key: cord-0773091-6wkk8ufv
authors: Mathew, Nyashanu; Rumbidzai, Chireshe; Fungisai, Mushawa
title: Exploring factors enabling the spread of COVID‐19: Narratives of health professionals in Harare, Zimbabwe
date: 2022-02-08
journal: Health Soc Care Community
DOI: 10.1111/hsc.13742
sha: cba5bb754c344fa3dfd437f6bbb3db204c5ff55d
doc_id: 773091
cord_uid: 6wkk8ufv

Low‐ and middle‐income countries (LMICs) are affected by an array of health problems ranging from the weak infrastructure health system to the shortage of equipment and qualified personnel in hospitals and other medical facilities. This makes it difficult for health systems in these countries to withstand pandemics like COVID‐19 leading to a rapid infection of the population. This research study was set to explore the factors enabling the spread of COVID‐19 in the city of Harare. The study utilised an explorative qualitative approach (EQA). The study recruited 40 (N = 40) health professionals who worked for the private sector and the Ministry of Health. One to one semistructured interviews were used to collect data. The data were thematically analysed and presented. Ethical approval was granted by the Joint Research Council of Zimbabwe (JREC). The study found that the shortage of personal protective equipment (PPE), disregard for social distancing, lack of running water, shortage of clinical supplies, overcrowded living houses, selective enforcement of restrictions and corruption were factors that enabled the spread of COVID‐19 pandemic in the city of Harare. There is need for more hospitals to be built and fully equipped with the necessary equipment if health delivery and management of people affected by COVID‐19 is to be improved. More importantly, the health system needs to be supported by a robust health promotion initiative to enlighten communities on pandemics like COVID‐19 and the need to observe utmost hygiene in all spaces.

is likely to sweep the nations if uncontrolled. The virus is reported to thrive well in poor hygienic conditions and weak health systems.

As with most countries, the demand for services was higher in public hospitals than in private hospitals which had the testing equipment (Ozili & Arun, 2020) . Countries with strong health systems like United States and United Kingdom were also experiencing challenges with COVID-19. United States is the worst-affected country with surging infections and deaths (Grant et al., 2020) . Iran's hospitals struggled to cope while in Spain, the private hospitals had to be nationalised to cope with the pandemic (Ozili & Arun, 2020) .

The countries that are mostly threatened by the pandemic have been reported to be low-and middle-income countries. This is mainly due to failings with regard to their health systems. One of the problems that affected nearly all countries in the world during COVID-19 pandemic was personal protective equipment (PPE) (Rowan & Laffey, 2020) . The shortage of PPE is worse in LMICs resulting in fast spread of COVID-19.

In the process of arresting COVID-19, social distancing is regarded as a key response to the pandemic (Kissler, 2020) . Social distancing involves creating a space between people to prevent infection of a pandemic. Social distancing is a challenge to many communities in LMICs due to scarcity of resources and living styles, for example, congested economic activities at places like markets or fetching water from one source (Sigh & Adhikari, 2020) . is spread through respiratory droplets passed from one person to another through sneezing, coughing and when people interact with each other in close proximity (ECDC, 2020) .

Running water is one of the requirements to successfully prevent rapid spreading of pandemics like COVID-19. However, many LMICs like Zimbabwe struggle to provide running water to many of its communities. People end up without clean water to frequently wash their hands and maintain the health standards expected to prevent the spread of coronavirus. This again makes it easy for COVID-19 pandemic to spread from one person to another. Furthermore, because of poor health infrastructure, lack of money to buy medication and equipment for the health facilities, many LMICs have poor supply of medication and equipment in hospitals (Geleto et al., 2018) .

This means that if people are admitted into such hospitals, there are chances that they can acquire infections and many people will struggle to recover.

Overcrowding and shortage of housing is one of the well-known long-standing problems affecting LMICs, for example, in the continents of Africa and Asia (Ezeh et al, 2017) . Lack of housing means that many people live in overcrowded conditions, and this creates a conducive atmosphere for infection and possible spread of pandemics like COVID-19. The situation is also exacerbated by selective enforcement of restrictions and corruption during lockdown (Kuiper et al., 2020) . This allows some people to travel around the country during lockdown with the possibility of catching and spreading COVID-19.

In light of the above-discussed assertions, this study sought to explore the factors enabling the spread of COVID-19 in the city of Harare.

The study utilised an explorative qualitative approach (EQA) conducted with health professionals to understand the enablers of COVID-19 pandemic. EQA is important for understanding the problem rather than offering the final solution to the problem (Gericke et al., 2018) . EQA just like any other qualitative research relies on understanding the lived experiences of the research participants. The research team included experienced qualitative researchers from Public Health and Nursing.

The study recruited 40 (N = 40) health professionals who worked for the private sector and the Ministry of Health. They included 10 (N = 10) nurses, 10 (N = 10) doctors, 10 (N = 10) pharmacists and 10 (N = 10) administrators. The inclusion criteria for participation were that the professionals were working in the private or public health sector. They should have worked in the sector for not less than 12 months and the healthcare organisation they worked for located in Harare, Zimbabwe. What is known about this topic?

• Low-and middle-income countries (LMICs) are affected by an array of health problems ranging from the weak infrastructure health system to the shortage of equipment and qualified personnel in hospitals and other medical facilities.

• One of the problems that affected nearly all countries in the world during COVID-19 pandemic was shortage of personal protective equipment (PPE).

• Running water is one of the requirements to successfully prevent rapid spreading of pandemics like What this paper adds about this topic • Identification of factors enabling the spread of COVID-19

• There is need to decentralise health facilities and make sure that remote and rural areas are well serviced to relieve big health facilities from congestion.

• There is need for professionals working in healthcare to be supported with modern equipment and training to enable them to withstand the surging impact of COVID-19 organisations with an information leaflet inviting their workers to take part in the study. Those who were interested in taking part were given detailed information about the study and the role of the participants. Only the details of those participants who had agreed to take part in the research had their names and details passed to the researchers. All the research participants signed written consent prior to taking part in the study.

One to one semistructured interviews were used to collect data.

The interviews were conducted over a period of 2 months. All the interviews were conducted via online platforms including Zoom, WhatsApp and Microsoft Teams at a mutually convenient prearranged time. The semistructured flexible interview guide was used for the interviews. The interview guide included questions on situations that enabled the spread of COVID-19 pandemic. To ensure the credibility of the data, probing questions such as 'as you men-tioned…, let us talk a little more about…' were used. The research participants were given time to revisit their experiences and reflect before the interviews and were assured that anything they contributed would be respected and valued. All the interviews were audiorecorded following permission from the research participants. The researchers also took notes during the interviews as a way of recording some critical non-verbal communication pertinent to the study.

The final sample size was based on data saturation when no new information was forthcoming.

The interviews were recorded and transcribed verbatim. Each transcript was about 15 pages long and it contained rich and informative data. The study utilised the four phases of the silences framework to analyse the data (Serrant-Green, 2011). The initial data analysis involved repeated reading of transcripts and extraction of significant statements to form the bases of themes. The identified significant statements were coded, and the initial codes were then regrouped into more abstract themes. The analysis was conducted manually. The codes were regularly reviewed to enhance accuracy and consistency. In line with the four phases of the Silences Framework when analysing data in the first phase, the researchers analysed data using captions from the research participants to consolidate the data. In the second phase, the research participants were invited to confirm the data analysed in the first phase as a true record of what they had told the researchers to ensure credibility of the data collected. In the third phase, the output from the second phase was subjected to the collective user voice group; this was a group of people who worked in the health professions but had not taken part in the research study. The idea was to subject the findings to a critical associative eye (Serrant-Green, 2011). In the fourth phase, the researchers analysed the draft from phase 3 to form the final output of the research study which was presented as the main finding of this study. Figure 1 shows the four phases of data analysis.

This method was adopted because it offered a clear systematic approach to data analysis while providing a concise and comprehensive account of the issues being studied with opportunities for verification by the research participants and associative user groups (Chan, Fung & Chien, 2013; Serrant-Green, 2011) .

Following the analysis of data, the research found that shortage of personal protective equipment (PPE), disregard for social distancing, lack of running water, shortage of clinical supplies, overcrowded living conditions, selective enforcement of restrictions and corruption were factors that enabled the spread of COVID-19 pandemic. 

All the research participants reported the shortage of PPE and alcohol gel for use in hospitals and other health facilities. They also reported fear of contracting COVID-19 leading to anxiety and stress. The shortage of PPE and alcohol gel also meant that the patients in the hospital were prone to COVID-19 resulting in co-morbidities. 

Most of the research participants reported that many people did not adhere to social distancing owing to activities associated with the need for survival, for example, in the marketplaces and places where people fetch communal water from boreholes. This gain led to the spread of the infections in the community owing to poor community facilities.

'I honestly understand why social distancing is going to be a problem here, our survival depends on going out every day and selling, we cannot honor these regulations of social distancing'hospital administrator. COVID-19 pandemic is straining healthcare resources worldwide, prompting social distancing measures to reduce transmission intensity of the virus (Kissler et al., 2020) . The research participants reported that there is gross disregard of social distance restrictions.

In the absence of any pharmaceutical intervention, the only strategy against COVID-19 is to reduce mixing of susceptible and infectious people through early ascertainment of cases or reduction of contact (Lewnard & Lo, 2020) . Populations for whom social distancing interventions have been implemented require and deserve assurance that the decision to enact these measures is informed by the best attainable evidence. The continuous disregard for social distancing in communities and other place means an increase of people being infected by COVID-19 pandemic and ultimate pressure on the already strained health systems or facilities. Furthermore, poor social distancing is not only meant for COVID-19 prevention but also for other infectious diseases within the population which might potentially lead to co-infection and congestion of health facilities. There is need for the government to establish a health promotion directorate to raise awareness with regard to social distancing among communities and service users in health facilities. Such initiatives are lacking in lowand middle-income countries (LMICs) like Zimbabwe (Kok et al 2015) .

A robust health promotion system can be key in reducing death and preventing illness. Health professionals need to pass on health messages regarding social distancing during their contact with patients in hospitals. Such messages may be vital in reducing the number of people who present with COVID-19 infections in treatment centres.

Hands are probably the single most route of virus transmission because in most cases, they come into direct contact with the mouth, nose and conjunctiva of the eyes to enable the contraction of virus (Haston et al., 2020) . All participants reported that there is lack of running water in healthcare settings for good hand hygiene and that the general hygiene of the health settings was below standard causing pathogens to breed on several surfaces. This has undoubtedly caused more COVID-19 infections in communities leading to more hospitalisation and pressure on health professionals and facilities at large. There is need for the central government to invest in providing running water in health facilities and communities to make sure that people can wash their hands and prevent the possible spread of pandemics like COVID-19. Poor health facilities have a direct impact on how health professionals can discharge their duties likewise lack of running water can be a source of many diseases not only COVID-19. It therefore means that the shortage of running water resulted in many people presenting with different ailments alongside COVID-19 in the hospital. It also meant that the healthcare professionals were supposed to be prepared to deal with multi-infections while fighting to contain the pandemic. It is therefore important that health professionals are not fixed on containing the pandemic but should also be checking for other ailments of infections that may arise during the pandemic.

Most of the research participants reported lack of medication supplies and equipment in major hospitals. They also reported poor hygienic conditions posing a threat to the safety of individuals coming to use the facilities with a possible cross infection. Poor supplies and lack of equipment in health facilities is a long-standing problem in many LMICs (Dalglish et al., 2013) . Poor supplies and lack of equipment can also be a source of demotivation for healthcare professionals from doing their work (Houghton et al., 2021) . It therefore meant that many health workers were not motivated to work in an environment which was poorly equipped. It made it difficult for the health professionals to meet their target and effectively attend to the patients presenting with COVID-19 and other ailments.

It is therefore important that hospitals or health facilities are fully equipped during the pandemic to make sure that health professionals are fully supported to discharge their duties.

There is need for the central government to commit more money to strengthening health systems and procuring medication and equipment. It is also important that health facilities in rural and remote areas are decentralised to enable local people to access the services without traveling long distances. Furthermore, this will also enable local decision-making in the distribution of resources.

While the rich in countries across the globe are getting tested and treated fast, with good healthcare facilities and financially self- This again meant that more people were being infected by COVID-19 pandemic worsening the situation in hospitals and communities. As alluded to earlier on the increase in the number of people affected by COIVID-19 meant that there was bound to be pressure on health facilities because of the hospitalisation of the affected people. Corruption and selective application of the law is a long running problem in many LMICs (Basu, 2012) . There is need to revamp the policing system through financial support and training to enhance professionalism and root out corruption. It is also important to develop a robust health promotion initiative to inform communities on the dire impact of COVID-19 and the need to observe lockdown rules and regulations.

There is need for professionals working in health to be supported with modern equipment and training in enabling them to withstand the surging impact of COVID-19. Furthermore, there is need to train more health personnel at different levels and make sure that all health facilities are staffed with qualified personnel. There is need to decentralise health facilities and make sure that remote and rural areas are well serviced to relieve big health facilities from congestion.

This study was carried out in Harare, which is the capital city.

However, in future research, encompassing other cities across the country may enable fair comparison of the situation in different parts of the country. The research utilised a qualitative approach, another research utilising both qualitative and quantitative approaches may be necessary to look at issues from different perspectives in terms of methodology.

LMICs are affected by an array of health problems ranging from weak health systems to shortage of equipment and qualified personnel. This makes it difficult for the health systems to withstand pandemics like COVID-19 leading to rapid infection of the population. There is need for developed countries like the Britain, Germany, North America and the Scandinavian to invest more through the United Nations to help developing counties like Zimbabwe, Zambia and Mozambique in building health facilities, training health professionals and equipping the facilities with modern equipment. More importantly, the health system in LMICs needs to be supported by a robust health promotion initiative through training healthcare professionals to use every opportunity to enlighten communities on pandemics like COVID-19 and the need to observe utmost hygiene. The current situation in healthcare has witnessed a sharp shortage of health professionals making the fight against pandemics like COVID-19 difficult. It is therefore important that current governments across the world invest in training and retaining more health professionals to strengthen their healthcare systems.

Our sincere thanks go to all professionals in the city of Harare who participated in this research study.

The authors declare no potential conflict of interest with respect to the research, authorship, and publication of this article.

The research was vetted and approved by the Joint Research Council of Zimbabwe (JREC). All the research participants read the information sheet and signed a consent form, which granted them the right to withdraw from the study at any time without giving reasons. The research participants were given a list of counselling health support services in the local area for support should they become affected after taking part in the study.

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