Parental Perceptions of COVID-19 Pandemic: Adherence to Laid Down Containment Measures

Objectives: To ascertain, the perceptions of caregivers of children on covid-19 containment measures, the need for adherence to the measures to understand the reasons for poor compliance. Design: Qualitative prospective cross sectional survey of representative sub strata of the community’s population. Analysis according to these themes was conducted using standard Centre for Disease Control, Atlanta Georgia package called CDC EZ TEXT. Setting: The Focus Group discussions (FGDs) and the key informant (KIIs) interviews were held in the hospital at the respective units of the Pediatrics department at the Federal Medical Center (FMC), Asaba. The FGDs and KIIs examined fifteen thematic areas. These focused on Knowledge of the cause of COVID-19, method of spread, implications of observance of the government imposed lockdown and other measures of disease containment. Participants: Consecutively recruited caregivers of children admitted to the various units of the Pediatrics department at the Federal Medical Center. Results: We consecutively recruited 61 consenting participants in FMC: 50 participants for the focused group discussion (FGD) and 11 for key informant interview (KII). They had fair knowledge of the causative organism of this pandemic, its method of spread and the implications of the disease containment measures were fully understood. Rather, the interviewees expressed their difficulties and frustrations in maintaining the rigors of application of these measures but would that government should expedite action towards the discovery of Protective vaccines because of the effect these measures had on their economic means of livelihoods. Conclusion: There is low personal and community engagement in implementation of containment measures. Further efforts should target community engagement.


Introduction
Corona virus disease is spreading rapidly at an alarming rate in Nigeria. [1]. As at the time of the study, there were 893 cases, affecting 25 states with Lagos, Abuja and Kano in the lead. [2]. So far, there is increasing community spread in all the states of the federation. The limited testing of so far within some communities has yielded identification of more than 6000. [2] The government of Nigeria, Federal and states have imposed infection control measures and contact tracing measures but the populace are not strictly adhering to these measures. Affected persons when they present with disease manifestation are not giving accurate history of travel, the states are not strictly adhering to the lockdown orders. Furthermore, there is no strict adherence to hand washing. Orders to wear facemasks are given; the populace do not adhere to appropriate use of the available homemade cloth facemasks.
The lockdown measure and physical distancing have proven effective in slowing down of virus spread to allow for eventual halt of disease spread. These measures may not be entirely culturally acceptable but when the rationale behind and their mechanisms of action are better understood by the communities' compliance may improve. In an effort to understand better the reasons for poor compliance to physical distancing it is necessary to conduct a survey of clientele users of the Pediatric and Obstetrics and Gynaecology units as subsections of the hospital population.

Objective
To obtain the end user perceptions of the need for compliance to the measure of physical distancing, and lockdown process and wearing of face masks; overall infection control measures.

Specific Objective
To promote better understanding of the containment measures so as to stimulate behavioral change in the participants.

Study Site
Pediatric Department has four major areas for care of pediatric patients: the children's emergency room (CHER), Neonatal Unit (NNU), Pediatrics specialist clinics (CHOP) and the main Pediatric wards: mothers from the Antenatal clinics (ANC) of the obstetric department were also involved. The survey involved all the mothers available at the time and at these locations. The hospitals' Ethics committee approved the study. Participants' gave their oral consent after information on the nature of the study.

Design
The survey utilized qualitative method mainly to allow free discussion with the clientele in the hospital. This technic is particularly useful to elicit the beliefs and opinion of a group, while they provide richness and depth. They have high face validity, easily understood and believable. [3][4][5][6][7][8] They also provide an opportunity to observe the interaction of participants, which can illustrate the process of composition and development of ideas.

Design Implementation
The qualitative method also offers the opportunity to learn more details about an event through the conduct of one to one in-depth interviews from an individual with more experience on the subject.

Focus Group Discussion (FGD)
There were two pairs of researchers: one was moderating while the other (the assistant) was recording. The moderating researcher introduced the themes while the assistant observed and noted the non-verbal communication of the participants. The discussion was recorded on tape after obtaining the consent of the participants. The participants' including the moderator and the assistant sat in a circle so that no one was in an advantageous position, while everybody was visible to the moderator and his assistant. The moderator welcomed everybody and then briefly explaining the purpose of the discussion initiated discussions. To enlist clients' Involvement: at the beginning of each session, the researchers explained the Basis of the session: "we are looking into the understanding of COVID-19 by the populace and so we will initiate discussion with you as a group. We will introduce topics and everyone would have opportunity to contribute for five minutes. We have planned a one-hour discussion for every group. If the rounds finish before the end of one hour, anyone else with further contributions to make can be allowed to speak for three minutes." We equally obtained their consent for the video recording. "We will make video recordings of the activities during the session to enable us generate a report for each session with your kind permission. Before we start, for those of you willing to participate we will request a brief introduction of yourself -Name, age, occupation and highest educational qualification." No one opted out. They all introduced themselves including the researchers. However, they indicated that they would not want to have their identity disclosed in the reporting of the data.
After introduction of the themes, each participant gave their views on the subject for five minutes.
During the discussion, the moderator followed the15 point thematic guide in the systematic order and every participant contributed to the discussion on each item of the guide.
During the group discussion, we strictly adhered to physical distancing. The researchers as well as the participants all wore their facemasks. The FGD method allowed free flow communication with only 5 participants at a one-hour session. During the activity, asides taking of notes, there were recordings both video and audio of this event to enable transcription of the activity and proper summaries to be generated for each session.

The Key Informant Interviews (KII)
The process was continued with key informant Interview (For in-depth discussion): The KII was conducted with health workers from the key areas of Pediatrics where the survey is focused on and one mother.

Data Analysis
These qualitative data was transcribed into the coded Summaries. The coded data was grouped into key themes based on the objectives of the study. Analysis according to these themes was conducted using standard Centre for Disease Control, Atlanta Georgia package called "CDC EZ TEXT".

Result
We consecutively selected 61 participants in FMC Asaba; 50 participants for the focused group discussion (FGD) and 11 for key informant interview (KII).

Focused Group Discussion FGD
The 50 participants for FGD comprised 44 mothers, 4 fathers and 2 unmarried female adolescents. Their age ranged between 18 and 30 years. Twenty-three of them were university graduates, 19 had secondary level of education, 10 completed primary school and one was a university undergraduate. Some of them were stay-at-home wives while others were businessmen/women, civil servants and hairdressers. There were 10 subgroups of 5 participants per group. Five of these mothers came for antenatal visit in the antenatal clinic (ANC); five other mothers visited the children's outpatients department (CHOP) with their children while the rest of the participants were taking care of their sick children admitted into the different pediatric units; children's emergency room (CHER), the newborn unit (NNU) and the ward. One each of the FGDs were held at: ANC, CHER and children's ward, while two were at NNU and three were at CHOP.
The first Theme explored their knowledge of Corona virus pandemic. They had fair knowledge as they mentioned the fact that it is a deadly virus, it is worldwide and contiguous, and 'It is a deadly virus spread from person to person.' When they were asked how the virus spread to people, they were vast in this aspect, mentioning handshake, sneezing, speaking, by breeze, close contact.
On where someone can catch the sickness, 'anywhere infected person has been to, can infect others.' Responses listed several places such as market, church, hospitals, parks, marriages, any gathering of people and anywhere at all.
Regarding who can get the sickness: the unanimous response by the participants was that anybody can get the virus, either man or woman.
When asked their view on how they will know whether somebody who is walking about has the sickness: Majority of the participants said that one could not know who has it without testing. A common view was; 'you cannot know because it is not written on the face.' Although some participants added that one can know an infected person if the person is coughing, sneezing frequently or has high blood pressure. There was also emphasis on importance of screening in making the diagnosis as they voiced out, 'you no go fit know who get am except if doctor test am. ' On the issue of knowing how to tell if the child of healthy looking someone who has the sickness also has it: they all dwelt on different symptomatology such as fever, sneezing, cough, difficulty with breathing and refusal to eat.
When it was asked how they can protect themselves or their child from contacting the disease? They reiterated the ongoing strategies including social distancing, avoiding handshakes, minding where one touches, washing of hands, use of sanitizers and keeping clean the environment. On the stay at home/indoors strategy, they also viewed it in another perspective, as a means of ensuring the safety of the children, 'stay at home because if you go out, your children will also go out to visit and play with other children. ' Regarding what someone can do to protect her breastfeeding child from contacting the disease, the participants gave varied answers. They advocated washing of hands and wearing of elbow length hand gloves during breastfeeding to ensure that both have no body contact. They also said that both should wear facemask if it is safe for the baby. The participants however suggested surrogate breastfeeding after separating mother and child, 'she should discontinue, stay away from the child and handover the child to someone to breastfeed.' When further probed on who should take over the breastfeeding, the participants mentioned grandmother or aunts. Another view shared by the participant was that mother should receive treatment and be allowed to breastfeed her child as it is done with HIV positive mothers, pending when corona virus vaccine will be available.
Concerning how Kangaroo Mother Care (KMC) should be done while still expecting to protect the premature baby: most of the participants had nothing to say even after elaboration on the principles and advantages of KMC. Nevertheless, the few participants who are acquainted with KMC aired their views: that the mother can cover herself and then continue to give her premature infant the KMC. It is also their view that the infected mother cannot go ahead with the KMC however, because the infant must have the KMC, the grandmother, the aunt or any relation can give it. In his or her words, 'maybe someone else will give it because there is no way the infected mother will not give the virus to her child on KMC. ' On what the public can do to prevent the spread of the disease, the participants went all out starting with creating vast awareness down to observing all the government directives. Such directives as staying at home, hand washing, use of hand sanitizer even after using ATM, sneezing inside the elbow if not using facemask, avoiding gathering of people, physical distancing and then no hand shaking. However, the participants expressed their reservation about the staying at home orders, 'staying indoors no go help because we are farmers but we go wash our hands anywhere we go. ' When asked what they know about the cure, it was the view of the participants that there is no cure yet. However, on what can be taken to cure the sickness, the participants mentioned taking alcoholic drinks (locally brewed spirit/ogogoro), hot water and chloroquine.
Their sources of information about the COVID 19 included television, Twitter, Facebook, radio, internet, messages from the communication networks, town criers and from friends and colleagues.
Regarding what ways government has laid down to tackle this matter: the participants were able to enumerate a number of measures such as building isolation centers, quarantine persons suspected to have the disease, closure of markets and providing testing kits. They also mentioned the daily updates on the disease progress and the availability of the NCDC testing centers.
Participants talked about what they termed the positive and negative impacts when asked what they thought about the shutdown enforcement by the government. The only positive impact of the lockdown the participants mentioned was that it curtailed the spread of the virus. Speaking about the negative impacts, the participants said that people needed to go out to make a living, look for money for food, house rent, hospitals bills and the rest. They also expressed concerns about the misinterpretation by people when one decides to be distant and the seemingly increase in the number of cases with the lockdown, 'it used to be in tens before lockdown, now it is in thousands even with the lockdown.'

Key Informant Interview (KII)
The 11 KII participants comprised 7 hospital cleaners, 2 porters, 1 security personnel and a patient's relative who was a journalist. There were 2 males and 9 females, with age ranging between 25 and 38 years. One had primary level of education; eight had secondary while two had tertiary. More in-depth discussion were on the Themes numbers 4, 10, 11 and 15 and it was a one to one interview lasting for 4-7 minutes per person.
On who can get the sickness, they all are of the opinion that anybody can get but a few of them added behavioral patterns that place one at high risk, 'anyone can get it especially those who fail to wear face mask, who do not wash their hands always and those who live in dirty environment'.
In-depth knowledge on what the public can do to prevent the spread of disease generated similar information. They mentioned safety precautionary measures such as wearing of facemask, washing of hands always and using hand sanitizer where the former is not feasible, keep distance from one another and avoid crowds. One of the porters mentioned in addition, 'to cough into the elbow or use tissue paper and dispose appropriately and that infected person should isolate from public'.
Concerning what they know about the cure, they all said that they do not know about any cure for now.
What they think about the shutdown enforcement by the government generated many concerns although majority 7 agreed that it is a good strategy, 'it is good because it can help stop the spread and manage the already existing cases'. They believed that it will help to protect the people and keep them safe, also offered civil servants the opportunity to rest and exercise. Nevertheless, one of the participants has this to say, 'it is okay but it was not well planned because there is nothing available for us to sustain life'. One of the two participants who believed that the lock down strategy would not work said so because of the observed low level of compliance even among government officials while the other strongly believed that it is only by Divine intervention there will be compliance. However, two participants did not like the idea of lockdown saying that it is hard for one to stay indoors for weeks, hear one of them, 'I don't like it. Transport fare and prizes of goods have gone up'.

Discussion
The interaction revealed a heightened level of awareness amongst parents and caregivers. However, such level of knowledge has not translated into action. Therefore, there is a mismatch between what they know and what they do. As observed, though anecdotal, the level of compliance to the prevention measures does not match this level of knowledge. This is borne out with the client reaction towards maintenance of the social distance and the lock down. Even though awareness exists, there are issues to be resolved such are: the means of enforcement of the implementation, how and where to report the violations, how cases of the violations should be treated and who should prosecute offenders. It appeared that these same clients did not yet appreciate the gravity and realness of the situation.
Indications from the responses of the FGDs and KIIs suggest that the knowledge and level of information was quite adequate, but the mismatch between knowledge and comportment might have arisen from the fact that these interventions were insufficient to stimulate self -engagement of the populace. Identification of personalized appealing approach to leverage community buy-in might ensure better application of the knowledge of safe precaution measures.
Legalization of the process and prosecution of the offenders without community engagement may not be appropriate solution towards efforts for disease containment. Community engagement coupled with the ongoing media communication, additional appropriate behavioral change communication strategy may yield results. There is apparent dichotomy between saving lives and working for livelihood. The measures taken do not meet the realities of the situation of most countries of lower and middle income settings. [9] The finding of this dichotomy as expressed by one of the KII interviewees actually highlighted an important fact that the lock down needed proper planning and preparedness. The responses from these FGDs suggests full understanding of the fact that even if places have to open up because of the economy, it might not actually be safe. Respondents called for government to open up so that livelihood will be earned and rather investments on Vaccine discovery research should be pursued. These statements have not addressed the need for adherence to the disease containment measures until the vaccine discovery. This emphasizes the need for Governments and societies' response to WHOs call on them to match the efforts of the front line health workers [10] through their actions. It makes common sense that since we are all in this together, society and individuals must match their actions by collaborating and cooperating to contain and limit spread of the virus through adherence with government directives.
Some of these statements illustrate the reality of the dichotomy situation identified herein. This dichotomy supports the report of Prasad, Sri and Gaitonde [9] who had actually alluded to the major findings of this report and suggested that a more holistic approach. It confirms the statement of the WHO that This pandemic is much more than a health crisis and Down Containment Measures requires a whole-of-government and whole-of-society response. [10] A comprehensive public health approach that would address social determinants and medical requirements as well as the consideration of the realities and the needs of the poor and marginalized communities. The suggested approach applied to the individual population situation might be a pragmatic way of coping with the situation. The containment of the disease in China was attained through the collective efforts of the Chinese population ranging from the collaboration of the communities to that of the individual. In order to improve compliance of our population to current government orders it might be beneficial for them to draw lessons from the outcome of solidarity of the Chinese people whose courage and conviction led to acceptance and adherence to what was considered the most difficult of the government containment measures. [11]

Conclusion and Recommendation
The current approach to implementation of Covid-19 response does not meet with the realities of our local environment situation. Since the effect of avoiding widespread and sustained community transmission of the Virus most likely outweigh any costs of preventing such a scenario, a more pragmatic approach should be identified and applied to cope with the demands of the current Covid-19 pandemic. [12][13][14][15]