Demographics Characteristics of the study participants
This section details the results from the data collection exercise. It should be noted that the data presentation has been split into two since the study interviewed two groups of people, namely health care workers and clients. 59 participants participated in this study and out of the 59 study participants 12 were HCWs and 47 were guardians. Thus 12 health care workers were interviewed and 47 guardians took part in focus group discussions.
Gender Distribution of the study participants
12 health workers were interviewed, from which 2 (17%) were female and 10 (83%) were male. While for the clients, all 47 (100%) were female.
Age Distribution of the study participants
Age of the study participants was categorized into a 4 class variable as follows: 18–19, 20–29, 30–39, 40+. The average age of HCWs was 38 while for the guardians it was 29. Table 3 is a representation of age distribution amongst the health care workers and guardians.
Age distribution for Health Workers and Guardians
Education Level of the study participants
All the 12 HCWs had completed secondary education. While for the guardians 35 had completed primary school, 11 had completed secondary education and 1 tertiary education. Additionally, 38 of the guardians were able to read and write and 9 were not able to do so.
Occupation status of the study participants
The average years of experience for the HCWs was 16. Additionally, 4 out of the 10 HWCs were senior HSAs and the others were just HSAs. While, for the guardians, 26 of them were house wives, 20 of them were doing businesses and 1 was on formal employment.
Content and Adherence
Adherence refers to the extent to which the delivered intervention corresponds to the designed intervention. As a general finding, from observations, it was noted that there was adherence to the protocols but to a lesser extent. The reasons for this vary from programmatic challenges to personnel. From observation it was noted that trainings and orientations were not extensive, this was later queried further where it was discovered that the HSAs had only 1 orientation session in which they were required to understand the entire protocol. This led to some parts of the protocol being adhered to and while others which are also crucial to the study being left out by the implementers on the ground. Some of the part of the protocols that were not adhered were pre-vaccination phase where guardians were not giving an opportunity to ask questions about the vaccine, during vaccination the vaccination points didn’t have first aid kits for management of side effects, in some instances guardians were not informed of management of post vaccine side effects and supervision of vaccine providers was not done by supervisors. Health care workers during the interviews expressed to know the study protocol however further discussions and responses showed that they did not fully understand the protocols.
Almost all respondents, both HWCs and parents/guardians were able to describe what the vaccine is and the aims of the vaccines in the children. Parents/guardians in the FGDs from both performing and struggling facilities expressed satisfaction in the effectiveness of the vaccine in preventing Malaria. Parents/guardians also said that they did not experience any problems with the vaccine.
Most of the HCWs, especially from the performing facility, in agreement also expressed satisfaction in malaria case reduction at the facility. This is what some HCWs and guardians had to say:
“We are seeing the number of malaria in children to be reduced if we compare to before. The reason is maybe the malaria vaccine” - (HCW, 53, Male, Facility 1).
“I have children, and previously all used to have regular malaria sickness in turns as if it was contagious. But now after the malaria vaccine programme it seems as if this has changed” - (Parent/Guardian, 18, Single, Female, Primary, facility 2)
“None. Ever since my child got vaccinated there weren’t any problems and even after the followed us up they found no problems with my child. We are very grateful and happy because the doctors are always available to us at all times”- (Parent/Guardian, 30, Married, Female, Primary, facility 2)
“The vaccine is being received well. Parents of children are happy to bring their children to get the vaccine” - (HCW, 35, Male, Facility 2).
All the HCWs expressed that there was generally a positive uptake of the vaccine by parents/guardians. All HCWS argued that almost parents/guardians accepted that their children receive the vaccine, with only one declining within the study period. HCWs expressed that the positive uptake can be attributed to the fact that parents have been hopeful of children free of Malaria which is a common disease in the district. Few other HCWs expressed that the positive uptake is as a result of good counselling they provide to the guardians/ parents. The HCWs went on to say the following:
“The vaccine is being received well. Parents of children are happy to bring their children to get the vaccines” - (HCW, 35, Male, Facility 2).
“Although implementing this has been challenging, almost all women whom we felt were eligible did not decline to take part in the study. I can only recall one woman and that’s it” - (HCW, 38, Male, Facility 2).
“I have seen other women come up to me and say I have a child and I want him to receive the vaccine, these are women with toddlers who are outside the eligible age, so it shows that the reception is generally positive. (HCW, 30-F, Facility 1)
All parents/guardians displayed a liking of the vaccine, stressing that the vaccine has reduced the number of cases they observed. The guardians had this to say:
“I’m just grateful that with the malaria disease that has been problematic, those of us in this vaccination program are able to see some change with it…...” - (Parent/Guardian, 27, Married, Female, Primary, facility 2)
“I had a child who died because of malaria, so when they said malaria kills I agreed, for me that is even why I received this vaccine. If we had this when we had our first babies as women we would have saved many children in the village”. - (Parent/Guardian, 30, Married, Female, Primary, facility 1)
On actual uptake, not all HCWs expressed that there was positive uptake. Some HCWs argued that just like many health care interventions, there were few challenges on uptake in the Malaria vaccine program, particularly attributed to low literacy levels and misinformation by the public.
On low literacy, some of the HCWs said the following:
“One problem I would think of is probably low literacy level of the population here in Mangochi. We can counsel women regularly and use appropriate routes through chiefs to reach out to them but comes of surprise to us that some people claim to not know anything about the vaccine, this shows that some have a problem with understanding this program” -(HCW, 29, Male, Facility 2)
While on misinformation some HCWs said the following:
“I think the vaccine has been accepted very well however there are some people who speak negative about it that discourages people from getting the vaccines” -(HCW, 40, Male, Facility 1).
While HCWs argued uptake was good, from observations and discussions with the DHO, facilities were still struggling to enroll targeted numbers in the program. As a program the DHO argued that district has struggled in enrolling more numbers, however, among those approached the decline rates have been lower. The DHO argued:
“I don’t think we can say we are happy as a district. We have had campaigns well received than this one. One facility is doing better, while others are struggling with the numbers. And this is not just a district level problem, we are seeing the same across the country in the districts implementing this program”.
One HCW in agreement attributed the struggle in uptake to the rollout of the program. The HCW argued that the rollout should have considered counter-information that may affect the uptake of the vaccine. He argued that the inability to deal with such things at the beginning caused challenges in terms of uptake:
“I know we have struggled but I think before we blame the people in the villages we should accept our part. This program was not well introduced. There are too many massages being shared nowadays, make fake news like the covid news. So on this vaccine, we have struggled to deal with that problems too” - (HCW, 34, Male, Facility 2)
Coverage, Dosage and vaccine administration
Study participants were also interviewed on coverage, dosage and vaccine administration. All parents/guardians, from both the facilities performing well and underperforming facility were able to describe who was eligible for the vaccine. Their understanding was as prescribed in the study guidelines.
On Coverage some parents/guardians had this to say:
“Children at the age of 5 months. If they are late for their initial vaccination, can still be started at 12 months’ age” - (Parent/Guardian, 33, Married, Female, Secondary, facility 2)
“All of our children are between what they said, 5 months and 22 months. So that’s where we know this from, even in the villages we can tell others that it’s from 5 months” - (Parent/Guardian, 33, Married, Female, Secondary, facility 1)
Additionally, all HWCs were also equally able to describe the guidelines, including the guidelines for enrolling a child who present late to the facility for their first dose. Some health workers HWC reported:
“It is a vaccine given to children aged 5 to 22 months, to prevent them getting malaria” - (HCW, 52, Male, Facility 1)
“There are 4 doses. 1st dose at 5 months, then 6 months, then 7 months and finally at 22 months” -(HCW, 38, Male, Facility 2)
One particular HCW candidly explained these guidelines. To an extent the explanation highlighted the depth of understanding of the guidelines by this particular HCW:
“You simply start them with the first dose if they are late and presented at age where dose 2 is due. From then on you proceed with same intervals. For example, if a child first presents at the age when dose 2 is due then we give the 1st dose right away then 2nd dose after 4 weeks, after 4 weeks the next dose, and the final dose at 22 months’ age still” -(HCW, 52, Male, Facility 2)
The high knowledge observed in the HCWs from the performing facility was also observed in the FGDs with parents/guardians, this however was not the case with FGD participants from the struggling facility. All parents/guardians from the performing facilities were able to describe why their children were enrolled into the vaccine program.
HCWs from underperforming facility attributed this low level of knowledge among parents/guardians to low literacy levels. One parent/guardian from the underperforming facility said that:
“I cannot manage to explain what it is. We could go to the hospital and meet advisors who advocate for malaria vaccine” - (Parent/Guardian, 19, Married, Female, Primary, facility 2)
From the Non-participant observation, it was noted that although, the parents and guardians are further informed and encouraged to use INTs and other standard preventive measures of malaria along with the vaccine. It was observed that parents and guardians aren’t given an opportunity to ask questions they could have regarding the vaccine. When asked why they (parents/guardians) could not ask the HCWs, some parents/guardians argued that the vaccines are offered in group set-up that does not allow one to express themselves fully. One respondents reported:
“Most times we are in a group and some are rushing to get back home since we stay in far places. So for me to keep on asking questions, I feel that I am making others go home late. If we had meetings with the doctors in person, I would ask where I was not sure.” – (Parent/Guardian, 21, married, female, primary, facility 1)
From observations it was also noted that the inferiority complex that clients from rural villages have towards HCWs could also be the reason why they do no ask question. One older respondent argued that she had full trust of the doctors, and that the information provided by HCWs was enough. She reported:
“I trust the doctors fully. Since my first child they have been helpful and they know what they are doing. I feel I should not ask any questions since the doctors know their jobs”. - (Parent/Guardian, 38, Female, Facility 1)
“I think my friends have said a lot about what it is, the other past wanted to know where we can get information, so most of our information we get here at the hospital from the doctors and nurses at the clinic, and we know they know what is good for our children”. - (Parent/Guardian, 39, Female, Facility 2)
From observations, on actual vaccine administration, a poor adherence to the protocol was reflected in this phase. Neither centers had a first aid kit available. The ages of the children were verified prior to administration of the vaccine however, crucial information regarding hypersensitivity reactions to previous vaccines were not obtained. The performing facility had ruled out contraindications to administration of the vaccine by asking mothers if their child has ever reacted to any medicine before. However, at facility 2, the contraindications were not ruled out, like their counterparts in the performing facility, by just getting the child’s history. Some guardians commented as follows:
“After being educated, the doctors here administer the vaccines. Also, there are researchers who follow us up in our house holds to check up on our children who have received malaria vaccine for any adverse effects. If there were any there are able to take us to the hospital” - (Parent/Guardian, 18, Single, Female, Primary, Facility 1)
“I don’t remember being asked on the reactions my child has had to other medications. They just offer counselling and start the vaccinations. We are told that if any happens we should come back to the hospital” - (Parent/Guardian, 32, Married, Female, Primary, Facility 2).
Despite most of the guardians expressing knowledge and understanding of the vaccine, it was observed that some parents were still struggling with some details about the vaccine such as the schedule or frequency of administration. One guardian had this to say:
“I’m not sure which one exactly because some vaccines are given on the side of the shoulder and others on the thigh” - (Parent/Guardian, 24, Single, Female, Secondary, Facility 1)
On coverage, from the interviews with HCWs, it was noted that all facilities in the district were not doing well. HCWs agreed that the low performance observed in the national aggregations were true but were quick to argue that the result was not entirely HCWs fault. Some HCWs argued that amongst those reached at the facility, the uptake was good, but in general there was still a problem in having the wider community accept the vaccine. Superstition and poor program implementation were the common factors mentioned by HCWs.
“Of course our facility is doing better when compared to the other facilities in the district. We are at 44% which is about 10% high than the district scores. So it’s good. But the way the program was started is the main problem. It’s difficult for me to convince people when I don’t have the backing of the chiefs. So those we convince are people who were already going to get the vaccine, either after being referred by their friends or they just follow medical advice”. - (HCW, 38, Male, Facility 1).
“Honestly, we are struggling. I mean when we compare other vaccine campaigns this one is not as good as the others. Maybe it’s also because it is new, people are used to measles and other vaccines, but the malaria one is new. The coming of the covid has also made things very difficult. We started gaining more numbers but after covid things became static. I don’t know how it will end” - (HCW, 34, Male, Facility 2)
“I wouldn’t say we are doing good. But here at this facility we are doing better as compared to other facilities, I am saying this because I talk with other HSAs from other facilities and they are complaining, both on materials and also just people making a decision to have the vaccine- (HCW, 30-F, Facility 1)
Despite providers being able to articulate the duration of the vaccine, parents/guardians had mixed responses as to how the vaccine was administered. Most participants from the study (more from the underperforming facility) were unable to describe how the vaccine was administered.
“I’m not sure how exactly the vaccine is given to the children and what is in that liquid they give” - (Parent/Guardian, 24, Single, Female, Secondary, Facility 2)
Storage, Transport and cold chain
From observation, it was observed that the guidelines for vaccine storage were well adhered to. The temperature was within the recommended range of 2 to 8 Degree Celsius and vials stored away from all cold air vents. There were no other food items in the fridge. Vaccines were placed in plastic trays within the racks. During transportation, vials were placed in cold boxes with adequate ice packs. Prior to the start of the clinic, vaccine expiry dates were checked and the vaccine vial monitor was checked to ensure viability of the vaccine. The diluent and antigen was reconstituted appropriately and used well within 6 hours of reconstitution with dedicated syringes. Some health workers commented as follows:
“Vaccines are placed on flex foam in the open after reconstitution of the vials. We do this preventing placing vaccines on the ground so as to not compromise desired temperature for the vaccines” - (HCW, 45, Male, Facility 1)
“We store it in vaccine carriers during transport and specialized refrigerators in the labs. We put ice packs in the vaccine carriers together with vaccines. In addition, Fridge cards (cold chain monitor cards) are also in there to be able to tell if the vaccines have been successfully transported without compromise”. - (HCW, 29, Male, Facility 2)
“We store it in Styrofoam carriers during transport and specialized refrigerators in the labs. We put ice packs in the carriers together with vials. - (HCW, 40, Male, Facility 1)
All HCWs demonstrated a wide base of knowledge on how to dilute and transport the vaccine. Almost all HCWs were able to explain in detail the processes and detailing out the technical aspects of reconstitution and transportation.
“The vaccine comes in a form of powder with its diluent. These two items are mixed by shaking the mixture, and then 0.5 (cc’s) is drawn and administered”- (HCW, 38, Male, Facility 2)
Management of Side effects
Further deficiencies were observed at both sites, reflecting poor knowledge on side effects as seen in both parents/guardians and HCWs. Parents and guardians were not informed of the signs and symptoms of adverse reactions to look out for; they are not informed about the possible side effects. In an observed session, the HCWs did not explain about side effects. The HCWs were just quick to say if the child falls sick, the parents/guardians should rush with the child to a health facility. One FGD responded argued that:
“In most sessions that I have attended we are just encouraged to come to the hospital. We don’t know if the child’s sickness has been caused by the vaccine or not. That is why it is not possible for me to say what problems the vaccine causes. These children get sick all times. They are just babies, so I don’t know.”- (24, female, married, facility 2)
From the observation, it was noted that the immunization tally sheet, which counts the number of doses provided, is not completed following the clinic. However, the HCWs will complete it at later day, usually more than two days later, which may lead to errors of documentation. This can perhaps be attributed to lack of consistent supervision noted in the study period. When asked, some HCWs argued that in some cases they run out of tally sheets while in the field, as such it was hard to document.
“I will be honest that in some cases I don’t have enough materials. We sometimes have to photocopy the documents on own and in such cases when I don’t have money, and more people show up, some will not have their details document. In some cases, we write in the hard cover but we still don’t have enough time to go back and transfer the details on the actual tally sheets”- HCW, 38, Married facility 2)
Assess the magnitude of the moderators of the implementation with reference to the implementation fidelity framework.
Strategies and feedback mechanisms
All HCWs reported that the program had no official feedback structures. They argued that they knew their supervisor, but the supervisor had never visited them in relation to the vaccine program. Thus, they relied on the knowledge they had received during training and had to ask other HSAs for clarification in cases where they were not sure. This was more prevalent in the underperforming facility, perhaps because of the location and distance to the district hospital. HCWs argued that in some cases their supervisors were not part of the team to be briefed about the program which made it difficult to have proper supervision. HWCs from the performing facilities cited that in cases of doubt they had human resources nearby to seek guidance from.
“Supervision /monitoring is lacking and this is because of lack of resources such as fuel and transportation means” - (HCW, 35, Male, Facility 2)
“On the vaccine we don’t have supervisors. That is a challenge because we need someone with more knowledge than ours to help us when we don’t do things right. But lucky for us sometimes we have other HCW who we can go to, but that doesn’t make all of work of good quality” -(HCW, 36, Male facility 1)
P: Senior HSAs are in a way supervisors, but are however excluded from any important meetings or briefings involving the EPI program” - (HCW, 38, Male, Facility 2)
In addition to HCW feedback and reporting mechanism, all HCWs reported that they had no feedback mechanisms with parents/guardians. They said that the only opportune time they had with parents/guardians is during a vaccination meeting, where most of them took initiative to ask parents/guardians if they had noted side-effects or other challenges with the vaccine. Some of the HCWs from the underperforming facilities argued that they believed that for parents/guardians who are shy to ask for clarification and stay further from the facility, seeking further help when they experience side-effects and problems was low. They argued that this would negatively affect adherence to the vaccine in cases where the side effects were severe. The HCWs argued as follows:
“Not exactly. We have only ever gotten one complaint from the people, and on that occasion the message was relayed by the village volunteers. We have no official feedback system”. - (HCW, 27, Male, Facility 2)
“Our work has no supervision; we usually try to make sure we are doing the best we can” - (HCW, 45, Male, Facility 1)
HCW and parent/guardian client challenges
Although at facilities, both the uptake and adherence seems good, there were number of challenges that are programmatic and also on individual level. The programmatic challenges, listed by HCWs, increased workload with no incentives, stock out of resources/supplies, erratic power supply, lack of proper trainings and refresher trainings and lack of sensitization and support from stakeholders.
Increased workload and no incentives
Another challenge was expressed by health care workers was the increased the workload. They argued that although the program was incorporated to the normal EPI programs, the work in the vaccine program was demanding and this made their overall work tiresome. This was heavily tied to lack of incentives for HCW participation in the program. All HCWs argued that allowances during the vaccine period would motivate most of them, as compensation to their increased workload. These sentiments were shared by HCWs from both facilities, with HCWs from the underperforming facility vocal and emotional on the topic. One of the HCW had this to say:
“I think yes. We are supposed to do our job regularly but with this vaccine added it can increase the workload that’s why some incentive would encourage a lot” -(HCW, 45, Male, Facility 1) P: “some allowance to help us do the extra work that has been brought by the vaccine would help many HSAs work harder. We do it now since it’s our job but we also know that there is now more work”- (HCW, 36, Male facility 1)
Stock out of resources/supplies
Stock-outs of resources to be used in the program was also mostly mentioned by the HCWs. All HCWs reported a stock-out of materials like syringes during their vaccination campaigns. HCWs argued that stock-out were problematic as they discouraged parents/guardians who were adherent. They argued that some parents/guardians have to travel long distances and when they experience a stock-out whilst at the vaccination station, such parents/guardians were not likely to return on the next suggested date. The HCWs argued as follows:
“During delivery of vaccines there is need for a corresponding ratio between syringes for delivery and actual vaccine vials. Syringes are usually low supply so sometimes we run out of syringes but still have the vaccines” -(HCW, 52, Male, Facility 1)
“Amount of malaria vaccine supply is not being tailored to suit the actual population of a catchment area. We are always finding ourselves to have run out of the vaccine midway when more vaccine supply should have been considered for areas with larger populations. This becomes a problem for other children who were scheduled and, in this case, fail get their due malaria vaccines” - (HCW, 27, Male, Facility 2)
“We usually see a lot of people and sometimes do not have enough stocks of vaccines to give them to all” - (HCW, 35, Male, Facility 2)
From observations it was noted that some stock outs were as a result of poor planning. For example, most HCWs had no tally sheets and resorted into writing vaccination details on papers. This was more common in the poor performing facility, HCWs argued that they depended on supplies from the district hospital, which were not supplied at the required intervals. In the program, tally sheets were introduced for planning purposes, and without them HCWs struggled to plan for the next vaccination activity. One HCW argued:
“Because we stay far from town we have to ask our friends to bring us the tally sheets. We use our own airtime to do that. And if they don’t bring the tally sheets there is nothing we can do about it. Sometimes when we visit we get those available so that we can use here”- - (HCW, 27, Male, Facility 2)
Furthermore, from observations, the deficiency in required additional IEC materials (flyers, pamphlets) also raised several red flags. Neither of the sites had the IEC materials available, nor did they have a table or chairs to operate from. They did however, have a provision of water and soap as well as a safe disposal box. Medications to counter allergic / adverse drug reactions were not available in either of the centers. Each facility had a vaccine register and child health profile with inadequate malaria vaccine stickers and no calendar. From the observation notes, we noted that child health passports were available in both centers, however, neither of the centers had none of the following: under 2-year-old registers; vaccine tally sheets; adequate malaria vaccine stickers; calendars; guide books for HSAs; reference manuals; nor a vaccine vial monitoring poster. Specifically, on guide books which supports the correct implementation of the SOPs, the HCWs added the following:
“No. the guidelines we use are those provided by the health facility” - (HCW, 52, Male, Facility 1)
“None, we use the guidelines provided by the health centers” - (HCW, 45, Male, Facility 1)
“We aren’t given any guidelines for our reference so it can be difficult to recall from trainings - (HCW, 27, Male, Facility 2)
“Guidelines for the schedules are available. Also, posters are available mostly in the offices that assist for easy remembrance - (HCW, 40, Male, Facility 1)
Erratic power supply
Erratic supply of electricity was also commonly mentioned. Some HCWs argued that electricity challenges do affect their effectiveness. HCWs argued that it would be a challenge if the malaria vaccine study were to be a national program before addressing the challenges that have been experienced so far. One of the HCWs had this to say:
“Erratic electricity availability at the health facility is a worry as they go off almost every day. This might put the vaccines at risk of being compromised due to failure to maintain constant refrigeration” - (HCW, 45, Male, Facility 1)
Lack of proper trainings and refresher trainings
Lack of extensive knowledge on the vaccine that is compounded with absence of refresher courses for HCWs was also a challenge. Training period for all HSAs was for 8 weeks, but an individual HSA would only be trained within 2 days. Most HCWs agreed that the training period was short and that there was supposed to be additional training or updated SOP shared to ensure the messaging going out is the same from all HSAs. Such an approach will equip the HSAs on how to deal with challenges from the field like traditional beliefs. Some HSAs had this to say:
“We did not cover extensive information about the vaccines. As such it is difficult to know how the vaccine works” - (HCW, 45, Male, Facility 1)
“I think it is good vaccine. However just as any program set up, a review meeting (to review the introduction of the vaccine) is needed, and this has not happened at all as an EPI unit. These would have been essential for us to have a platform to voice any concerns”. - (HCW, 38, Male, Facility 2)
“The challenge in the training is that the program provided just vaccination basics. I see this is a challenge as vaccination in general has a lot of science involved and was not taught extensively, as such hoped that more education be provided” -(HCW, 35, Male, Facility 2)
Lack of sensitization and support from stakeholders
Another challenge mentioned by HCWs was lack of proper sensitization, specifically, lack of support from chiefs. HCWs argued that unlike many vaccine campaigns where chiefs were trained and tasked to sensitize locals, the vaccine program excluded chief’s involvement. HCWs argued that it was a challenge to convince parents/guardians who look up to chiefs for guidance.
The HCWs had this to say:
“We don’t have support from chiefs really. Other campaigns involved chiefs, they went and had trainings so that when the villagers go to them they [chiefs] can help remove misconceptions. So for this one we are struggling to get people whose neighbors have not accepted the vaccine before”. -- (HCW, 38, Male, Facility 2)
“In the time of covid-19, we are facing many challenges. It’s difficult because we are dealing with many challenges, including covid-19. And without chiefs’ help, it’s double the problems we face. It would have been helpful if chiefs had cleared the path for us” - (HCW, 45, Male, Facility 1)
“Look, some campaigns have chitenjes, t-shirts, some sort of campaigns that help people to easily accept. In some cases, we hear songs and dramas on the radio, those things seem simple but they do help to change the mind set of people. See Mangochi is the lowest in the country on this vaccine and I think we can say some of the causes is lack of proper awareness” - (HCW, 52, Male, Facility 1)
Although not mostly mentioned, Covid-19 was also one of the reasons mentioned to have challenged HCWs. The extent of how covid-19 was a problem would only be extensively explored later, as during data collection field activities had just been suspended.
“We usually run out of syringes and vaccines. COVID-19 has also reduced the number of people coming for the vaccines - (HCW, 45, Male, Facility 1)
“So it’s mixed, like for me I had few women ask me if they should still be coming, some were saying there is covid at the hospital. Yet some are still coming. But I cannot say they have stopped coming due to covid. Had it been a covid related service maybe they could have stopped, I know people have a lot of wrong facts about covid- (HCW, 30-F, Facility 1)
Participants of the FGDs however seemed to have embraced Covid-19 and did not report it as a challenge. Most respondents argued that the hospital knows the rules that must be followed to protect them from the virus.
“As the lady has already explained, I would just like to add that with these days of the corona virus pandemic, they make sure they (HSAs) bring a bucket of water with soap to wash hands and say if we do not wear masks we will not be assisted. Also, they advise us to stay in a distanced line although other mothers do not follow this stubbornly” - (Parent/Guardian, 32, Married, Female, Primary, Facility 1)
We are fine, as of now I think we are used that this virus is here to stay. When we come to the hospital, they make sure that we are following the rules, so it has not affected our ability to come here– (Parent/Guardian, 33, Married, Female, Primary, Facility 2)
“As you can see most of them have masks and gloves on, since covid started, we have seen that all doctors wear those, so we know they are also protecting us- (Parent/Guardian, 22, Married, Female, Primary, Facility 1)