International Journal of Medicine and Health Development

ORIGINAL ARTICLE
Year
: 2022  |  Volume : 27  |  Issue : 2  |  Page : 169--175

COVID-19 lockdown in Enugu, Nigeria: Challenges and concerns of caregivers of children with chronic neurological illnesses


Adaobi I Bisi-Onyemaechi1, Ann E Aronu1, Ugo N Chikani1, Pascal U Chime1, Ndubuisi A Uwaezuoke1, Obinna C Nduagubam2, Ngozi C Ojinnaka1,  
1 College of Medicine, University of Nigeria Ituku-Ozalla, Enugu, Nigeria
2 College of Health Sciences, Enugu State University Teaching Hospital Parklane, Enugu, Nigeria

Correspondence Address:
Adaobi I Bisi-Onyemaechi
College of Medicine, University of Nigeria Ituku-Ozalla, Enugu.
Nigeria

Abstract

Background: COVID-19 pandemic has had a severe impact on the global economy and the public health systems of all affected countries. Objectives: To understand the challenges (health, cognitive, economic, and psychological) posed by the lockdown for the COVID-19 pandemic on caregivers of children with chronic neurological disorders in Enugu, Nigeria. Materials and Methods: A focused group discussion was done with seven caregiver-patient pairs while observing all precautionary measures. The responses of the participants were recorded, transcribed, and analyzed. Results: There was limited access to physicians to review the children’s health, lack of money for medications with worsening of symptoms in some cases. Some children had forgotten what they had learnt during the previous academic period whereas others had torn their books. The policy imposed hunger on the households. Caregivers lost their jobs, and others had their businesses locked down and were unable to provide food. Children had access to cloth face masks but seldom adhered to its use. The participants were well adapted to handwashing. One participant had access to a hand sanitizer. The lockdown of worship centers conferred a sense of anger, frustration, and hopelessness among some of the participants. Conclusion: The lockdown affected access to health services, interrupted learning, superimposed hunger, and affected the social well-being of the study participants. It is recommended that locally adapted strategies be developed to mitigate unintended effects of health policies on sick children and their caregivers.



How to cite this article:
Bisi-Onyemaechi AI, Aronu AE, Chikani UN, Chime PU, Uwaezuoke NA, Nduagubam OC, Ojinnaka NC. COVID-19 lockdown in Enugu, Nigeria: Challenges and concerns of caregivers of children with chronic neurological illnesses.Int J Med Health Dev 2022;27:169-175


How to cite this URL:
Bisi-Onyemaechi AI, Aronu AE, Chikani UN, Chime PU, Uwaezuoke NA, Nduagubam OC, Ojinnaka NC. COVID-19 lockdown in Enugu, Nigeria: Challenges and concerns of caregivers of children with chronic neurological illnesses. Int J Med Health Dev [serial online] 2022 [cited 2022 Jul 1 ];27:169-175
Available from: https://www.ijmhdev.com/text.asp?2022/27/2/169/339024


Full Text



 Introduction



The COVID-19 pandemic has had a severe impact on the global economy and the public health systems of all affected countries.[1],[2] Different strategies have been adopted to limit the spread of this pandemic. These include hand and respiratory hygiene, wearing of face masks when in public, and global lockdown of almost all human activity. As much as 99% of children all over the world are affected by the lockdown.[3] This lockdown has had severe consequences on different aspects of human existence. The lockdown has further worsened the poor socioeconomic situation of sub-Saharan communities initially characterized by poverty, ignorance, and weak health systems.

Children are not exempted from the effects of COVID-19, the lockdown policy inclusive. Although not directly affected by the viral infection as much as the adults,[4] some studies have documented the effects of the lockdown policy for the virus on different aspects of child health and well-being: loss of income for food and household supplies, school closures, home quarantine and restrictions, and inability to access health services.[5],[6],[7] About 1.5 million children have had their education paused due to the pandemic,[8] and those who cannot afford online learning are left out. Low-income families in Sub-Saharan Africa were affected by the expected financial crises after the pandemic. This situation is worse for children living in poor and deprived societies such as Nigeria, where survival is dependent on daily income for most of the population.[9] Businesses have been closed, and non-emergent health services have been reduced to the barest minimum; all these are meant to reduce spread of the virus.

Children with preexisting medical conditions would further be made vulnerable to their underlying illnesses by the effect of the lockdown policy.

Neurological disorders such as epilepsy, cerebral palsy etc. are among the most common chronic illnesses in children in Enugu.[10] These children, though not at risk of imminent death, require significant resources for living. These include anti-epileptic drugs, physical therapy and minding (cerebral palsy), regular hospital visits etc. The effects of the pandemic would significantly increase the demands of care for these children, putting them at a higher risk of abuse and neglect.

This study, therefore, sought to understand the impact of the lockdown for the COVID-19 global pandemic (health, economic, psychological, and cognitive) on caregivers and children with chronic illnesses who in Nigeria are dependent on others for daily functioning depending on their disease severity. This would help in its mitigation, as the battle against the pandemic continues and the development of strategies are well adapted to local contexts to prevent or reduce any unintended effect of this policy on children in the event of future episodes.

 Materials and Methods



Ethical approval

This was obtained from the health research ethics committee of the University of Nigeria Teaching Hospital Enugu, Nigeria. Written informed consent forms were also signed by the study participants.

Study participants

These consisted of caregivers and children with epilepsy, cerebral palsy, Duchenne muscular dystrophy, and brain tumor, who attend the pediatric neurology clinic of the University of Nigeria Teaching Hospital, the biggest and busiest tertiary health facility in South East Nigeria. A focused group discussion (FGD) was conducted with these participants. Inclusion criteria were: caregiver/patient pair who had been hospital appointed during the period of the study and who were willing to visit the hospital facility despite the wave of the pandemic. Exclusion criteria were: those who did not consent to participate in the study.

Procedures

Telephone contacts of the caregivers were obtained from the hospital records, and caregivers were invited through a phone call for the FGD. The purpose of the study was explained by the researchers, and consent to participate was sought and obtained. The study took place in the neurology clinic of the children outpatient department of the hospital. A total of seven caregiver–patient pairs participated in the discussion while observing all precautionary measures (face masks, physical distancing, handwashing, and sanitizing).

The study participants signed an informed consent form before participating in the study, and oral assent was obtained from the children. At the start of the discussion, the moderator acknowledged the presence of the audio recording equipment, assured participants of confidentiality, and gave people the opportunity to withdraw if they are uncomfortable with being taped. The researchers were guided by written-out, open-ended questions as they interviewed the study participants. The responses of the participants were recorded, transcribed, and analyzed. The duration of the discussion was 85 min.

The FGDs were transcribed verbatim in English, and the transcripts were reviewed by listening again to the voice record while proofreading the transcript. A codebook was developed to serve as an analysis plan to guide the review and synthesis of findings from the discussion on the impact of COVID-19 lockdown policy on the health of the child. The codebook contains themes and subthemes identified through a snowballing process from the transcripts (see annex).

 Results



Overall, all the children who participated in this study were in school, except one who had remained out of school due to current ill health. All were affected by lockdown due to the recent COVID-19 pandemic. Challenges of the COVID-19 lockdown are discussed under the headings given next.

Child’s access to health-care services

There seemed to be limited access to physicians and drugs, occasioned by lack of access to drug stores and physicians in the hospital to review the child’s health status, and lack of money to buy medications as parents’ means of livelihood were disrupted.

“Yes,the lockdown affected us in several ways. The sickness got worse, presently she has fever in addition to previous symptoms. You can see how she is looking. We’re confused”…FGD male participant 02

The lockdown led to nonadherence to hospital appointments. These were due to lack of access to transportation and increases in transportation costs consequent to the lockdown policy.

“You see, I should have come for check-up in March but I could not come, that’s why I came in May. I couldn’t afford all her drugs, the drug she was supposed to be taking twice daily, she was given only once because I couldn’t buy all her drugs due to price increase” …FGD female participant 01

“It affected my child very well because we didn’t have money to buy the drugs she’s supposed to be taking, we didn’t have money to buy them. The convulsions got worse during the lockdown because we couldn’t move around, and she was not taking her drugs as recommended”….FGD male participant 03

The increase in the cost of medications and transportation (both availability and cost) was a huge limitation to health care for the participants. Specifications on the number of passengers per vehicle led to increases in the cost of transportation. As a result, only patients who could afford high transportation costs could visit the hospital for health services.

“The cost of transport increased twice the original price, we used to pay N2,000 but now we pay N3,000. The transporters are now talking and practicing physical distancing. You pay for yourself and pay for another seat”…FGD male participant 02

Parents resorted to borrowing for transportation and medications. None of the caregivers in this study had private cars, and the children were able to visit the hospital only when someone volunteered to drive them. Caregivers faced other logistics challenges, such as bridging the trips and sleeping over with relatives due to the lockdown policy.

“We will have to look for where to sleep because of the curfew to avoid being impounded on the way”…FGD male participant 02

Inability to access health care was multidimensional: Health providers, as a part of infection prevention and control, were not available for non-emergent services. Patients were turned back, without prior notice, from seeing the doctor.

“The other day we came for treatment, we were sent away. Nobody attended to us, we were not allowed in. However, the sickness didn’t get worse although he wasn’t taken his drugs as recommended because drugs were not available”…FGD female participant 04

Child’s access to learning and learning materials

Lockdown policy affected the children’s learning and access to learning materials, and this was reported by the participants. Findings show that children seemed to have forgotten what they had learnt during the previous academic period after the prolonged stay at home.

“They have forgotten what they previously learnt in school. They have torn all their books as they play with it”…FGD female participant 05

“They don’t read because they no longer go to school. I keep chasing them around, I don’t rest”…FGD male participant 04

Caregivers expressed mixed reactions of worry and helplessness over the lack of motivation and interest of their children to study at home. Some of the children refused to join the online school program (radio program) offered by the state government. However, lack of interest in the state-led online program was due to the fact that it was not structured to individual classes.

“The school of a thing is worst in my house. God help us that this virus should not re-occur and this present pandemic be eliminated. My house is scattered, you know, when they go to school I rest. But now that they don’t go to school it affects me. However, my children read if you insist but if you don’t pressurize them, they won’t.”…FGD female participant 02

Children instead watched television and played games with other children within the neighborhood, which posed a risk for transmission of the virus.

Lack of interest to participate in the state-led radio school program was complicated by a lack of power supply for the devices.

“He now plays too much every now and then. We do not usually have light for the radio school or to charge phones”…FGD male participant 07

Effect of the lockdown policy on the child’s family livelihood

The policy super-imposed hunger in the households as parents could not attend to their jobs. Households rarely ate recommended daily servings and mix of food. Some people lost their jobs, whereas others had their businesses locked down, leading to an inability to generate income for household feeding.

“As for food, we barely eat. If we eat once a day, we thank God. Before lockdown, we eat three square meals, but now the lockdown made me not to be going out, no work”…FGD male participant 01

“It also affected our feeding. There are children that do not accept any other food other than tea. Like my son if you don’t give him tea in the morning or tell him that there is no money for tea, then you are looking for trouble”…FGD female participant 04

Usually, markets open at 7 am and close at 6 pm. After the lockdown, markets were initially closed completely but later eased to three times a week, operating from 9 am to 4 pm. Caregivers who were small-scale business owners complained that the period of operation was not enough for them to make enough money to feed the family.

“This really affected me too much because I sell bitter-leaf in the market and now they insist that market must close at 4pm. For me, it’s from 4pm that I make more sales”…FGD female participant 06

“I’m a trader and within this period, we find it difficult because taskforce chases us around. So source of income is badly affected, sometimes, we only able to come if we receive financial help from someone for transport”…FGD male participant 03

Child’s access and adherence to COVID-19 infection prevention and control guidelines

The participating children had access to cloth face masks, but they seldom used them. The need to wear face masks for COVID-19 infection prevention and control is compulsory to gain access to health facilities.

“He resisted but I said he must wear it”…FGD female participant 05

“Among my children it’s only this child here that wears each time we visit hospital. We don’t wear the mask while at home”…FGD male participant 06

Unlike face mask use, the study participants were well adapted to regular handwashing.

“He washes his hands very well and even if I don’t remember they will remind me”…FGD female participant 04

“They wash their hands regularly, but we do not have money for hand sanitizer”…FGD participant 02

The children do not seem to understand the rationale behind regular handwashing, and they expect to be served food after handwashing. When food is not served, some express dismay to their caregivers.

“They wash their hands but will usually ask you “where is the food”. You wash your hands and you don’t see food, and actually there is no food”…FGD male participant 01

“He washes his hands several times but he will ask for food after washing hands. Then I will have to explain to him that it’s because of COVID 19”…FGD male participant 05

Among all the discussants, only one reported the availability and use of a hand sanitizer. The nonuse of a hand sanitizer was attributed to a lack of money to buy it.

Psychosocial consequences of the lockdown policy on the child and caregivers

Findings from this study show that people attribute the status of their health and well-being to faith and relationship with God. There was a sense of anger, helplessness, and depression among the study participants due to the lockdown of places of worship.

“It actually affected us because when you have problems, you go to church to pray to God or you get comfort from hearing the word of God. Now you don’t have anywhere to worship. So that is making us to think a lot and have anxiety. In my church, there is no online worship, the church is completely closed”…FGD female participant 03

“We are weighed down but prayer actually relieves us of anxiety. But again, it affected my interaction and connection with other people and groups, no job, no interaction, nothing”…FGD male participant 01

“Spiritually, the lockdown affected us. You see this my child here, when he starts having seizures again, I take him to worship center. We pray and listen to other people’s testimonies, you’re encouraged and comforted”…FGD female participant 04

The loss of social interaction was attributed to the lack of money to purchase drinks and the closure of drinking places. Some caregivers longed to get back to society and continue interactions.

“It’s when you see money that you drink, otherwise, if you don’t have money to eat you cannot drink else you fall off the road”…FGD female participant 07

Caregivers were worried over their inability to receive COVID-19 palliatives from the government, irrespective of the claims by the government over the radio and television. This created a feeling of deprivation among some of the participants.

“Whether it is true or not, I heard that government is sharing money, palliatives and we have not gotten any. I heard that in the north, even those who are in puda (women in puda) receive palliatives. I have not received any here”…FGD male participant 02

 Discussion



The COVID-19 pandemic has been reported to have a potential for long-term unwanted outcomes on children all over the world. In this study, almost all children studied were affected by the lockdown policy. Their lockdown experience, however, varied across each child in relation to his/her household background. Findings from the study also indicated that the COVID-19 lockdown disrupted the activities of children and the caregivers who participated in this study. These negative impacts also affected their existing neurological conditions.

Child’s access to quality health-care services

Although access to quality health-care services is considered fundamental, all over the world, the COVID-19 pandemic is edging health-care systems to their limits and forcing health-care institutions to make difficult decisions on how to ensure access to care while sustaining the struggle against the transmission of COVID-19.[11]

In Nigeria, huge gaps exist in the provision of quality health care and these are currently being widened by the COVID-19 pandemic. Findings from this study indicated that lockdown negatively affected the health of the children who participated in this study through limited access to physicians and drugs, loss of jobs and subsequent lack of money to buy drugs, and lack of transport to health facilities.

The majority of the population are not under the National Health Insurance Scheme and pay out of their pocket for health services. The policies put in place to curb the spread of the virus resulted in dwindling resources for families and increasing difficulty to afford health care as observed in this study. There was an increase in the cost of goods and services, including health care, transportation, and drugs. All non-emergent cases were deferred to reduce the risk of coronavirus transmission. This calls for the development of alternative consultation methods, for example, telephone and Internet consultations while awaiting the easing of the lockdown. There is also a need for health facilities to open channels of communication to avoid patients being turned back after struggling to keep up with their appointments, as was the case with some participants.

Child’s access to learning and learning materials

Nigeria is one of the over 46 countries implementing nationwide closure of schools.[12] This is one of the government’s efforts at curbing the spread of COVID-19 through non-pharmaceutical interventions. School closure has proven to be of some benefit in delaying disease transmission during previous disease outbreaks around the world.[2],[13] However, it may be difficult to measure the specific impact of school closures alone in the presence of other social distancing measures.[14]

The pandemic and its preventive measures had a negative impact on children’s access to learning and learning materials in most countries. This is worse for disadvantaged children and their families, leading to interrupted learning and compromised nutrition.[15],[16] This study shows that the children seemed to have forgotten what they had learnt during the previous academic period, which ought to have been reinforced if learning resumed. Internet and electricity access in many parts of Nigeria is still limited, and this resulted in the inefficiency of alterative learning platforms as was noted from this study. The full impact of the lack of access to learning on children is currently not fully ascertained and may be far-reaching.

The United Nations Educational, Scientific and Cultural Organisation (UNESCO) recommended the use of distance learning programs and open educational applications and platforms.[17] However, most schools in Enugu state are unable to provide or sustain these programs as they are faced with issues such as funding for devices, power supply, and Internet access. Earlier studies reported that school closure in response to the pandemic has a direct and remote impact on the children as well as their teachers, families and far-reaching socioeconomic consequences.[13],[18],[19],[20] Although these consequences are known to the government, there is a fear of school reopening and a rise in infection rates, as has been reported.[14]

Challenge of the lockdown policy on the child’s family livelihood

The participants revealed that the lockdown policy super-imposed hunger in their households. Households rarely eat recommended daily servings and mix of food. For example, some of the caregivers lost their jobs, whereas some others had their shops and businesses closed, leading to an inability to earn money for household feeding. The economic impact of the COVID-19 lockdown has been documented in several other studies.[15],[16],[17] The impact of the lockdown was, however, more profound on families with a lower socioeconomic status.[17]

Enugu state indigenes are largely traders, farmers, and civil servants. The lockdown policy by the government led to the closure of markets, and junior civil servants were asked to stay at home. Although some level of farm work continued, people had problems with selling their products as markets were closed. People ran short of cash for food. There were job losses, businesses were closed and those that operated did so at suboptimal levels. Family incomes dropped significantly, especially those in the private sector; death from hunger became more imminent. Food security is one goal that governments of the underdeveloped and developing countries should aim at achieving.

Child’s access and adherence to COVID-19 infection prevention and control guidelines

This study revealed that the study participants were uncomfortable with some of the infection prevention control measures. Even though they complied largely with the handwashing measures, the regular and correct use of face masks was found to be unpleasant to many of the children, as they were forced to put their masks on when going out. Although the children had access to face masks and handwashing, adherence to regular and correct use of face masks by children was poor and challenging to parents. Some parents also felt that children had a low risk of contracting the disease, hence they were not strict on the regular and correct use of face masks by their children. It was not strange that the children expected food after episodes of handwashing, as this what they had always been taught: “ wash hands before and after meals” and this proves that if the message of regular handwashing is sustained, they would also comply.

Psychosocial consequences of the lockdown policy on the child and caregivers

Although medical literature shows that children are less susceptible to COVID-19, they are the hardest hit by the psychosocial impact of the pandemic.[21] Reports suggest that children are severely affected through the effects of its mitigation.[22],[23]

The children and their caregivers in this study felt a sense of helplessness and depression, as they could not go out of their homes at will to play or attend religious activities, similar to what has been documented.

The psychological burden associated with the pandemic can be attributed to the lockdown more than the morbidity. Other factors that have been associated with the psychosocial burden of COVID-19 include school closure and minimal outdoor activity.[24],[25],[26],[27],[28],[29],[30]

Measures to attenuate the psychosocial impact should be an integral component of crisis response during pandemic conditions.[25]

 Conclusion



The lockdown for the COVID-19 pandemic has had varied negative impacts on children. Efforts must be intensified toward mitigating them.

Recommendations

Governments at all levels should take efforts toward ensuring health insurance for all citizens.

In the event of any pandemic and lockdown policy, the government should

Prioritize efforts to continue education for all children using other alternative learning platforms.

Provide economic assistance to low-income families who are the ones that are hit the hardest by the economic impact of the lockdown for the COVID-19 pandemic.

Improve children’s access to quality and specialized health-care services using alternative platforms.

Acknowledgment

Nil.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Author contribution

AB conceptualized the study, contributed to data collection and data analysis, wrote the initial and final draft, and approved of the final version of the article. AA contributed to data collection and data analysis, wrote the final draft, and approved of the final version of the article. UC contributed to data analysis, wrote the final draft, and approved of the final version of the article. NU contributed to data collection and data analysis, wrote the final draft, and approved of the final version of the article. ON contributed to data collection and data analysis, wrote the final draft, and approved of the final version of the article. PC contributed to data collection and data analysis, wrote the final draft, and approved of the final version of the article. NO conceptualized the study, contributed to data collection and data analysis, critically reviewed the final draft, and approved of the final version of the article. The article has been read and approved by all the authors, the requirements for authorship have been met, and each author believes that the article represents honest work.

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