2.1 Fear of COVID-19
According to clinicians, parents displayed high levels of reluctance to attend the ED, predominantly driven by a fear of contracting COVID-19; as one clinician put it, they “saw the hospital as a place of you know, risk of contracting COVID” . As outlined above, these concerns were cited when explaining the reason for delayed presentations.
“they felt they would have presented a bit sooner that they didn't want to come to a department where they could have had a risk of COVID” 
In the beginning of the pandemic, parents rang EDs “non-stop” to enquire about the presence of COVID-19 in the hospital. Many clinicians sensed that parents were weighing up the risk of attending the ED against the severity of the child’s illness, and were more inclined to “wait and see”, managing the illness at home, due to the perceived risk of exposure to COVID-19:
“they were pushing their own boundaries and were allowing themselves a little bit more risk or their perception of risk before seeking medical advice because probably the perceived risk of a well child with a temperature was less than the perceived risk of coming here and being exposed to COVID-19” 
Clinicians also reported that parents were anxious to socially distance from other patients, and as spatial limitations often lead to difficulty in implementing social distancing, parents would often wait outside the building. Clinicians explained that parents were unaware of the infection control measures put in place in hospitals, such as streaming and triaging for COVID-19, and reacted positively and felt reassured when observing the measures implemented:
“I think most of them were very reassured when they came in because they were told no, we had a separate COVID streaming area.” 
2.2 Stay Home, Stay Safe: Public Health Messaging
As cases of COVID-19 first began to increase in Ireland, authorities introduced restrictions on movement and issued public health advice, instructing people to stay at home. The initial drop in ED attendances coincided with this messaging and a number of clinicians felt it may have led some parents to believe they should not attend hospitals, particularly for issues that parents perceived to be not absolutely urgent:
“it was like everybody was being told do not attend your ED, do not attend your ED, do not attend your ED” 
“parents were less inclined to present maybe with the normal bits and pieces because they were told to cocoon and stay at home” 
One clinician felt the strength of the message to “stay home, stay safe” was quite effective, and parents may have been unwilling to go against this in case they put their child at risk:
“I think because the governments message was so good initially of stay home stay safe, it really was gosh if we break that, could he really be at risk of picking up COVID and dying” .
Another clinician relayed an interaction with a parent who misinterpreted the government message to stay home as including not being allowed to travel to the hospital:
“she fully believed that if she was stopped by the guards [police] on the road that they would tell her to turn back” .
Furthermore, it was evident that parents believed hospitals were overwhelmed with COVID-19 patients. One clinician felt this perception was connected to media depictions of “front line staff being to the pin of their collar” , which may have impacted parents decision to present. When introducing themselves, parents were extending apologies to staff about their attendance:
“we didn't want to come in, you know we didn't want to, we knew you were busy” 
Parents were citing their awareness of health system capacity as a reason for being apprehensive to attend, and this belief contributed to parents holding off on presenting, such as in the case of one child who presented many days after suffering a serious laceration:
“The mum was reluctant because she said she thought we’d be out the doors with sick children, so she didn’t want to be just turning up with a cut – which wasn’t really a cut at all, it was quite a serious injury” 
Clinicians pointed to the need for a public communication strategy aimed at reassuring parents of both the infection control measures EDs have put in place, as well as to promote the message that EDs are fully operational and not overwhelmed. Some felt this could alleviating parental concerns and prevent delayed attendance or avoidance:
“I think if we can....present to the public that we’re open....if you need to come to hospital we’re ready to help you but we have these measures in place to keep it as safe as possible”