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Barriers to optimal care and strategies to promote safe and optimal management of sick young infants during the COVID-19 pandemic: A multi-country formative research study

PSBI Formative Research Study Group

Bangladesh site – Rasheda Khanam, Jennifer Applegate, Abdullah H Baqui (Department of International Health, John Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland, USA); Arunangshu Dutta Roy, Salahuddin Ahmed (Projahnmo Research Foundation, Dhaka, Bangladesh); Main Uddin (Jagannath University, Dhaka, Bangladesh); Mohammod Shahidullah (Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh); Ethiopian site – Amha Mekasha, Abiy Seifu Estifanos, Damen Hailemariam, Dorka Woldesenbet, Nigussie Assefa, Lulu Muhe (Tikur Anbessa Hospital, Addis Ababa University, Addis Ababa, Ethiopia); Solomie Jebessa (St. Paul Millennium Medical College, Addis Ababa Ethiopia); Himachal Pradesh, India site – Priyanka Adhikary, Nivedita Roy, Temsunaro Rongsen-Chandola, Nidhi Goyal (Centre for Health Research and Development, Society for Applied Studies, New Delhi, India); Vinod Sangal (Government of Himachal Pradesh, India); Sarmila Mazumder (Society for Essential Health Action and Training, New Delhi, India); Nita Bhandari (Knowledge Integration and Translational Platform; Society for Essential Health Action and Training, New Delhi, India); Uttar Pradesh, India site – Hina Mehrotra, Pramod Kumar Singh, Vinay Pratap Singh, Aarti Kumar, Vishwajeet Kumar (Community Empowerment Lab (CEL), Lucknow, Uttar Pradesh, India); Yashwant Kumar Rao, Rupa Dalmiya Singh, Arun K Arya (Ganesh Shankar Vidyarthi Memorial Medical College, Kanpur, Uttar Pradesh India); Nigeria site – Robinson D Wammanda, Laila Hassan, Ishakau Hassan (Ahmadu Bello University Teaching Hospital, Zaria, Nigeria); Emmanuel Ejembi Anyebe (University of Ilorin, Ilorin, Kwara State, Nigeria); Pakistan site – Benazir Baloch, Imran Nisar, Nudrat Farheen, Sana Qaiser, Dania Mushtaq, Maryam Mansoor, Kiran Lalani, Fyezah Jehan (Aga Khan University, Karachi, Pakistan); Coordinating centre – Rajiv Bahl, Karen Edmond, Shuchita Gupta, Sachiyo Yoshida, Yasir Bin Nisar (Department of Maternal, Newborn, Child and Adolescent Health and Ageing (MCA), World Health Organization (WHO), Geneva, Switzerland); Shamim A Qazi (Consultant, retired staff member of WHO, Geneva, Switzerland).

DOI: 10.7189/jogh.12.05023

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Abstract

Background

Essential health and nutrition services for pregnant women, newborns, and children, particularly in low- and middle-income countries (LMICs), are disrupted by the COVID-19 pandemic. This formative research was conducted at five LMICs to understand the pandemic’s impact on barriers to and mitigation for strategies of care-seeking and managing possible serious bacterial infection (PSBI) in young infants.

Methods

We used a convergent parallel mixed-method design to explore the possible factors influencing PSBI management, barriers, and facilitators at three levels: 1) national and local policy, 2) the health systems, public and private facilities, and 3) community and caregivers. We ascertained trends in service provision and utilisation across pre-lockdown, lockdown, and post-lockdown periods by examining facility records and community health worker registers.

Results

The pandemic aggravated pre-existing challenges in the identification of young infants with PSBI; care-seeking, referral, and treatment due to several factors at the policy level (limited staff and resource reallocation), health facility level (staff quarantine, sub-optimal treatment in facilities, limited duration of service availability, lack of clear guidelines on the management of sick young infants, and inadequate supplies of protective kits and essential medicines) and at the community level (travel restrictions, lack of transportation, and fear of contracting the infection in hospitals). Care-seeking shifted to faith healers, traditional and informal private sources, or home remedies. However, caregivers were willing to admit their sick young infants to the hospital if advised by doctors. A review of facility records showed low attendance (<50%) of sick young infants in the OPD/emergencies during lockdowns in Bangladesh, India (both sites) and Pakistan, but it gradually increased as lockdowns eased. Stakeholders suggested aspirational and pragmatic mitigation strategies.

Conclusions

We obtained useful insights on health system preparedness during catastrophes and strategies to strengthen services and improve utilisation regarding PSBI management. The current pandemic provides an opportunity for implementing various mitigation strategies at the policy, health system, and community levels to improve preparedness.

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The ongoing COVID-19 pandemic poses unprecedented challenges, particularly to low- and middle-income countries (LMICs), where health systems are unprepared for coping with such catastrophic situations. The quality of health care services suffers due to inadequately skilled health care personnel and a lack of equipment, medicines, and other supplies. The already over-burdened health systems in these countries have been further challenged during the pandemic, which disrupted essential health and nutrition services for the most vulnerable populations – pregnant women, newborns, and children [1,2].

Despite neonatal mortality decreasing over the last few decades, it still accounts for 46% of under-five deaths globally [3]. Preterm birth complications, intrapartum-related events, and infections are the most common causes of neonatal deaths worldwide [3]. However, in South Asia and sub-Saharan Africa, neonatal infections account for 35% of neonatal deaths [4]. The World Health Organization (WHO) recommends inpatient treatment for young infants <2 months of age with possible serious bacterial infection (PSBI) [5,6]. Studies have shown that these infants can be managed on an outpatient basis when referral to hospital is unfeasible [710] and have resulted in the development of new guideline [11,12]. Several studies have shown the feasibility and acceptability of WHO guideline on PSBI outpatient treatment in Africa and Asia [1326]. Secondary analyses of clinical trials [7,8] have shown that infants with any sign of clinical severe infection had a higher mortality rate when hospitalised compared to outpatient treatment [27].

We conducted formative research to understand how the COVID-19 pandemic impacted the identification, care-seeking, and management of young infants with PSBI, specifically identifying barriers and corresponding mitigation strategies. The insights obtained from formative research would also be relevant for the planned PSBI trials [28,29].

METHODS

Study design and participants

The formative research used a mixed-methods design. We followed a convergent parallel design, where quantitative and qualitative data were collected concurrently to analyse the two components independently and interpret the results together [30]. We collected information iteratively at each level of the conceptual framework (Appendix S1 in the Online Supplementary Document) by interviewing respondents in each category to identify emerging themes and subthemes. New emerging areas were incorporated into the subsequent interviews, and the process was repeated until the point of saturation was reached.

Procedures

The study was conducted in six settings: Bangladesh, Ethiopia, India (two sites: Himachal Pradesh (HP) and Uttar Pradesh (UP)), Nigeria, and Pakistan. The population consisted of individuals from low socioeconomic urban or rural backgrounds. The population size ranged from 300 000-5 000 000 (Appendix S2 in the Online Supplementary Document). Health care services in the study area were provided through public and private facilities and outpatient clinics, all of which had neonatal care units. Efforts were made to harmonise the study procedures by implementing a common standard protocol used from the outset through the conceptualisation stage, and proposal and study tools development, analysis, report writing, and manuscript preparation. All sites used a generic study protocol and standard study instruments. The site investigators analysed their data with inputs from all site investigators.

Trained and experienced social scientists and anthropologists collected qualitative data, while trained workers with health research experience gathered the quantitative data. Data collection varied across sites from December 2020 to March 2021. The quantitative data were collected retrospectively. The pandemic and subsequent lockdown period lasted for about three months at each site, from March/April to May/June 2020. All precautionary measures were taken against COVID-19 spread during data collection. The research assistants were checked for signs and symptoms of COVID-19 infection before their field visits.

For qualitative data, all sites used observations and in-depth interviews (IDIs), while focus group discussions (FDGs) were also conducted on all sites except two in India. Participants were selected from the entire geographical area served by the selected hospitals. Community health workers (CHWs) identified key informants (KIs). CHWs, staff nurses, medical officers, program managers, and most-visited private practitioners were interviewed. IDIs were conducted at various sites as follows: 12-49 with caregivers, 5-6 with KIs, 6-35 with CHWs, 5-14 with doctors, 6-12 with nurses, 4-10 with program managers and 3-7 with private practitioners. The IDIs continued until saturation was achieved and were all audio-recorded. Apart from HP and UP, all sites also conducted FGDs with caregivers and KIs. Data were obtained from 16-50 CHWs, and we surveyed 1-7 health facilities.

Quantitative data covering a preceding period varying from 9 to 12 months were collected retrospectively across sites from randomly selected CHWs and health facilities through observation, examination of health facilities records and CHWs’ registers. The key indicators by month were the number of sick young infants seeking care from outpatient departments (OPD), emergency services, or admissions and deliveries. The proportion of deliveries that occurred at home and the postnatal visits by CHWs during this time were ascertained. Closed-ended questionnaires were used.

Analysis

Transcripts prepared from audio-recorded IDIs were reviewed to identify emerging themes and sub-themes, which were further extended for each target group. Relevant verbatim passages under each theme and sub-theme were extracted and translated into English. Framework analysis was used to examine the participants’ experiences and perspectives. The key themes were: identification of PSBI signs, care-seeking practices, treatment of sick young infants, barriers and enablers, the effect of the pandemic and lockdown on routine services, and mitigation strategies suggested by the respondents.

For the quantitative analysis, we explored barriers existing pre-COVID-19 and aggravated and new barriers during COVID-19. Simple means and proportions were estimated to examine the trends in service provision and utilisation of health care services. The quantitative and qualitative data were triangulated to understand the agreement across both.

Role of the funding source

WHO received a grant from the Bill & Melinda Gates Foundation (#INV-001311). The funders had no role in the study design, data collection, analysis, interpretation, report writing or submission for publication.

Patient and public involvement statement

Research question development was informed by the large burden of infection-related mortality among young infants worldwide. Patients were not advisers in this study, nor were they involved in the design, recruitment, or conduct of the study. Results of this study will be made publicly available through open-access publication where study participants may access them.

Ethical considerations

Ethical approvals were obtained from the WHO Ethics Committee and the local ethics committees of all participating institutions. Each individual gave written informed consent for interviews and audio recordings.

RESULTS

Identification of PSBI signs

About two-thirds of caregivers listed high fever, inactivity, decreased movements, and inability to feed as symptoms requiring medical attention, but they did not report others, such as cold body and limbs (hypothermia), fast breathing, or noisy breathing. It was primarily evident among first-time mothers or those living in nuclear families. Elderly women/mothers with older children were more aware of signs requiring urgent attention (Box 1 – Example 1).

Box 1.  Examples of verbatim quotes from qualitative data

Example 1 Baby’s grandmother was telling me about the chest indrawing of the baby, and she instructed me to use home remedies for my child. We always listen to her. (Caregiver, Ethiopia).

Example 2 The fear that symptoms like cough, fever, breathing difficulties might be related to Corona, they tend to hide the information from others. (CHW, UP, India).

Example 3 People used to say, without showing the child, that the child is okay…were afraid of me and sometimes people even fight during visit…started calling me ‘Covid Wali’. (CHW, UP, India).

Example 4 My children were sick multiple times with fever, cough, and breathing difficulty during corona. However, my mother-in-law and sister-in-law suggested not to take the babies to the doctors as they will test the baby for corona, and they will isolate and separate my baby from me. (Caregiver, Bangladesh).

Example 5 We Pahadis (people who live in the mountainous regions) have enough strength to walk miles after miles (to reach the hospital), but how much pain and discomfort can a baby tolerate? It takes time to walk, and small babies do not have the power to suffer pain for that long, but we do not even have that much money to hire a vehicle to reach the hospital fast. (Caregiver, HP, India).

Example 6 Families do not bring the infants during the early phases of the illness. Since the cases come when they develop complications (or at a severe stage), they are not easy to manage at our health centre. So these families are forced to take the child to other higher facilities, or else the child will die. (Health Provider, Ethiopia).

Example 7 The entire pediatric outpatient department was turned into a COVID-19 unit due to lack of space and emergency because of which no babies could be treated. (Medical Officer, Pakistan).

Example 8 There was much fear due to the corona among the families, fear that corona testing itself would result in corona. (Caregiver, UP, India).

Example 9 We don’t have any specific guidelines for managing infants in Kaduna State; although we have some national guidelines that can be domesticated, unfortunately, even domesticating the guidelines has always been the problem. …………However, we have guidelines for only a few conditions, for instance, treating very severe malaria, child transmission of HIV, cases of eclampsia and postpartum haemorrhage, which is distributed to all the hospitals. (Health facility staff, Nigeria).

Example 10 This time there is not much supply here. All the injections are being brought by patients only, and we are continuously sending indent for hospital supplies. We have been facing problems for more than one and a half months. One or two BP machines are out of order, IR thermometers we do not have…weighing scale we have…no instruments, one incubator, one side bed. (Staff Nurse, UP; India).

Example 11 Yeah, everyone was taking the child to a health facility, even during that time (Lockdown). I do not know anyone who kept his child at home due to COVID. (Father, FGD; Adama, Ethiopia).

During those times (lockdown), transportation had stopped, but I would visit the clinic by walking on foot and take a loan from my relatives to seek care. (Caregiver, Bishoftu, Ethiopia).

Example 12 What will happen now after COVID….no matter how the baby is…. this much mind has been made up that that work will be done after wearing gloves only, proper sterilization will be done…baby and family, both can have difficulty (infection). (Health care Provider, UP; India).

Example 13 …and with these people NURTW (National Union of Road Transport Workers, Nigeria), we try to procure some tricycles in collaboration with another project; we are able to procure this tricycle ambulance so we can establish it, but we had so many challenges ….in fact the voluntary collaboration with NURTW we can say is even better than the tricycle we distributed to all the political wards in the state, though the voluntary collaboration is mainly for pregnant women those that need attention. (Official from Ministry of Health, Nigeria).

Example 14 We tried not to stop the service by using digital technologies like creating telegram groups with regional focal groups and receiving technical support. We managed the protocols and documents to help the health post function. Moreover, we carried out a LEAP remote training platform for 3 or 4 days using their phones by SMS and Interactive Voice Response for HEWs on how to continue maternal and child health services provision during COVID. (Policy Maker, Ethiopia).

Example 15 In fact, the training was not restricted to health care providers. The findings indicated that the sensitization/orientation training was also given to the community, community and religious leaders. (Health care Provider, Nigeria).

CHW – community health worker, FGD – focus group discussion, HEW – health extension worker; HP – Himachal Pradesh, NURTW – National Union of Road Transport Workers; SMS – short message service; UP – Uttar Pradesh

Caregivers, KIs, and health care providers (HCPs) considered exposure to awareness generation activities as helpful. These included a mobile health service provided by the government of India [31], mother and child protection cards [32], community meetings, camps, and training sessions organised during the pre-COVID-19 period at different sites. Most caregivers across all sites depended on CHWs to identify and refer sick infants during the home-based postnatal care visits (Table 1). However, about one-fifth of CHWs could not list the danger signs requiring immediate referral. Most CHWs reported that identifying PSBI signs was challenging during the pandemic due to the disruption of home visits or assessing the infant without touching (Box 1 – Example 2). CHWs also reported that caregivers were apprehensive about their visiting homes, suspecting them as COVID-19 carriers (Box 1 – Example 3).

Table 1.  Key pre-COVID-19 barriers, challenges, and facilitators, aggravated due to COVID-19 and new barriers and facilitors for identification of infants with possible serious bacterial infection (PSBI) by study site

ANMs – auxillary nurse-midwives, CHW – community health worker, HCP – health care provider, HBPNC – home-based postnatal care, KI – key informants, PPE – personal protective equipment, PSBI – possible serious bacterial infection

Most HCPs in Nigeria and a few in Bangladesh, Ethiopia, and HP, India, said a shorter post-delivery stay at the health facility reduced the opportunity of orientating mothers about danger signs. A large proportion in southeast Asia and a few Nigerian caregivers reported that families concealed the information about their infants’ illness from CHWs due to fear of COVID-19-related stigma and isolation in the hospital. Whereas one-third of caregivers from India and Nigeria reported seeking care immediately because COVID-19 and PSBI symptoms overlapped. About three-fourths of HCPs and program managers in Indian sites and a few in Africa reported a reduction in other common illnesses. Facilitating factors were improved hygiene practices, restricted social gatherings and movement outside the home, absence of birth rituals, quality time spent with children, close watch on infants, low pollution levels, and media promotion to prevent other common illnesses (Table 1).

Care-seeking practices

Most caregivers at the southeast Asian sites and around half at the African sites tried home remedies in the early stages of illness, seeking outside care only when the infant was unresponsive (Table 2). Four-fifths of mothers reported their husbands and parents-in-law not allowing care-seeking from hospitals. Women with multiple children or those living in nuclear families found it challenging to travel alone to the health facility or admit their infants. In UP, India, three-fourths sought care from informal (untrained) private providers. Care-seeking outside the home was affected during the lockdown. One-fifth of caregivers at all sites (apart from UP, India) preferred the private sector and local pharmacies, as they perceived them safer than government hospitals in this pandemic. Furthermore, government facilities were either closed or had restricted opening times and services available in OPDs. Caregivers avoided government facilities due to mandatory COVID-19 testing, which resulted in delays in receiving treatment. Most also said they could not afford private care (Box 1 – Example 4).

Table 2.  Key pre-COVID-19 barriers and challenges aggravated due to COVID-19 and new barriers and facilitators for care-seeking and referral during by study site

ANMs – auxillary nurse-midwives, CHW – community health worker, HCP – health care provider, IPD – inpatient department, KI – key informants, OPD – outpatient department, PSBI – possible serious bacterial infection

Travel restrictions, non-availability of transport, increased police surveillance and interrogation, a significant financial strain for families, especially those who had lost jobs, reduced quality of care, and unpredictable staff availability at government facilities were also barriers to care-seeking (Table 2). Some of these existed before the pandemic (Box 1 – Example 5).

Treatment, adherence and follow-up of sick young infants

Two-thirds of the facility staff across all sites stated that inadequate human resources and staff shortage due to COVID-19 duties or quarantined staff, insufficient supplies of oxygen and medicines for young infants, and unhygienic conditions in the facilities led to reduced utilisation of facilities and sub-optimal management of young infants, in both OPD and inpatient facilities (Table 3).

Table 3.  Key pre-COVID-19, aggravated due to COVID-19 and new barriers and facilitators for inpatient and outpatient treatment, compliance and follow-up care by study site

ANMs – auxillary nurse-midwives, CHW – community health worker, HCP – health care provider, IPD – inpatient department, KI – key informants, OPD – outpatient department, PSBI – possible serious bacterial infection

Three-fourths of the caregivers at all sites reported poor care at the facility and limited-time interaction with HCPs, who did not touch or examine the infants. The facility staff was in a hurry to refer or discharge newborns in most sites except Ethiopia. However, an Ethiopian HCP said that the parents only brought a seriously ill infant who needed a referral to a referring facility (Box 1 – Example 6).

Mothers reported high treatment costs due to the pandemic aggravated by unemployment, worsening their economic condition. The problem was less pronounced in Nigeria because the study population consisted predominantly of rural communities with farmers or petty traders. Small space, overcrowding, and long waiting hours were barriers that existed even before the pandemic (Table 3) (Box 1 – Example 7).

Several hospitals were closed completely, offered restricted services, or were partially or completely converted to COVID-19 care centres (Table 3). Almost all caregivers at all sites expressed apprehension about visiting hospitals, fearing exposure and undergoing COVID-19 testing could lead to extended quarantine and stigma if tested positive (Box 1 – Example 8).

Almost all HCPs in India and Nigeria reported the absence of clear guidelines on essential newborn care, particularly for low birth weight or preterm newborns and breastfeeding during the pandemic. There was a lack of clarity about the management of sick young infants and their testing for COVID-19. (Box 1 – Example 9).

HCPs said they discouraged the admission of infants except in emergency. About half of the facility staff across the sites and a majority in Nigeria emphasised that district and sub-district hospitals (secondary level) functioned sub-optimally even in the pre-COVID-19 due to limited numbers of ventilators, incubators, stockouts of essential medicines and equipment, poor infrastructure, insufficient space, and inadequate laboratory facilities. Caregivers said that the waiting time was always very long, even in the pre-COVID-19 period (Table 3). The facility staff mentioned that the COVID-19 related supplies such as personal protection equipment (PPE), hand sanitisers, and face masks were also in short supply. At some sites, the lockdown aggravated the shortage of commodities. In UP, India, the program managers reported an acute shortage of medicines and essential supplies in non-COVID-19 designated hospitals (Box 1 – Example 10) while, medicines for non-COVID-19 illnesses in the COVID-19 designated hospitals were being wasted, and prolonged disuse of equipment (such as incubators, radiant warmers) for routine care made some almost non-functional.

Almost all program managers saw staff shortage as a considerable challenge, which existed during the pre-COVID-19 period, except in Ethiopia, where only one-fifth cited it being a problem. Specialists/paediatricians were not available, and there was high staff turnover. Referral linkages between primary and referral facilities were lacking as only a few referral facilities were accessible. Three-quarters of HCPs in Nigeria and about a quarter each in HP and UP in India reported non-availability of treatment guidelines and clearly defined referral criteria for sick young infants even before the pandemic. Infants born within same facilities were preferred for admission in neonatal units, if needed, over those who were referred from outside for inpatient care. Some HCPs at the secondary and primary levels felt incompetent to manage sick newborns (Table 3).

Facility records review showed low attendance of sick young infants in the OPD/emergencies during lockdowns, but it gradually increased as lockdowns eased (Figure 1, panels a-f). In Pakistan, OPDs in government and some non-government facilities were closed during the lockdown. In Ethiopia, the IDIs and FGDs reflected that care-seeking for sick young infants from health facilities and CHWs was substantially affected during the lockdown. However, quantitative data did not show a considerable difference, probably due to limitations in the extracted health system data. Although strict lockdown was enforced briefly in Ethiopia, caregivers still visited the hospitals with their sick infants (Box 1 – Example 11). Admission of sick young infants in the hospitals across all sites remained the same throughout the survey period, except in Bangladesh, where inpatient admissions were reduced during the lockdown.

Figure 1.  Number of deliveries, outpatient (OPD)/emergency visits and inpatient (IPD)/neonatal care unit (NCU) admissions by month at each study site.

Deliveries in the secondary and tertiary care facilities

The program managers reported that the secondary and tertiary care facilities within the catchment areas handled delivery cases well during the pandemic, even those with complications. They concluded that these facilities could provide adequate intrapartum and newborn care, and that further strengthening would be helpful in improving service provision. Facility staff at some sites remarked that mothers’ agreement to their infants’ admission even during the pandemic showed the community had faith in the public health system.

The number of deliveries in the study facilities was the lowest during the lockdown at all sites compared to the pre-and post-lockdown periods (Figure 1, panels a-f). In HP (India), referral to higher facilities outside the study catchment areas for complicated cases was the lowest during the lockdown period, and these were managed in the local hospitals. As a result, complicated delivery rates were higher in these hospitals during the lockdown (34%) and post-lockdown (33%) period compared to the pre-lockdown period (28%) (data not shown).

A rebound in births was observed at all sites post lockdown (Figure 1, panels a-f). The facilities at the tertiary and a few at the secondary level appeared to be more resistant with higher resilience under the adverse circumstances during the lockdown period. Some of these facilities recruited doctors and nurses on a contract basis. The primary and most of the secondary levels facilities succumbed to the crisis. It could be due to an inadequate number of facility staff because many of them were infected with the COVID-19 infection and were in quarantine, poor infrastructure, and non-availability of equipment at the primary and secondary levels. Many primary-level facility staff were deployed for COVID duties, affecting staff availability, which was already a challenge at these facilities. Due to infrastructure issues and limited space, a separate COVID-19 unit could not be set up at the primary and secondary levels.

The negatively affected services included OPDs, normal deliveries, and inpatient treatment, including the paediatric wards, which were shut down. Only emergency services were operational. However, the footfall of patients had drastically reduced. Caregivers who used to visit government hospitals switched over to local clinics or private hospitals because of the paucity of hospital staff and fear of contracting the COVID-19 infection. Additionally, patients faced difficulties reaching the hospitals due to travel restrictions during the lockdown, affecting public transportation services.

Effect on routine services

About four-fifths of all facility staff and CHWs across all sites and slightly less than one-fifth in Ethiopia reported that routine services such as vaccination and antenatal and postpartum care were adversely affected, and community clinics were closed during the lockdown. Caregivers were afraid of taking their children for vaccination. Outpatient care was adversely affected at different sites, either due to suspension of services or availability for limited hours, or non-availability of HCP. CHWs across all sites were not keen to carry out their responsibilities due to inadequate PPE supplies and incentives for COVID-19 duties. In Ethiopia, CHWs continued to implement their routine activities, received training on COVID-19, and engaged in COVID-19 screening and awareness-raising campaigns.

Home-based postnatal visits for newborns and referral of sick young infants were also reduced. The quality was affected due to social distancing as CHWs reported assessing newborns from a distance. All routine services in the community were stopped for 20 days during the lockdown in Bangladesh. Scheduled visits were done for 55%-75% young infants in January-March 2020, compared to 15%-53% in the lockdown and 45%-51% in the post-lockdown periods in Pakistan, UP and HP (India) (data not shown).

Changes in hospital policies

Safety measures, such as screening and isolation of women until COVID-19 test results were available, a separate operation theatre and labour room for COVID-19 positive patients, triaging and screening of children with fever or cough, and a separate ward for COVID-19 positive children were adopted during the pandemic at most study facilities across all sites. These measures, however, often delayed treatment initiation. Keeping newborns with their mothers to promote exclusive breastfeeding was practised at some sites irrespective of COVID-19. Program managers at a few sites reported that a COVID-19 hazard allowance was introduced as an incentive for HCPs. Furthermore, referral linkages across different levels of health facilities and CHWs were strengthened by establishing effective post-discharge follow-up care, strict enforcement of hygiene and infection control practices, and the utility of mobile phones for better communication (Box 1 – Example 12). The program managers said that round-the-clock emergency services in facilities were ensured. Most caregivers expressed complete faith in the government health system and adhered to the recommendations.

Mitigation strategies

Already implemented strategies

In Ethiopia, HCPs received monetary incentives and tax relief. Hospitals providing neonatal care services were spared from changing to COVID-19 centres. Increased duty hours and a restriction on annual leave for HCPs were imposed. Transportation services/allowance were allocated for staff. In UP (India), contactless home-based postnatal visits were being conducted during COVID-19. Policy changes were implemented in HP (India) such as introducing COVID-19 testing, isolation wards, and separate operation theatres and labour rooms for COVID-19 positive women. Similarly, COVID-19 testing was mandatory for all infants with signs and symptoms of pneumonia and the establishment of special COVID-19 wards for COVID-19 positive cases. In UP and HP, India, infants were discharged earlier if they were stable than the routine period to ensure availability of space and reduce hospital exposure. They were contacted for follow-up. Many safety and precautionary measures were taken for HCPs to ensure their continued services (Table 4 and Table 5).

Table 4.  Common mitigation strategies across all study sites by the level of implementation at policy level, health systems level, and community and caregiver level

ANC – antenatal care, ANMs – auxillary nurse-midwives, CHW – community health worker, HCP – health care provider, HR – human resource, IEC – information, education, and communication, IPD – inpatient department, NICU – neonatal intensive care unit, OPD – outpatient department, PDSA – plan-do-study-act, PHCs – primary health centres, PSBI – possible serious bacterial infection, SHG – self health group, SOPs – standard operating procedures

Table 5.  Site-specific strategies by the level of implementation at policy level, health systems level, and community and caregiver level

ANC – antenatal care, ANMs – auxillary nurse-midwives, CHW – community health worker, HCP – health care provider, HR – human resource, IEC – information, education, and communication, IPD – inpatient department, NICU – neonatal intensive care unit, OPD – outpatient department, PDSA – plan-do-study-act, PHCs – primary health centres, PSBI – possible serious bacterial infection, SHG – self health group, SOPs – standard operating procedures

*As per the guidelines issued by the state government, districts and geographical areas within a district were declared as ‘Green Zone’, where no COVID-19 positive cases were reported, ‘Orange Zone’, where less than 15 COVID-19 positive cases were reported, and ‘Red Zone’or ‘Hot spot’, where >15 COVID-19 positive cases reported.

Strategies that are in the pipeline

A few program managers informed that strategies such as establishing the COVID-19 isolation centres, separate floors for COVID-19 care, and limiting attendants for admitted patients were in the pipeline. Giving incentives to HCPs to perform COVID-19 duties, conducting frequent COVID-19 tests, ensuring adequate supplies of PPE, building social welfare funds for those in need, conducting web-enabled community awareness, and rehabilitating local means of transport such as the tricycle initiative in Nigeria were also being planned as mitigation strategies.

Ideas for new strategies

Almost all program managers and HCPs (except in Ethiopia) said that for early identification of PSBI, information, education, and communication activities were critical for awareness of danger signs in neonates requiring immediate care-seeking from appropriate sources, utilising existing government platforms. They said that door-to-door health awareness messages through CHWs would be continued during the pandemic.

Program managers in HP, India, and Nigeria suggested alternative means of transportation to improve care-seeking by strengthening the indigenous options of ‘doli’ system (palanquins), bike ambulances, and tricycle initiatives to transfer patients in the absence of ambulances, especially on narrow roads unsuitable for four-wheelers (Box 1 – Example 13). High compliance with safety measures and appropriate sanitisation in the facilities and ambulances would ensure staff safety and improve service utilisation as reported by HCPs.

Program managers, facility staff, and KIs unanimously recommended the establishment of separate infrastructure and staff for COVID-19 and non-COVID-19 care. Where this was not possible, they suggested separate facility entrances and floors housing these patients as an alternative. Mobile clinic to treat sick young infants was another popular suggestion by the program managers in India. Audio and video calls, availability of round-the-clock toll-free numbers with access to a panel of doctors, developing simple digital applications and video-based tutorials on prevention and management of infections, telegram groups, and online meetings for HCPs; which would improve the management of sick young infants during the pandemic was also suggested (Box 1 – Example 14).

Program managers also listed filling staff vacancies, adequate training, including frequent virtual training sessions for CHWs, appropriate tools, and adequate supervision of CHWs to improve their performance (Box 1 – Example 15). They recommended standardised training for all CHWs in managing sick young infants. Additionally, they said that using digital screening tools, such as handheld pulse oximeters and a digital platform to follow sick young infants closely, would improve the performance of CHWs, which would be helpful even after the pandemic.

The constitution of a competent local supervisory committee for enforcing social accountability was also suggested. Almost all program managers reported that appropriate incentives for COVID-19 duties were urgently needed to improve staff motivation. They recognised that service quality was negatively impacted during the pandemic due to stress, anxiety, fear, fatigue, excessive workload, and exhaustion from wearing PPE for prolonged periods. Extending facility service hours, appointmenting qualified doctors at primary health care centres, increasing job tenure with less frequent transfers of senior doctors were suggested, along with increasing the number of health centres proportionate to the population and establishing neighbourhood clinics with the provision of essential services to improve long-term treatment access. In HP (India), the program managers added that strict actions were needed against people who harassed and humiliated frontline HCPs during the pandemic.

Program managers, in general, emphasised the need for urgent improvement of service quality. They recommended capacity strengthening and motivation of HCPs through online platforms or on-site visits by senior paediatricians from tertiary level hospitals. Some program managers in India suggested task shifting with the training of Auxiliary Nurse-Midwives to administer injectable antibiotics to young infants and engaging private doctors through public-private partnerships as beneficial strategies.

All program managers and HCPs considered the adequate and continuous supply of medicines and other commodities essential for inpatients and OPDs. Additionally, funding assistance from not-for-profit research institutes or local organisations would be helpful. Support for transportation of sick young infants to the hospital and the presence of a dedicated toll-free number would improve referral. Facilitating staff vaccination would reduce the burden on the government.

The need for free or subsidised treatment provision was reported across all sites by caregivers and KIs because of increased travel and treatment costs and financial stress due to loss of employment. Providing financial schemes through government-established loans (with low-interest rates) would also facilitate care-seeking and treatment by poor people. As a long-term strategy, irrespective of the pandemic, around half of the program managers suggested small and micro industries for employment, provision of health insurance to staff, ensuring fund availability for needy patients to access private services, and decreasing bureaucratic challenges associated with accessing welfare funds by the poor could be valuable strategies to improve health services and utilisation.

DISCUSSION

This formative research provided valuable insights into the challenges of managing sick young infants during the COVID-19 pandemic. Many existed before the pandemic [1326], but became pronounced during the pandemic. The key challenges were: lack of awareness on early identification of serious illnesses requiring care-seeking from sources outside the home, use of home remedies leading to delay in care-seeking, access barriers due to long distances and inadequate or expensive transportation, suboptimal treatment at health facilities due to poor infrastructure, inadequate human resources, unavailability of essential equipment, limited laboratory support, and insufficient medicines and other supplies. The new normal, characterised by restricted movement, reduced transportation, limited-service availability at facilities for illnesses other than COVID-19, and resource reallocation, impacted appropriate treatment for sick young infants. Additionally, fear of COVID-19 infection in the hospital, limited community activities by CHWs, and increased financial stress affected prompt care-seeking. However, it was encouraging that several mitigation strategies were proposed to manage sick young infants across all study sites.

The sub-optimal functioning of health systems in LMICs is known. This research provided an independent understanding of the functioning of the health systems at these sites and obtained profound insights into the possible reasons for barriers and challenges. Some, inherent to the health systems at the various study sites, were expected to persist post-pandemic, impeding access to appropriate care. The care-seeking and care provision were affected due to the pandemic. Essential health care services were disrupted, access was further restricted, and out-of-pocket expenditures escalated due to exorbitant rates for private transportation and increased cost of treatment in private facilities. Loss of employment precipitated financial stress for almost all families.

Limited data are available on the challenges in managing sick young infants in LMICs during the COVID-19 pandemic. A recent survey revealed stress among HCPs and indicated the absence of clarity and guidelines regarding the care of newborns during the pandemic [33]. Another explored the effect on maternity services during the COVID-19 pandemic’s initial stages, when over 700 maternity workers reported antenatal and postnatal care reductions and a shift in birth location from hospital to home [34]. They reported compromised quality of care, particularly evidence-based respectful care practices such as birth companions, family visitation, keeping newborns and mothers together, and breastfeeding. A higher workload due to staff shortages, longer shifts, and increased stress levels were reported [33]. Most data was from maternity HCPs, with less than ten respondents from the neonatal care domain.

There is concern that the negative impact of the COVID-19 pandemic and lockdown on care-seeking practices and CHWs’ performance may become a permanent community behaviour (post-COVID). Many caregivers who shifted to faith healers, alternate systems of health care, formal and informal private sector, or home remedies might consider these as better options closer to home. Another concern was getting government services back on track, such as appropriate home-based CHWs’ postnatal care visits and quality of care at the government hospitals. However, our data were reassuring, indicating that the community returned to pre-COVID-19 practices. Once the lockdowns were lifted, the number of infants visiting the facilities and institutional deliveries reverted to almost pre-COVID-19 levels.

Amidst all the reported challenges, some positive aspects were brought forth. Despite the difficulties, the community sustained faith in the government health system and complied with medical advice for inpatient or outpatient treatment at most sites. Community members at a few sites who started utilising local hospitals due to limited access to far-off tertiary care hospitals were generally satisfied, reinforcing their faith in the health systems. Additionally, even during the COVID-19 pandemic, routine services such as immunisation, antenatal care, and postnatal home visits, although reduced, did not stop entirely. During the post-lockdown period, the situation started improving but did not reach the pre-lockdown status by the end of the study, which is about three months of follow-up data collection. As reported by HCPs and program managers, an unexpected pandemic-related finding was the reduction in the burden of illnesses and seasonal vector-borne infections such as malaria and dengue, although quantified evidence was outside the scope of this study.

Mitigation strategies emerged from HCPs and beneficiaries based on real-life experiences, unlike the top-down approach of identifying solutions. Some of the recommended strategies, such as separate dedicated infrastructure, human resources, exclusive ambulance services for COVID-19 patients, COVID-19 screening of all patients reporting to the facilities, and shifting out COVID-19 positive cases could reduce the spread of infection. Other strategies such as reassuring the community of hospitals’ safety, conducting extensive community awareness programs, taking strict actions against people harassing and discriminating frontline health workers, as well as giving out incentives, health insurance, appropriate PPEs, and vaccines for HCPs would increase service utilisation and staff motivation. As suggested by the private providers, strategies for retaining good doctors in the government sector and public-private partnerships in hard-to-reach remote areas may be considered long-term solutions. In the absence of conventional ambulances, the alternative transportation options with indigenous innovations are worth exploring. Mobile apps and handheld equipment for community-level workers, telemedicine, audio-visual aids, and digital platforms for case identification, treatment, follow-up care, and supportive supervision can be tested for feasibility and may be helpful even beyond the pandemic. Community empowerment, ownership, and participatory actions through the constitution of supervisory committees with community representations, and resource mobilisation for the neediest, as suggested by respondents, could be promising for generating demand and ensuring equitable health service access and utilisation.

Our study has some limitations. The quantitative data were collected retrospectively, so recall bias in reporting cannot be overlooked. Further, the quantitative data were collected concurrently from the records in the facilities and records of the CHWs. Due to the disruptions caused by the pandemic, there is a possibility that the data may not have been captured rigorously with missing data, which could be the reason for the discrepancy between the qualitative and quantitative data. It was not possible to confirm data reliability, as it was not a prospective process. At some sites, FGDs could not be conducted because of social distancing norms. The qualitative method had to be restricted to IDIs and observations only.

The study strengths included obtaining information from multiple stakeholders for comprehensive insights. The study was conducted across six sites in five LMICs, generating rich qualitative information from various contexts. The researchers did not drive the solutions and mitigation strategies. These emerged from various stakeholders, including public and private HCPs at different levels and the end-users, who could share their thoughts. Such solutions may be useful to consider in the long run for similar settings. Many suggested strategies were beyond the pandemic challenges, as these were inherent barriers within the health systems under normal conditions.

CONCLUSIONS

Sick young infants are among the most vulnerable groups needing protection during the pandemic. Our findings provide valuable insights for policymakers. There is an urgent need for clear guidance for the care of normal and sick young infants during the pandemic. It also indicates that the health systems need to be flexible and adaptive. Decentralised decision-making autonomy, ability to mobilise funds or use untied funds with appropriate documentation, procurement of supplies as and when needed, simple operational strategies to recruit and train staff at short notice, and many other pragmatic solutions to optimise operationalisation emerged. Our research provides important insights into the preparedness of health systems facing such catastrophes. While some of the solutions are aspirational and long-term, some are feasible and implementable immediately without substantial investments. The long-term strategies may have implications for crucial policy level changes to strengthen the health system and effectively deal with such public health challenges in the future.

Additional material

Online Supplementary Document

[1] Funding: This study received funding from the Bill & Melinda Gates Foundation (#INV-001311).

[2] Authorship contributions: All authors contributed equally.

[3] Competing interests: The authors completed the ICMJE Unified Competing Interest Form (available upon request from the corresponding author) and declare no conflicts of interest. RB, KD, SY, SG, and YBN are the WHO staff members and SAQ is an ex-staff member. Their opinions and interpretations expressed in this manuscript do not represent WHO policies or recommendations.

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Correspondence to:
Yasir Bin Nisar
Department of Maternal, Newborn, Child, and Adolescent Health and Ageing
World Health Organization
20 Avenue Appia 1211, 27
Geneva
Switzerland
[email protected]