Socio-demographic data
Employment of mothers in the urban areas included vendors, seamstresses and housewives, in decreasing order; whereas mothers in the rural areas were vendors, farmers, housewives, shea butter producers and seamstresses, again in decreasing order.
Three main themes emerged during the interviews with mothers and HCPs: (1) General effects of the COVID-19 pandemic, (2) effects of COVID-19 on health seeking and health services, and (3) effects of the pandemic on the malaria situation. These main themes have been grouped into 12 sub-themes (Table 1,2,3).
Theme 1: General effects of the COVID-19 pandemic
Sub-themes were identified as (a) finances, livelihood and food security, (b) health service provision, and (c) education and hygiene (Table 1). Direct impacts of the pandemic were limited, little or no COVID-19 infections were detected in most of the participating health facilities, and the mothers reported few to no COVID-19 cases in their communities. However, the indirect effects on life in general, on health care and malaria services were strongly felt for both mothers and HCPs, as shown by the following aspects.
Table 1: General effects of the COVID-19 pandemic
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Health care professionals
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Mothers
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Finances, livelihood and food security
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Change in workload
Stigmatization
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Loss of income
Over-dependence on male reference persons
High costs of living
Dropout of school and further education (children & mothers)
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Health service provision
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Staff shortage
Lack of PPE
Limited outreach to rural communities
Reduced health care funding
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Limited accessible health services
Inability to buy medications, PPE, pay for transportation
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Education and hygiene
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Misinformation about COVID-19
Increased health education about COVID-19
Impaired control and information on non-COVID-19 diseases
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Improved personal & environmental hygiene
Inadequate education on non-COVID-19 diseases
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Perceived as the strongest impact of the COVID-19 pandemic on mothers’ lives were the negative effects on jobs and increased financial difficulties. Restrictions in movement and social gatherings impeded the informal work sector, affecting mostly women and subsequently their children. The majority of them had insufficient personal income, which increased their dependency on their husbands, who had also frequently lost their jobs. The pandemic led to price increases of many commodities and transportation, which further increased the economic hardships and difficulties to access healthcare. Some women were forced to take loans they could not repay. The financial disruptions caused by COVID-19 also affected food security for both, urban and rural mothers, as prices of agricultural products and food increased and led some to think about fleeing: “We even thought of running away from Ghana because we could not sell our things. How do you get money to buy food?” (mother of child 2-5y, urban). Especially in rural communities, some families had difficulties paying school fees, with the situation pronounced for families where mother-ward pairs were students. HCPs’ affirmed the increased financial challenges on patients, adding that those who had no health insurance suffered the most.
Similar to the mothers, the general effects of the COVID-19 pandemic on HCPs centered on their work situation. Some reported a workload decrease as patient numbers reduced, while others experienced an increase as schedules were changed with prolonged working hours. Disease control officers particularly reported an increased workload as they were responsible of the COVID-19 management, adding additional burden to the surveillance of non-COVID-19 diseases. “I was not always here, I was doing contact tracing. So the surveillance activities [for non-COVID-19 diseases] have not been done.” (disease control officer, urban).
Many HCPs faced stigmatization from their families and the community, as they were perceived as COVID-19 transmission sources. Further, HCPs reported misinformation about the virus. “People had misinformation about what it was, a lot of different information, that it was a virus that was programmed or designed to affect Africans” (nurse, urban). The believe that the virus did not exist was common in the society and the vaccination uptake was limited. HCPs reported funds being redirected by the government and external partners to COVID-19 related activities and thus reducing the funding of other routine care services. “I had an impression that there was lack of money, it affected us. We received less funds. The whole attention was for COVID. For COVID, we had everything that we needed but for the other health issues, we were lacking.” (nurse, urban). Low patronage of health facilities also led to financial challenges as internally-generated funds were reduced. Similar to the mothers, the HCPs faced financial challenges in paying for transportation, which impacted their outreach services, especially in rural settings.
Most HCPs mentioned a lack of personal protective equipment (PPE) in health facilities, especially for non-COVID-19 related activities. Additionally, the use of PPE for outreach activities was impeded due to stigma associated with their wearing, and this increased the risk of infection among HCPs. “If I would have dressed in a PPE, the person wouldn’t have allowed me to pick that [COVID-19] sample because of the community’s stigmatization. So I had to go like that and I ended up infecting myself” (disease control officer, urban). Mothers reported negative aspects about nose masks, like buying them at high prices if they needed to enter public places, including health facilities or markets to sell their goods.
Mothers and HCPs mentioned health education on COVID-19 via radio or television channels as well as community health volunteers to have helped in managing the pandemic, reaching the communities and motivating patients to visit health facilities again. However, mothers and HCPs felt that the sensitization about other diseases that present with COVID-19-like symptoms and the importance of seeking professional care was neglected. Mothers and HCPs alike revealed positive effects on overall hygiene, including hand washing. “I think corona has brought us some good in our health, because it has increased people’s awareness of personal and environmental hygiene” (mother of child 2-5y, urban). “The preventive measures that were put in place, even though they were meant for COVID, but in a way, they affected other conditions too, because the handwashing, nose masks, social distancing, in a way, they were also preventing other conditions like diarrhea” (nurse, rural). The decrease in communicable diseases due to COVID-19 control measures led to a perceived decrease in the workload of some HCPs.
Theme 2: Effects of COVID-19 on health seeking
Sub-themes were identified as (a) fear of COVID-19 infection, (b) COVID-19 testing, (c) behavior of health care providers, (d) access to clinics and HCPs, and (e) access to medicines (Table 2).
Table 2: Effects of the COVID-19 pandemic on health seeking
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Health care professionals
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Mothers
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Fear of COVID-19 infection
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Reduced patient contact/handling
Low patient load for routine services, only for emergencies
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Fear of visiting health facilities and schools
Fear of non-COVID-19 illness
Less attendance for ANC, increased home deliveries, use of traditional birth attendants
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COVID-19 testing
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Lack of testing
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Stigma for COVID-19 like symptoms
Fear and stigma of testing positive and isolation
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Behavior of health care providers
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Poor quality care in symptomatic patients
Patients’ fear of infection from HCPs
Stigma
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Low HCPs accessibility
Low quality HCPs care in symptomatic patients
Disruption of ANC and community outreach clinics
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Access to clinics and HCPs
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Less routine child vaccinations
ANC closure in tertiary facility
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HCPs shortage
Health facility closures/ reduced opening hours/ reduced emergency services at night
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Access to medicines
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Varied medicine availability: low demand leading to no effect/ reduced stock from supply issues
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Lack of medicines
High medication prices
Self-medication using over-the-counter drugs preferred to herbal treatment
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Perspectives expressed by both HCPs and mothers showed that fear of getting infected with COVID-19 while visiting health facilities was the most important effect of the pandemic on general healthcare and related health seeking behaviors, and was pronounced among patients with comorbidities, the elderly and pregnant women. There was also hesitancy sending children to school due to the fear of getting infected from COVID-19 non-COVID-19 diseases. Staff shortages were seen as attendance to work decreased due to fear of infection. In the tertiary facility, high risk staff such as pregnant women and the elderly staff, were advised to stay at home and the antenatal care (ANC) unit provided limited services only on fixed appointments instead of open walk-in for some weeks.
Mothers faced the lack of frontline HCPs, facility closures or reduced opening hours, especially for emergency services at night. “There was a night that my child had severe fever. We went to the hospital and it was locked. We had to knock on an over-the-counter owner to sell us a drug to ease it. It was a terrible night at the time of coronavirus.” (mother of child 2-5y, rural).
Reports of not being palpated and weighed at the ANC led many women to stop seeking for those services. The consequence were home deliveries and reliance on traditional birth attendants with its associated birth complications. Attendance rate for routine health care services and childhood vaccinations dropped drastically. The ‘stay-at-home if your condition is less serious’ advice at the first peak of the COVID-19 pandemic contributed to reduced attendance numbers. Health facilities were only a last resort for patients when their home treatment failed or the condition worsened. “So they [the patients] were out, they did not seek health care unless it’s an emergency case” (nurse, rural). Routine community-based child vaccinations were disrupted as many mothers stopped bringing their children to the clinics.
Beside the fear of infection and stigma when presenting with COVID-19-like symptoms, fear of testing positive and being isolated led many mothers to change their health seeking behavior and attempted to manage the illness at home until the symptoms became severe: “When you are not well, the fear of being tested positive would either delay or prevent you from seeing a doctor in a hospital” (mother of child 6-23m, rural). This was also confirmed by HCPs: “Most people were expecting that if you come to the hospital with fever, cough, or some of those symptoms, you would be classified as COVID, so people did not want to seek health care” (nurse, urban). Many HCPs reported the possibilities for COVID-19 testing were very scarce or non-existent, as the antigen rapid diagnostic tests were only available in the tertiary center through international research project supplies. As a result, suspected cases were not followed up in most facilities, leading to basing diagnosis and isolation decisions of suspected cases on presented symptoms.
Mothers opined that the behavior of HCPs concerning patient care greatly affected their health seeking behavior. Many mothers alleged the non-availability of staff in health centers to provide treatment while some refused contact with symptomatic persons, especially those coughing. “This child was sick and when we came [to the health center], they refused to attend to him because of the high temperature he had.” (mother of child 2-5y, urban). HCPs confirmed a change in treating their patients. “As a health worker, you were afraid of a patient, you differently gave the patient care, so the care was compromised a bit.” (nurse, rural). But also, HCPs observed behavioral change among their patients, mainly due to patients’ fear of health staff infecting them and many HCPs reported stigmatization from their families and the community: “The cooperation of patients with the health care staff was also less because they see the staff as in higher risk [for COVID-19 infection], and it’s true.” (nurse, rural). Social distancing also brought some positive changes for patients’ care, as the number of patients attended in one consulting room reduced leading to improved patient privacy.
Views of HCPs regarding medicine stocks in health facilities were quite varying. Some reported no effects on medicine stocks during the pandemic as the number of patients and subsequently the need for medications in health facilities reduced. However, some indicated shortages attributed to the pandemic or to general supply factors. “In terms of the supplies, we still don’t have them out of COVID, so I’m not able to say if it was due to COVID or if this is just one of our challenges.” (nurse, rural). In contrast, mothers experienced shortage in hospitals’ medication stocks. They had to buy the medicines that were not available in facilities at higher prices from privately-owned pharmacies and over-the-counter chemical shops. “They will tell you there is no medicine due to corona so they will just write the medicine for you if you can afford and if you can’t afford it, this will affect you and the baby inside” (mother of child 6-23m, urban). The need to pay for medication further increased financial challenges, adding to the already difficult financial situation of families: “Here were times when your child was sick and the same amount [of farm products]that your husband earned [prior to the pandemic] to get you money to send your child to the hospital was not even enough to feed the family.” (mother of child 2-5y, rural).
Over-the-counter drugs and herbal medications became the first option for symptom relieve. “The hospital was our last resort. You will give the child all the herbs you think would be of help, only when the condition became worse, we sent our children to the hospital. Especially if it involves cough and fever” (rural, children 2-5y). However, some communities stopped using herbs from the bush as medications during the COVID-19 period because “they said Corona was from bush animals. So those going to the bush to get these herbs, like the man in our house, were also afraid to go to the bush” (mother of child 2-5y, urban).
Theme 3: Effects of COVID-19 pandemic on malaria services
Sub-themes were identified as (a) malaria preventive measures, (b) differential diagnosis of malaria and COVID-19, and (c) malaria treatment (Table 3). Beside the general health service challenges, both rural and urban participants expressed concerns about the effects of COVID-19 on malaria-centered services. Key impacts were again financial deficits, following reallocations of funds by the government and international donors to ease COVID-19.
Table 3: Effects of the COVID-19 pandemic on the malaria situation
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Health care professionals
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Mothers
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Malaria preventive measures
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Inconsistent chemoprophylaxis intervals
Reduced access to chemoprophylaxis and ITNs
Low malaria funding
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Lack of chemoprophylaxis and ITNs
Non-willingness to take chemoprophylaxis
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Differential diagnosis of malaria and COVID-19
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Inadequate education on symptomatic similarities
Increased malaria testing leading to shortage of malaria test kits
Increase in severe and complicated malaria in health facilities
Checklist-based COVID-19 diagnosis; COVID-19 test lacking
Respiratory symptoms: children treated as malaria, COVID-19 only considered in adults
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Presumptive symptomatic treatment
Hospital only when self-medication failed
High malaria morbidity and complications
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Malaria treatment
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Focus on COVID-19, neglect of other diseases
Shortage of antimalarials in rural areas
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Patients handled as COVID-19 without confirmation
Lack of antimalarials and limited opening of clinics leading to alternative medicine use
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ITN: insecticide treated net
Malaria prevention programs suffered some drawbacks. Medications for intermittent preventive treatment in pregnancy (IPTp) was out of stock in some facilities, especially in the rural communities, as well as ITNs. “At the time of COVID, they will write for you to go and buy the [chemoprophylaxis] drugs and [the HCPs] will also not give you the net.” (mother of child 6-23m, rural). Some side effects of the chemoprophylaxis mimic COVID-19 symptoms, which reduced women’s willingness for drug uptake. Meanwhile, at the peak of the pandemic, when ANC services were limited, the time interval between the chemoprophylaxis distribution was inconsistent and extended. In most of the study communities, the seasonal malaria chemoprevention programs for children under five years continued during the COVID-19 period leading to reductions in malaria morbidity. “[Malaria] reduced, because the drugs that were given reduced the effect of malaria. Even when the child gets malaria, it does not worsen and then gets better again” (mother of child 2-5y, rural). The drug administration approach was changed from central distribution points to door-to-door administration by community nurses who also provided general health education. However, a challenge with the new approach was the stigmatization of HCPs who entered the communities to provide this intervention as they were seen as possible sources of COVID-19 infection. Additionally, there was a lack of PPE for these interventions thereby increasing the risk of COVID-19 infection. “We didn’t really have PPEs, we just went into the community and hoped that nothing bad happens”(nurse, urban).
Health care seeking behavior for malaria-related symptoms depended largely on general health education as malaria and COVID-19 share commonalities in symptoms. “Education and sensitization were not enough because COVID-19 and malaria share some common symptoms like fever. […] if you are getting malaria, you can get this particular symptom, but it doesn’t mean that it’s COVID-19,[…]. So they should go to the health facilities for a sample to be taken.” (disease control officer, urban). Health facilities also provide education on common diseases as malaria, but this has been missed by many patients during the pandemic: “Malaria is one of the common things we educate on [at health facilities]. So, when you don’t come to seek health care, you don’t have the opportunity to be educated.” (nurse, rural). Hospitals became the last resort for severe malaria cases as patients stopped seeking professional help for mild symptoms, and this situation increased malaria fatality. “From the statistics, we recorded quite a high number of [malaria] mortality, due to the fact that there is late attendance” (nurse, rural). Except for the tertiary facility, there was no avenue to test for COVID-19. HCPs reportedly diagnosed COVID-19 using checklists based on clinical signs and symptoms in adults. Beside, some HCPs used malaria rapid diagnostic tests (RDTs), on the premise that a positive malaria test excludes possible COVID-19 infection, neglecting the possibility of co-infections. “What we also did were malaria test kits. When it tested positive, you can equally say that this patient has malaria and no COVID.” (nurse, rural). Meanwhile, in the tertiary facility, cases of severe malaria and COVID-19 co-infection were documented. Among children presenting with those general symptoms like fever, HCPs initiated malaria treatment right away. Thus, during the peak of COVID-19, there were more malaria tests conducted than before and presumptive treatment based on malaria symptoms became less common among HCPs. Some facilities reported malaria RDTs shortages during the COVID-19 peak. This compelled them to use microscopy blood smears which was time consuming and not available in rural facilities.
Overlapping of COVID-19 and malaria symptoms led to difficulties and misconceptions with patient management as there was extra focus on COVID-19. “When my child had fever, we just knew that it was malaria but they treated us like it was corona, so they didn’t want to come closer to us.” (mother of child 2-5y, urban) “It was difficult at a point to diagnose, because the focus then was on COVID-19 and some of the symptoms mimic that of malaria. We were sometimes kind of overlooking the other diseases we used to treat and now focusing more on COVID-19” (medical doctor, tertiary facility, urban). Mothers and some HCPs reported shortages in antimalarials. Especially for simple malaria, presumptive symptomatic treatment by self-medication from over-the-counter stores or left-over orthodox and traditional medicine was the norm as shown by this quote: “We were told not to seek health services from unlicensed practitioners and herbalists, but we had no choice at the time of the pandemic” (mother of child 6-23m, rural).
In particular, the limited opening hours of health facilities due to COVID-19 social restrictions presented serious challenges for the malaria treatment, especially in the rural settings where the few health facilities are widely scattered.