Coronavirus (COVID-19) dementia action plan: equality impact assessment

Assessing the impacts and identifying opportunities to promote equality

Having considered the data and evidence gathered, this section focuses on considering the potential impacts - negative and positive - that the policies in this plan might have on each of the protected characteristics. Each of these aspects also relates to the wider commitments in the plan around human rights and equalities.

Do you think that the policy impacts on people because of their age?

Aspect

Eliminating unlawful discrimination, harassment and victimisation

Being part of the community - benefit:

Efforts around buddying and befriending are likely to improve awareness of dementia, a condition which mostly effects older people, and to therefore reduce unlawful discrimination, harassment and victimisation on the basis of age.

Aspect

Advancing equality of opportunity

Preventing dementia - benefit:

The majority of those with dementia are over 65, though work on preventing dementia is also likely to positively impact those who are at risk of being diagnosed with dementia under 65.

Support for family carers - benefit:

17% of people aged 50 to 64 provide unpaid care to a relative, friend or neighbour. This compares to 2% of under-25s, 10% of 25-49 year olds and 11% of over-65s. Support for family carers is likely to particularly benefit those between 50 and 64, or who are over 65.

Family carers for those with dementia under 65 may face particularly challenging circumstances, e.g. longer periods of uncertainty, dual loss of employment and income due to caring, frustration and grief, lack of peer support, and responsibility for families and young children. Supporting family carers is likely to help aid these challenges.

Supporting a skilled and knowledgeable workforce and service modernisation - benefit:

Upskilling the workforce and modernising service is likely to benefit those under 65 with dementia by making the workforce more knowledgeable about diagnosing, treating and aiding those of a younger age with dementia.

Being part of the community - barrier:

Those under 65 with dementia often have different needs around issues including childcare, employment, age appropriate peer support and financial impact, and may particularly benefit from efforts to keep them integrated in the wider community and provide appropriate peer support.

Support for a timely diagnosis and post-diagnostic community support - barrier:

There are a number of barriers to people being diagnosed, even under the proposed policy. Symptoms may be misattributed to other conditions such as stress, depression, menopause, excess alcohol use and relationship difficulties. Younger people are more likely than older people to have one of the rarer causes of dementia where the symptoms are less familiar to clinicians.

Living well at home - barrier:

There are barriers to living well at home for those with dementia under 65. Many of those diagnosed with dementia under 65 are still working and/or have mortgages, children, car etc. They are often not told about the benefits they are entitled to, leading to debt. Filling in benefits forms can be a very stressful and disempowering experience, too.

Aspect

Fostering good relations between people of different ages

Being part of the community - benefit:

Initiatives around befriending are likely to encourage those of younger age groups to build up contact with older people, given the higher incidence of dementia amongst those who are 65+.

Do you think that the policy impacts disabled people?

Disability

Eliminating unlawful discrimination, harassment and victimisation

Supporting a skilled and knowledgeable workforce and service modernisation - benefit:

Having a person who is profoundly deaf being cared for and supported by health and social care workers who can't communicate with them using BSL is a deprivation of human rights and severely affects the wellbeing of the Deaf BSL user, as well as creating anxiety for their unpaid carers. Stakeholders argued that the emphasis on upskilling staff could be reframed by specifically employing staff who are BSL users. Supporting a skilled and modernised workforce through education regarding the needs of people with learning/intellectual disabilities and dementia will move towards eliminating discrimination, harassment or victimisation against these people on account of their disability.

Being part of the community - barrier:

In all areas of life, citizens with a learning/intellectual disability experience significant discrimination and prejudice. These attitudes are very likely to present a barrier to citizens with a learning/intellectual disability having equal access to this policy.

Living well at home - barrier:

The lack of high quality social care support for people with learning or disabilities may present a barrier to realising this policy. Isolation is more pronounced for these people, because of overall and society wide prejudice. Neighbours may abuse or intimidate rather than provide support, which presents additional barriers and undermines living safely at home as an option.

Disability

Advancing equality of opportunity

Support for family carers - benefit:

16% of people who provide unpaid care to a relative, friend or neighbour are deaf or have partial hearing loss; 16% have a physical disability; 11% have a mental health condition. Supporting unpaid carers would therefore intersect with supporting those with a disability, a significant proportion of whom provide such unpaid care. For people with learning/intellectual disabilities, a key concern during the pandemic has been the removal of their support hours at the start of the pandemic, which has had a detrimental impact both on people with learning/intellectual disabilities and their family carers. Further support for carers through implementation of the Carer's Act will help to recognise the burden that this pandemic has placed on them through the removal of available support services/ reduction of support hours; particularly where they are caring for someone with dementia and a learning/ intellectual disability. Supporting carers and involving them in care decisions is key as they are likely to notice issues for people with learning/ intellectual disabilities and dementia early on.

Preventing Dementia - benefit:

Social isolation has been identified as a later life factor for dementia. As such, establishing the connection with hearing loss has the potential to positively impact two of the 9 factors which, if eliminated, could help prevent 35% of dementia cases. Sight Scotland research has shown that two thirds of blind and partially sighted people say their visual impairment has contributed to problems of loneliness and social isolation. So far there has been insufficient work done to support Deaf-blind people to access the health improvement efforts around heart health, brain health etc. and healthy lifestyle choices and behaviours such as exercise, healthy eating, which could help prevent dementia. Targeted efforts to focus on preventing dementia amongst those who are Deaf-blind would be of particular help.

Being part of the community - benefit:

Those with hearing loss are potentially at risk of social isolation; those with hearing loss and dementia are doubly susceptible and the limited social interaction during lockdown increases the risk even further. Those with a learning/ intellectual disability and dementia may also be particularly at risk of social isolation during lockdown, particularly with the shutting of day services, and the increased risk of COVID-19 for some people with learning/ intellectual disabilities, meaning many may have had to shield. 57% of people with learning/ intellectual disabilities who responded to the SCLD's survey said they felt lonelier since lockdown measures were put in place. This issue appears to be particularly felt by those in residential settings (including supported accommodation) who can no longer receive visits from their family. Commitments to supporting people safely, e.g. through buddying or befriending, and commitments to strengthen national and local linkages on the Scottish Government's Social Isolation and Loneliness Strategy will be particularly beneficial to those most at risk of isolation during the pandemic (and beyond).

Living well at home - benefit:

Using technology can make a huge difference to keeping someone with a learning/ intellectual disability, or who is blind, Deaf, Deaf-Blind, or faces sight or hearing loss, at home and therefore in the space they feel most comfortable. This can be done by making them feel safe and secure, e.g. through use of key safes, installing door monitors. From a visual impairment perspective it may be useful to add voice activated and responsive technology. Design features which are dementia friendly, such as lighting aids, are often visual impairment friendly too. For people with learning/ intellectual disabilities, access to digital connection can help to facilitate equality.

Living safely in a care home - benefit:

A third of those with learning/ intellectual disabilities who have died from COVID-19 lived in residential care homes. Ensuring safety in care homes will help ensure people with learning/ intellectual disabilities and dementia are properly protected. For people with hearing loss or who are Deaf or Deafened, there may be issues around care home staff wearing masks, as they may need to lip read - although there is officially an exemption for care home staff around wearing masks when caring for with people with a sensory deafness, blindness.

Supporting a skilled and knowledgeable workforce and service modernisation - benefit:

Currently, not all health and social care workers or families will be knowledgeable about dementia in people with learning/ intellectual disabilities, so they may miss signs and symptoms of early stages of dementia. There is a national shortage of both interpreters for British Sign Language (BSL) and health and social care workers who can communicate in BSL. Blind and partially sighted people also have communication and care needs which require visual impairment awareness in health and social care services. For Deaf-blind people, the ideal for hospital appointments, as outlined in the MEL 1998(4), is to have access to a specialist Guide Communicator Service. For people with learning/ intellectual disabilities and dementia, communication around understanding a diagnosis is key. Non-verbal communication should be taken into consideration, such as easy read, talking mats, etc. This has an influence on the support and care they receive and their specific communication needs. Best practice information and guidance, e.g. from Dr Karen Watchman, should be disseminated and involvement of learning/ intellectual disabilities nurses could be crucial. Modernisation and upskilling the workforce should help to address these particular issues for people with dementia and learning/ intellectual disabilities difficulties or a sensory deafness, blindness - if new staff are suitably recruited and existing staff trained.

Improving the hospital experience - benefit:

People with learning/ intellectual disabilities and dementia are sometimes prescribed inappropriate medication acting as a sedative. Improving the hospital experience would include a move away from this practice. Moreover, their paid carers are too often not allowed into hospital due to double-funding. Continuity of care would be key to improving the hospital experience for those with learning/ intellectual disabilities and dementia.

Support for a timely diagnosis and post-diagnostic support - barrier:

Communication difficulties, and an increased potential for sensory loss also hinder diagnosis as the person with learning/ intellectual disabilities may be unable to articulate what is happening to them. There is also a high risk of misdiagnosis. People who are deaf, deafened, blind, deaf-Blind, partially sighted or hard of hearing and who develop dementia face additional challenges, including an increased sense of disorientation and risk of social isolation. The onset of dementia may be more difficult to detect by family and carers. The Scottish Human Rights Commission has raised concerns that disabled people may end up with an inappropriate or inadequate care or support package due to lack of proper assessment, or in the case of adults with incapacity, the lack of a full assessment may have further repercussions with respect to procedural safeguards (as a result of removing the requirements of the Self-Directed Support Act). Deaf-Blind Scotland reported that sensory loss is often not viewed as a priority for self-directed support assessment, ignoring inclusive communication as a pivotal mediator in achieving all desirable health and social outcomes. Likewise, for people living with sight loss or who are Blind and have dementia, there is a concern over diagnostic overshadowing - support being provided for the person with dementia, but their visual impairment not being properly identified and treated. This can apply in care home environments too. Even with a diagnosis, there are issues with getting the right support for people with learning/ intellectual disabilities as services are too often not tailored to their needs and there may be issues accessing "mainstream" services.

Preventing dementia - neutral:

People with learning/ intellectual disabilities have a higher risk of developing dementia compared to the rest of the general population, with a significantly increased risk for people with Down's syndrome at a much earlier age. There is not enough evidence to say whether targeted efforts at preventing dementia would be successful at reducing this risk.

Do you think that the policy impacts on men and women in different ways?

Sex

Eliminating unlawful discrimination

Preventing dementia - neutral:

Women are more likely to be diagnosed with dementia than men, in part due to their higher average life expectancy.

Sex

Advancing equality of opportunity

Support for family carers - benefit:

Survey data published for Carers Week 2020 suggests that there are now as many as 1.1 million unpaid carers in Scotland, of which 61% are women. This is an increase of 392,000 since the start of the pandemic, with 78% of carers having to provide more care than they were prior to the coronavirus outbreak. Since the start of the pandemic, a lot of carers lives have changed dramatically, as has the physical/mental health of the person they are caring for, the lack of day services and respite has resulted in real negative impact upon carers. A policy of supporting family carers is likely to help women, who are more likely to be carers and may have been doubly impacted from a loss of income (women were more likely to have been furloughed than men during the first wave of the pandemic), and extra caring responsibilities.

Do you think that the policy impacts on women because of pregnancy and maternity?

No foreseen impact of these policies on women because of pregnancy and maternity.

Do you think your policy impacts on people proposing to undergo, undergoing, or who have undergone a process for the purpose of reassigning their sex? (the Equality Act 2010 uses the term 'transsexual people' but 'trans people' is more commonly used); or on people who are intersex or who have a variation in sex characteristics?

Transgender

Eliminating unlawful discrimination

Supporting a skilled and knowledgeable workforce - benefit:

Training would help staff to recognise instances of unlawful discrimination within healthcare/ care settings, including from other residents, and would ensure staff do not unlawfully discriminate against those with dementia in their care according to their gender identity. This would improve how comfortable trans people feel openly expressing their gender identity in care homes, hospital or healthcare settings and/ or when accessing support services. Evidence gathered during this equality impact assessment will be used to help develop specific training to ensure a skilled and knowledgeable workforce.

Transgender

Advancing equality of opportunity

Supporting a skilled and knowledgeable workforce - benefit:

This could help advance equality of opportunity for trans people by ensuring staff are aware of their specific needs, including the possible impact of cessation of hormones due to the onset of dementia (for trans people who have gone through a process of gender reassignment); or by encouraging trans people to feel comfortable being open about their gender identity with health and care staff. Targeted training is needed to realise this.

Support for a timely diagnosis and post-diagnostic community support - barrier:

For transgender people, widespread discrimination and poor experiences of healthcare can present significant barriers to help-seeking for dementia, including accessing diagnosis and post-diagnostic support. Trans people are more likely to live by themselves or to not have a partner. This can impact upon their diagnosis, as people living alone are less likely to have a timely diagnosis, as someone else is less likely to notice a change in their behaviour. Dementia plans have to acknowledge that trans people are still routinely pathologised.

Living safely in a care home or living well at home - barrier:

Personalised care plans are key to ensure people can express and recognise themselves, but the discrimination and lack of understanding in some environments limits these care plans being truly personalised for trans people with dementia. Care environments are still often unwelcoming environments for LGBT people and this needs to be addressed. Massive work is needed to ensure trans people feel safe expressing their gender identity in a care home, sheltered housing or acute care setting.

Being part of the community - neutral:

For many trans people, community will not be geographic, but rather about befriending or buddying with people from the wider trans or LGBT community. Some trans people have found themselves more included in their local community due to the local support offered by COVID-19, but others have not. Many people may have been shut off from a community that is geographically dispersed. Digital exclusion is still a big issue, as online connectivity excludes people further who can't deal with tech due to neuro-diverse challenges and technology accelerates beyond capabilities of older people in particular.

Do you think that the policy impacts on people because of their sexual orientation?

Sexual orientation

Eliminating unlawful discrimination

Support a skilled and knowledgeable workforce and service modernisation - benefit:

Training would help staff to recognise instances of unlawful discrimination within healthcare/ care settings, including from other residents, and would ensure staff do not unlawfully discriminate against those with dementia in their care according to their sexual orientation. This enable lesbian, gay or bisexual people to feel more comfortable openly expressing their sexual orientation in care homes, hospital and/or healthcare settings and when accessing support services. Evidence gathered during this equality impact assessment will be used to help develop specific training to ensure a skilled and knowledgeable workforce.

Sexual orientation

Advancing equality of opportunity

Support a skilled and knowledgeable workforce and service modernisation - benefit:

Lack of contact with outside support networks due to COVID-19 may be particularly distressing for those with dementia who are not 'out' to staff about their gender identity. Many LGB people say they would be uncomfortable with care home staff or paid carers knowing their sexual orientation. Training the workforce to be more knowledgeable and sensitive about sexual orientation will help ensure more LGB people with dementia feel more comfortable in health and care settings. Very few care homes identified that they had LGB people in their care when asked: more awareness is needed, but this requires tailored training for staff.

Living safely in a care home - barrier:

Psychological safety is important in care homes - LGB residents will have grown up in a different era, in which their sexual orientation was pathologised, meaning proactive action is needed for them to feel psychologically safe in this environment. Very few care homes identified LGB people in their care - more awareness is needed in the care residents receive. Massive work is needed to ensure LGB people feel safe expressing their sexual orientation in a care home, sheltered housing or acute care setting.

Support for a timely diagnosis and post-diagnostic community support - barrier:

Many LGB people are not 'out' to their GP and may be reluctant to engage with dementia and mental health services because of the history of LGB sexual orientations being pathologised, as well as ongoing prejudice in health and social care settings. This may present a barrier to LGB people accessing timely diagnosis and post-diagnosis support. LGB people are also more likely to live by themselves and to not have a partner. This may impact upon their diagnosis, as people living by themselves are less likely to have a timely diagnosis, as less likely to have someone else notice a change in their behaviour.

Being part of the community - neutral:

People who are LGB are more likely to live alone, be single as they age, not have children, and are less likely to be in regular contact with their biological family. Older LGB people may feel out of place in traditional dementia support groups and dementia cafes and may fear that others will react negatively if they talk openly about their partner or family of choice. For many LGB people, community will not be purely geographic, but rather about befriending or buddying with people from the wider community. Some LGB people will have found themselves more included in their local community due to the local support offered by COVID-19, but others will not have. Many people may have been shut off from a community that is geographically dispersed. Digital exclusion is still a big issue, as online connectivity excludes people further who can't deal with tech due to neuro-diverse challenges and technology accelerates beyond capabilities of older people in particular.

Support for family carers - barrier:

LGB carers may be caring for family of origin or 'family of choice'; be dealing with challenging birth family dynamics, assumptions around being single, having no dependents; lack of acceptance of LGB identity; find they are excluded as their relationship is not accepted by a partner's biological family; face discrimination and assumptions when using services. Focusing only on family in a biological sense and failing to provide appropriate support for LGB carers further contributes to stress of carers who may already be experiencing financial, physical and emotional pressures. An LGB person who is caring for their partner with dementia may also face exclusion from decision making by their partner's biological family in relation to formal care and end-of-life arrangements.

Do you think the policy impacts on people on the grounds of their race or ethnicity?

Race/ ethnicity

Eliminating unlawful discrimination

Race/ ethnicity

Advancing equality of opportunity

Improving the hospital experience - benefit:

There is a need to make hospital settings culturally sensitive. The use of interpreters can be challenging as individuals may request the translator's gender is the same as theirs. Improving the hospital experience would include greater awareness of these challenges and sensitivities.

Supporting a skilled and knowledgeable workforce and service modernisation - benefit:

Service providers are often overwhelmed when it comes to the needs of the general population, meaning the needs of marginalized communities often get overlooked, including people from minority ethnic communities. Service modernisation and ensuring a skilled and knowledgeable workforce could well improve the experiences of minority ethnic people with dementia and/or their carers, if this includes upskilling the workforce on the particular needs of minority ethnic communities and the potential barriers to them seeking or receiving necessary support.

Support for a timely diagnosis and post-diagnostic community support - barrier:

Research by the Life Changes Trust highlighted that Black and Minority Ethnic communities often have specific barriers to diagnosis such as very low levels of knowledge of dementia and the different forms it can take; very little understanding of diagnosis and prognosis; difficulties in obtaining a formal diagnosis; problems of accessibility and appropriateness of existing information materials; stigma of dementia leading to isolation and withdrawal from the community; difficulties in accessing support services, particularly as the condition worsened; the need to challenge assumptions about an individual's ability to care as part of an extended family network and lack of accessible support services. All these present significant barriers to timely diagnosis and post-diagnostic support. Moreover, most cognitive tests are developed and standardized in one ethnic group, which may not transfer appropriately to another ethnic group due to culture, education, language or other factors. People from minority ethnic communities who experience dementia are less likely to present to services and tend to make contact at a later stage of the illness. Evidence from systematic reviews of qualitative research suggests that barriers to help/support-seeking for dementia are knowledge, society and/or healthcare related. Language barriers may contribute. There are also particular barriers for people of minority ethnic backgrounds, such as those from gypsy/ traveller communities accessing services, including around literacy, discrimination and a lack of knowledge around service provision or accessing services. All of these factors may act as barriers to people from minority ethnic backgrounds accessing a timely diagnosis and post-diagnostic support.

Being part of the community - barrier:

Community approaches to dementia differ according to specific cultural backgrounds. There may be barriers to community integration after diagnosis in some communities, which may prevent those diagnosed with dementia from being part of their community. People from minority ethnic backgrounds are generally less likely to feel they belong to their community: in 2018 72% of minority ethnic adults said they felt a very or fairly strong sense of belonging to their community, compared to 79% of adults from white ethnic groups.

Palliative and end of life care - barrier:

When planning for the future, some cultures may be more resistant to developing personal plans around end of life. There may be a lack of buy-in for the process of planning for end of life and bereavement. Some people of minority ethnic backgrounds can lack faith in the future and the services that would be available to them, due to previous experiences of poor service provision, and navigating the system can be very daunting.

Support for family carers - neutral:

In some cultures, it may be more common to regard caring as something to be kept within the family or seen as part of the role you take on as a relative or spouse, particularly for women, with paid support being seen as unsuitable. However, that can also mean public sector providers assuming, often incorrectly, that everyone from a minority ethnic community has strong community/ family support networks or can readily provide unpaid care. Support for family carers may particularly benefit those who are expected to support relatives or a spouse with dementia, but this may need to be particularly targeted or tailored to people from ethnic minority communities, including those who may have less trust in institutions. Research by MECOPP has shown specific barriers to carers from Gypsy/ traveller backgrounds accessing support, for example.

Do you think the policy impacts on people because of their religion or belief?

Religion or belief

Eliminating unlawful discrimination

Religion or belief

Advancing equality of opportunity

Living well at home - benefit:

For some religious communities, living in multi-generational households is more common, meaning a greater chance that the dementia patient will receive support at home for longer. Efforts to support those with dementia living well at home may be particularly beneficial to people of certain religious or cultural backgrounds.

Supporting a skilled and knowledgeable workforce and service modernisation - benefit:

It is not enough for staff just to know the basics of cultural awareness. Staff also need to be able to deal with dissonance and the fact that someone may no longer want certain things as their dementia progresses. The issue of autonomy and choice in times of change and transition becomes very important. A policy of supporting a skilled and knowledgeable workforce could help to ensure this, if it is properly targeted.

Living safely in a care home, improving the hospital experience - barrier:

A patient with dementia living in a care home or being treated in a hospital setting may struggle to explain their needs/ preferences for intimate care that relate to their religion and culture, for example a strong preferences for washing in running water (Hindu, Sikh, Muslim) or not having hair trimmed or cut (Sikh). This could act as a barrier to realising these policies.

Palliative and end of life care - neutral:

There are varying ways in which people approach bereavement and end of life according to religious differences, as NHS Scotland resources such as this show. Support should be sensitive to different end of life approaches according to religious beliefs, and aware of different beliefs and customs.

Being part of the community - neutral:

community approaches to dementia differ according to specific religious backgrounds or beliefs. In some faith communities, there may be barriers to integration in community after diagnosis related to taboos around dementia, while others may have specific services for people with dementia. For some cultural and religious minorities, there may be preferences for providing care within the community.

Do you think the policy impacts on people on other grounds?

Socioeconomic deprivation

Eliminating unlawful discrimination

Socioeconomic deprivation

Advancing equality of opportunity

Living well at home - benefit:

COVID-19 has had a more negative impact on the most deprived in Scotland, which may prevent those with dementia who experience socioeconomic deprivation from living well at home, particularly as people in the most deprived areas were 2.1 times more likely to die of COVID-19 than those living in the least deprived areas. Measures to ensure everyone with dementia is able to live well at home will help those who are struggling most as a result of COVID-19's disproportionate impact (if properly targeted).

Support for a timely diagnosis and post-diagnostic community support - barrier:

This policy promotes "virtual" post-diagnostic support using a range of on-line tools and a promotion of mixed type of service for the foreseeable future. Socioeconomic disadvantage is a defining factor in digital exclusion and policies focused on virtual post-diagnostic support may limit the access of those from lower socioeconomic backgrounds.

Preventing dementia - neutral:

It is important to recognise the disproportionate economic impact of COVID-19 on the poorest, and the potential for this to disrupt work to prevent dementia.

Rural/ remote location

Eliminating unlawful discrimination

Rural/ remote location

Advancing equality of opportunity

Being part of the community - benefit:

Efforts around befriending and buddying via community groups could help to include those from rural/ remote locations who may feel particularly isolated as a result of COVID-19, particularly where groups can be set up for people in these locations to meet safely and third-sector organisations can assist at the local level.

Living well at home and support for family carers - barrier:

Accessing the right technology for supported living is likely to be more challenging in a rural/ remote area, as there are many connectivity issues due to geographical remoteness. This causes frustration for the person with dementia and problems for their carer. Ensuring correct access to tech for people with dementia and their carers is key to ensure they can live well at home and that their family carers are supported.

Support for a timely diagnosis and post-diagnostic community support - barrier:

Virtual post-diagnostic support using a range of on-line tools and a promotion of mixed type of service for the foreseeable future is likely to exclude those who are already digitally excluded and rely on face-to-face services. Many of those in rural/ remote communities do not have good access to the internet, due to a lack of available tech or poor broadband connection. This makes it difficult for them to use technological alternatives offered in place of face-to-face services.

Digital exclusion

Eliminating unlawful discrimination

Digital exclusion

Advancing equality of opportunity

Support for a timely diagnosis and post-diagnostic community support - barrier:

Virtual post-diagnostic support using a range of on-line tools and a promotion of mixed type of service for the foreseeable future is likely to exclude those who are already digitally excluded and rely on face-to-face services.

Living well at home - barrier:

The transition to digital during COVID-19 will have left behind those who are digitally excluded. Older people are also less likely to use the internet and digital devices than younger people, and digital exclusion may present a significant barrier to people with dementia living well at home, both during COVID-19 and beyond.

Being part of the community - neutral:

Efforts around befriending and buddying via community groups could help to include those who are digitally excluded and are likely to feel particularly isolated as a result of COVID-19; however, this relies on alternative means than technology being used for these efforts. Otherwise, this would further exclude those without digital access.