual disabilities during the COVID-19 emergency in Italy.
In particular, the pandemic seemingly had a negative influence on the everyday life of disabled individuals affected by sensorineural impairments. Among the most relevant issues experienced by study subjects were a fear of SARS-CoV-2 contagion and concern about the future, especially among individuals affected by hearing deficits, who were also more likely to be worried about communication barriers caused by the mandatory use of face masks. Furthermore, most interviewees expressed dissatisfaction about the access/delivery of health and social care services during the emergency. Whilst remote services were relatively appreciated for business activities and rehabilitation programs, distance learning and relationships with schoolmates were instead rated unsatisfactory.
Both disabled groups expressed dissatisfaction with the access and delivery to health/social care services, including accident and emergency, and the probability for anguish linked to possible communication barriers due to face masks when dealing with healthcare staff. This may generate concern and fear of abandonment of not being able to have a caregiver available, an indispensable figure given their low sense of autonomy. This bad feeling could play a critical role in developing future psychological distress among the most vulnerable individuals.
As recently recommended by the WHO, in medical care facilities "when caring for members of different populations, including deaf communities," the use of face masks introduces potential harms and risks that should be carefully considered [21]. It is therefore recommended to design patient-centered health care protocols tailored at the clinical needs of all users, with a reception phase capable of promptly understanding any discomfort experienced by disabled individuals in the first place [18,21].
Specific software technological applications are now available for the conversion of texts into voice and vice-versa, allowing the provision of an adequate level of communication for patients affected by hearing disabilities, thus maximizing their compliance and resilience with health care [22]. Unfortunately, resources for these advanced services are limited, causing potential frustration in patients and health/social care workers.
In the present survey, half respondents suffered from sleep disorders (falling asleep, sleep maintenance, and daytime sleepiness), more likely those affected by visual disabilities. Sleep disorders significantly increased during lock-down [23], particularly among people with visual impairments, probably for a reduced perception of light, which plays a fundamental role in the circadian rhythm [24]. Recent studies reported that the prevalence of insomnia and hypersomnia is around 40% and continuously increasing among individuals fearing SARS-CoV-2 contagion and social isolation [25]. Considering the enormous impact sleep disorders have on the global population, governments should consider setting up ad hoc programs to assist patients in overcoming sleep disturbances. Cognitive behavioral therapy (CBT) may support individuals with insomnia by modifying their behavior in terms of stimuli control, sleep restriction, sleep hygiene, relaxation training and cognitive therapy [26]. CBT can be delivered in groups, single face-to-face sessions, or online [27].
Despite the limits of distance learning, school support was still guaranteed to the majority of respondents in the present study. Such remote services represent one of the key elements of social integration for individuals affected by disabilities. However, whilst remote services somehow ensured the continuation of business activities and rehabilitation programs by distance during the COVID-19 emergency in Italy, modern technologies were not as effective to maintain school activities and the respective interpersonal relationships for disabled students. The efficacy of distance learning is in fact influenced by multiple methodological aspects [28,29].
From the analysis of free open questions, better access to health and social care and the use of transparent masks were the most frequent solutions proposed to mitigate the untoward impact of COVID-19 social restrictions. Whilst more effective against the spread of droplets, allowing also to maintain the physiological temperatures of upper airways under cold environmental conditions [30], traditional face masks can in fact cause communication barriers, especially in individuals with hearing disabilities, typically relying on lip reading and facial expressions. Nonetheless, transparent masks are not a certified PPE yet; hence, they are not accessible everywhere. Alternatively, protective face shields, which are classified by the US Food and Drug Administration as class 1 (low risk) medical devices based upon the level of risk for a user or a patient, could contribute to mitigate some of the communication barriers and anxiety experienced by individuals affected by hearing impairments [31,32].
Virtual tele-consultations could also be a potential solution for some disabled patients, and real-time subtitles are offered for free from some platforms (Google Meet and Microsoft Teams). Digital healthcare received a big boost during the COVID-19 emergency, accelerating the implementation of telemedicine services [11]. Tele-audiology options are already common practice in some countries, allowing the remote transmission of images by smartphone or tablets and the examination of patients through an online health platform. Tele-audiology solutions are also useful for the distance training of health professionals involved in the management of deafness and hearing loss [33].

Conclusions
In agreement with recent reports, this study confirmed that the prevalence of psychological distress during the first COVID-19 pandemic wave-in terms of the fear of SARS-CoV-2 contagion and concern for the future-was high among individuals affected by sensorineural disabilities in Italy [22].
Isolation and concerns for the future may have negative impacts on the psychological wellbeing of people with hearing and visual deficits, who already face stressors in the course of their lives as compared to the general population [34].
Remote services were more appreciated for business than school activities. The use of face masks may generate significant communication barriers for sensory disabled individuals, particularly in those affected by hearing deficits. The use of class 1 PPE face shields could be introduced in health facilities and schools to mitigate the communication discomfort caused by face masks.
The COVID-19 pandemic has put health services under pressure, especially those delivering social and psychological care [35], spontaneously accelerating the evolution of novel technology and implementing remote services such as telemedicine, tele-rehabilitation, tele-consultation, and new digital infrastructures for modern data communication [11].
Future studies investigating the knowledge of novel tele-medicine technologies and their applications among patients with neurosensory disabilities are recommended, assessing the awareness of new paths of health and social care, with the aim of improving the access and delivery of health/social services in these particular social categories, reducing patients' waiting lists, and containing the cost of care.
Supplementary Materials: The following are available online at https://www.mdpi.com/article/ 10.3390/ijerph181910208/s1, Supplementary File S1: A survey on the impact of COVID-19 on individuals with hearing and visual disability during the first pandemic wave in in Italy.