Companion restrictions in the emergency department during COVID-19: physician perceptions from the Western Cape, South Africa.

OBJECTIVES: To determine emergency department (ED) physicians' perceptions regarding hospital companions being prohibited from accompanying the patient during COVID-19. DESIGN: Two qualitative datasets were combined. Data collected included voice recordings, narrative interviewing and semistructured interviews. A reflexive thematic analysis was conducted and guided by the Normalisation Process Theory. SETTING: Six hospital EDs in the Western Cape, South Africa. PARTICIPANTS: Convenience sampling was used to recruit a total of eight physicians working full time in the ED during COVID-19. RESULTS: The lack of physical companions provided an opportunity for physicians to assess and reflect on a companion's role in efficient patient care. Physicians perceived that the COVID-19 restrictions illuminated that patient companions engaged in the ED as providers contributing to patient care by providing collateral information and patient support, while simultaneously engaging as consumers detracting physicians from their priorities and patient care. These restrictions prompted the physicians to consider how they understand their patients largely through the companions. When companions became virtual, the physicians were forced to shift how they perceive their patient, which included increased empathy. CONCLUSION: The reflections of providers can feed into discussions about values within the healthcare system and can help explore the balance between medical and social safety, especially with companion restrictions still being practised in some hospitals. These perceptions illuminate various tradeoffs physicians had to consider throughout the pandemic and may be used to improve companion policies when planning for the continuation of the COVID-19 pandemic and future disease outbreaks.

Care seeking for under-five children and vaccine perceptions during the first two waves of the COVID-19 pandemic in Lagos State, Nigeria: a qualitative exploratory study.

OBJECTIVE: To explore healthcare seeking practices for children and the context-specific direct and indirect effects of public health interventions during the first two waves of COVID-19 in Lagos State, Nigeria. We also explored decision-making around vaccine acceptance at the start of COVID-19 vaccine roll-out in Nigeria. DESIGN, SETTING AND PARTICIPANTS: A qualitative explorative study involving 19 semistructured interviews with healthcare providers from public and private primary health facilities and 32 interviews with caregivers of under-five children in Lagos from December 2020 to March 2021. Participants were purposively selected from healthcare facilities to include community health workers, nurses and doctors, and interviews were conducted in quiet locations at facilities. A data-driven reflexive thematic analysis according to Braun and Clark was conducted. FINDINGS: Two themes were developed: appropriating COVID-19 in belief systems, and ambiguity about COVID-19 preventive measures. The interpretation of COVID-19 ranged from fearful to considering it as a 'scam' or 'falsification from the government'. Underlying distrust in government fuelled COVID-19 misperceptions. Care seeking for children under five was affected, as facilities were seen as contagious places for COVID-19. Caregivers resorted to alternative care and self-management of childhood illnesses. COVID-19 vaccine hesitancy was a major concern among healthcare providers compared with community members at the time of vaccine roll-out in Lagos, Nigeria. Indirect impacts of COVID-19 lockdown included diminished household income, worsening food insecurity, mental health challenges for caregivers and reduced clinic visits for immunisation. CONCLUSION: The first wave of the COVID-19 pandemic in Lagos was associated with reductions in care seeking for children, clinic attendance for childhood immunisations and household income. Strengthening health and social support systems with context-specific interventions and correcting misinformation is crucial to building adaptive capacity for response to future pandemics. TRIAL REGISTRATION NUMBER: ACTRN12621001071819.

Towards definitions of critical illness and critical care using concept analysis.

OBJECTIVE: As 'critical illness' and 'critical care' lack consensus definitions, this study aimed to explore how the concepts' are used, describe their defining attributes, and propose potential definitions. DESIGN AND METHODS: We used the Walker and Avant approach to concept analysis. The uses and definitions of the concepts were identified through a scoping review of the literature and an online survey of 114 global clinical experts. We used the Arksey and O'Malley framework for scoping reviews and searched in PubMed and Web of Science with a strategy including terms around critical illness/care and definitions/etymologies limited to publications in English between 1 January 2008 and 1 January 2020. The experts were selected through purposive sampling and snowballing, with 36.8% in Africa, 25.4% in Europe, 22.8% in North America, 10.5% in Asia, 2.6% in South America and 1.8% in Australia. They worked with anaesthesia or intensive care 59.1%, emergency care 15.8%, medicine 9.5%, paediatrics 5.5%, surgery 4.7%, obstetrics and gynaecology 1.6% and other specialties 3.9%. Through content analysis of the data, we extracted codes, categories and themes to determine the concepts' defining attributes and we proposed potential definitions. To assist understanding, we developed model, related and contrary cases concerning the concepts, we identified antecedents and consequences to the concepts, and defined empirical referents. RESULTS: Nine and 13 articles were included in the scoping reviews of critical illness and critical care, respectively. A total of 48 codes, 14 categories and 4 themes were identified in the uses and definitions of critical illness and 60 codes, 13 categories and 5 themes for critical care. The defining attributes of critical illness were a high risk of imminent death; vital organ dysfunction; requirement for care to avoid death; and potential reversibility. The defining attributes of critical care were the identification, monitoring and treatment of critical illness; vital organ support; initial and sustained care; any care of critical illness; and specialised human and physical resources. The defining attributes led to our proposed definitions of critical illness as, 'a state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided and the potential for reversibility', and of critical care as, 'the identification, monitoring and treatment of patients with critical illness through the initial and sustained support of vital organ functions.' CONCLUSION: The concepts critical illness and critical care lack consensus definitions and have varied uses. Through concept analysis of uses and definitions in the literature and among experts, we have identified the defining attributes of the concepts and proposed definitions that could aid clinical practice, research and policy-making.

'We have a plan for that': a qualitative study of health system resilience through the perspective of health workers managing antenatal and childbirth services during floods in Cambodia.

OBJECTIVE: Health system resilience can increase a system's ability to deal with shocks like floods. Studying health systems that currently exhibit the capacity for resilience when shocked could enhance our understanding about what generates and influences resilience. This study aimed to generate empirical knowledge on health system resilience by exploring how public antenatal and childbirth health services in Cambodia have absorbed, adapted or transformed in response to seasonal and occasional floods. DESIGN: A qualitative study using semi-structured interviews and thematic analysis and informed by the Dimensions of Resilience Governance framework. SETTING: Public sector healthcare facilities and health departments in two districts exposed to flooding. PARTICIPANTS: Twenty-three public sector health professionals with experience providing or managing antenatal and birth services during recent flooding. RESULTS: The theme 'Collaboration across the system creates adaptability in the response' reflects how collaboration and social relationships among providers, staff and the community have delineated boundaries for actions and decisions for services during floods. Floods were perceived as having a modest impact on health services. Knowing the boundaries on decision-making and having preparation and response plans let staff prepare and respond in a flexible yet stable way. The theme was derived from ideas of (1) seasonal floods as a minor strain on the system compared with persistent, system-wide organisational stresses the system already experiences, (2) the ability of the health services to adjust and adapt flood plans, (3) a shared purpose and working process during floods, (4) engagement at the local level to fulfil a professional duty to the community, and (5) creating relationships between health system levels and the community to enable flood response. CONCLUSION: The capacity to absorb and adapt to floods was seen among the public sector services. Strategies that enhance stability and flexibility may foster the capacity for health system resilience.