Surviving in place: The coronavirus domestic violence syndemic

Changes in Sexual Behavior and Satisfaction and Violent Behavior during COVID-19 Lockdown: Explorative Results from the Italian Cross-Sectional Study of the I-SHARE Multi-Country Project

BACKGROUND

The COVID-19 pandemic has had effects on sexual and reproductive health and intimate partner violence (IPV). This study aims to describe changes in sexual health and IPV in the Italian population both during and after the lockdowns.

METHODS

This cross-sectional online study was conducted, as part of the I-SHARE multicountry project, between June 2020 and January 2021. Recruitment was carried out through convenience sampling; a total of 329 participants were included in the analysis. A generalized linear model was used to analyze the difference in sexual health and IPV variables before, during, and after the lockdown.

RESULTS

Fifty-three percent of the participants reported having sexual problems during the first wave of the pandemic. Sexual satisfaction decreased during the first wave, and then, returned to the pre-lockdown level. While during the lockdown, some activities were reduced (such as kissing, cuddling, and sexual activities with a steady partner), for other activities, no difference was reported (such as masturbation, sexual activities with casual partners, or sexting). Few participants reported having issues accessing HIV testing and contraception. There was no difference in terms of physical and sexual violence, while there was a significant decrease in feeling vulnerable to sexual or physical assault during the first wave.

CONCLUSIONS

The first wave of the pandemic has had significant effects on sexual health. This should be taken into consideration when preparing for future epidemics and health emergencies.

Conceptualizing COVID-19 syndemics: A scoping review

Background

COVID-19's heavy toll on human health, and its concentration within specific at-risk groups including the socially vulnerable and individuals with comorbidities, has made it the focus of much syndemic discourse. Syndemic theory recognizes that social factors create the conditions that support the clustering of diseases and that these diseases interact in a manner that worsens health outcomes. Syndemics theory has helped to facilitate systems-level approaches to disease as a biosocial phenomenon and guide prevention and treatment efforts. Despite its recognized value, reviews of syndemics literature have noted frequent misuse of the concept limiting its potential in guiding appropriate interventions.

Objective

To review how the term 'syndemic' is defined and applied within peer-reviewed literature in relation to COVID-19.

Design

A scoping review of definitions within COVID-19 literature published between January 1, 2020 to May 15, 2023 was conducted. Searches took place across six databases: Academic Search Premier, CINAHL, JSTOR, MEDLINE/Pubmed, PsycINFO and Scopus. PRISMA-ScR guidelines were followed.

Results

Content analysis revealed that COVID-19 has varied clustered configurations of communicable-non-communicable diseases and novel communicable disease interactions. Spatial analysis was presented as a new strategy to evidence syndemic arrangements. However, syndemics continue to be regarded as universal, with continued misunderstanding and misapplication of the concept.

Conclusion

This review found that current applications of syndemics remain problematic. Recommendations are made on the design of syndemic studies. A syndemic framework offers an opportunity for systems-level thinking that considers the full complexity of human-disease interactions and is useful to inform future pandemic preparations and responses.

Intimate Partner Violence During COVID-19 Restrictions: A Study of 30 Countries From the I-SHARE Consortium

Intimate partner violence (IPV) causes substantial physical and psychological trauma. Restrictions introduced in response to the COVID-19 pandemic, including lockdowns and movement restrictions, may exacerbate IPV risk and reduce access to IPV support services. This cross-sectional study examines IPV during COVID-19 restrictions in 30 countries from the International Sexual HeAlth and REproductive Health (I-SHARE) study conducted from July 20th, 2020, to February, 15th, 2021. IPV was a primary outcome measure adapted from a World Health Organization multicountry survey. Mixed-effects modeling was used to determine IPV correlates among participants stratified by cohabitation status. The sample included 23,067 participants from 30 countries. A total of 1,070/15,336 (7.0%) participants stated that they experienced IPV during COVID-19 restrictions. A total of 1,486/15,336 (9.2%) participants stated that they had experienced either physical or sexual partner violence before the restrictions, which then decreased to 1,070 (7.0%) after the restrictions. In general, identifying as a sexual minority and experiencing greater economic vulnerability were associated with higher odds of experiencing IPV during COVID-19 restrictions, which were accentuated among participants who were living with their partners. Greater stringency of COVID-19 restrictions and living in urban or semi-urban areas were associated with lower odds of experiencing IPV in some settings. The I-SHARE data suggest a substantial burden of IPV during COVID-19 restrictions. However, the restrictions were correlated with reduced IPV in some settings. There is a need for investing in specific support systems for survivors of IPV during the implementation of restrictions designed to contain infectious disease outbreaks.

Labor trafficking of children and youth in the United States: A scoping review

BACKGROUND

Child labor trafficking is a largely unexplored and unpublished phenomenon in the United States.

OBJECTIVE

To 1) characterize the state of the science on child labor trafficking, and 2) identify empirical information regarding risk and protective factors, and physical/behavioral health needs of labor-trafficked children/adolescents.

METHODS

This scoping review involved an electronic review of five databases; the search was restricted to studies in English or Spanish and published between Jan 1, 2010-Oct 16, 2020. The search yielded 1190 articles; 48 studies qualified for full review and 8 met inclusion criteria (US-based study addressing risk factors/vulnerabilities for child labor trafficking; protective factors; health impact; or health/behavioral healthcare).

RESULTS

Only one study had sufficient sample size to compare sex to labor trafficking among minors; some did not separate data by age group or by type of trafficking. A few shared data from a common source; one was a single case review. Findings suggested that sex and labor trafficking may share common risk factors (e.g., prior child maltreatment and out-of-home placement) as well as within group differences (e.g., labor trafficked children had less prior child welfare involvement than those involved in sex trafficking and were more likely to be younger, male, Black or non-white, and Hispanic). Multiple physical/behavioral health symptoms were reported and may be useful items for a healthcare screen.

CONCLUSIONS

Child labor trafficking research in the U.S. is in its infancy, although the results of this review point to opportunities for screening and case conceptualization that may be useful to practitioners.

The International Sexual Health And REproductive Health during COVID-19 (I-SHARE) Study: A Multicountry Analysis of Adults from 30 Countries Prior to and During the Initial Coronavirus Disease 2019 Wave

BACKGROUND

There is limited evidence to date about changes to sexual and reproductive health (SRH) during the initial wave of coronavirus disease 2019 (COVID-19). To address this gap, our team organized a multicountry, cross-sectional online survey as part of a global consortium.

METHODS

Consortium research teams conducted online surveys in 30 countries. Sampling methods included convenience, online panels, and population-representative. Primary outcomes included sexual behaviors, partner violence, and SRH service use, and we compared 3 months prior to and during policy measures to mitigate COVID-19. We conducted meta-analyses for primary outcomes and graded the certainty of the evidence.

RESULTS

Among 4546 respondents with casual partners, condom use stayed the same for 3374 (74.4%), and 640 (14.1%) reported a decline. Fewer respondents reported physical or sexual partner violence during COVID-19 measures (1063 of 15 144, 7.0%) compared to before COVID-19 measures (1469 of 15 887, 9.3%). COVID-19 measures impeded access to condoms (933 of 10 790, 8.7%), contraceptives (610 of 8175, 7.5%), and human immunodeficiency virus/sexually transmitted infection (HIV/STI) testing (750 of 1965, 30.7%). Pooled estimates from meta-analysis indicate that during COVID-19 measures, 32.3% (95% confidence interval [CI], 23.9%-42.1%) of people needing HIV/STI testing had hindered access, 4.4% (95% CI, 3.4%-5.4%) experienced partner violence, and 5.8% (95% CI, 5.4%-8.2%) decreased casual partner condom use (moderate certainty of evidence for each outcome). Meta-analysis findings were robust in sensitivity analyses that examined country income level, sample size, and sampling strategy.

CONCLUSIONS

Open science methods are feasible to organize research studies as part of emergency responses. The initial COVID-19 wave impacted SRH behaviors and access to services across diverse global settings.

Gender-Based Violence in the Asia-Pacific Region during COVID-19: A Hidden Pandemic behind Closed Doors

Since the early stages of the COVID-19 pandemic, there have been reports of increased violence against women globally. We aimed to explore factors associated with reported increases in gender-based violence (GBV) during the pandemic in the Asia-Pacific region. We conducted 47 semi-structured interviews with experts working in sexual and reproductive health in 12 countries in the region. We analysed data thematically, using the socio-ecological framework of violence. Risks associated with increased GBV included economic strain, alcohol use and school closures, together with reduced access to health and social services. We highlight the need to address heightened risk factors, the importance of proactively identifying instances of GBV and protecting women and girls through establishing open and innovative communication channels, along with addressing underlying issues of gender inequality and social norms. Violence is exacerbated during public health crises, such as the COVID-19 pandemic. Identifying and supporting women at risk, as well as preventing domestic violence during lockdowns and movement restrictions is an emerging challenge. Our findings can help inform the adoption of improved surveillance and research, as well as innovative interventions to prevent violence and detect and protect victims.

Identifying and Responding to the Complex Needs of Domestic Violence Housing Practitioners at the Onset of the COVID-19 Pandemic

The social, financial, and emotional repercussions of the COVID-19 pandemic has left many organizations that support survivors of intimate partner violence questioning how to maintain core services while addressing compounding individual, organizational, and public health issues. Stay-at-home orders and other COVID-19 mitigation strategies have resulted in reduced shelter availability and increased intimate partner violence rates. Coupled with the economic impact of the pandemic, these factors have threatened financial and housing stability. To better understand these challenges and provide immediate support, The National Alliance for Safe Housing (NASH) co-hosted a peer support call to provide a virtual platform for practitioners to ask questions, discuss challenges, and share strategies for quality service provision during the COVID-19 pandemic. Over 800 practitioners from across the United States participated in the NASH call, most of whom were advocates, program directors, and managers. NASH gathered data on practitioners' needs from a brief survey from the registration form analyzed using conventional inductive content analysis. Practitioners' primary concerns were situated within eight questions, which we categorized into four meta-categories: (1) managing residential housing programs; (2) getting survivors materials resources; (3) keeping staff safe; and (4) maintaining organizational operations. The paper concludes with community-grounded and empirically supported practice recommendations aligned with practitioners' expressed needs.

'I will rather be killed by corona than by him…': Experiences of abused women seeking shelter during South Africa's COVID-19 lockdown

BACKGROUND

In April 2020, the United Nations predicted that the COVID-19 pandemic will have a 'calamitous' impact on the lives of women. This was based on concerns about an upsurge in Intimate Partner Violence (IPV) arising from increased opportunities for relational conflict due to forced co-existence and therefore additional time spent with abusive partners.

AIM

Research has shown an increase in IPV during times of crisis. The COVID-19 pandemic has generated unprecedented circumstances and stress, and opportunities to do research to understand whether the COVID-19 pandemic impacted on IPV experiences were limited. Thus, the present study aimed to understand women's experiences of being in and leaving an abusive relationship during the COVID-19 pandemic.

METHODS

Individual, telephonic interviews were conducted with 16 women living in domestic violence shelters within three Provinces during South Africa's lockdown period.

RESULTS

Findings reveal that the public health measures implemented by the South African Government to curb the spread of the virus, may have placed vulnerable groups at increased risk of violence. Specifically, lockdown likely magnified the risk for escalation of abuse in families already experiencing IPV prior to COVID-19. The study highlights an IPV and COVID-19 relationship, showing that the gender insensitive pandemic control measures, such as stay at home orders and travel restrictions, likely placed women at risk of increased abuse. Given the recurrency of COVID-19 epidemic waves, attention must be given to gender disparities or many South African women may experience worse outcomes.

CONCLUSION

This study reminds us that being ordered to stay at home is not always the safest option for women and thus, in a country with one of the highest levels of GBV, it becomes imperative to ensure that IPV safeguards are integrated into COVID-19 measures. It also becomes evident that COVID-19 requires enhanced ways of responding by paying attention to gender disparities.

The International Sexual Health And Reproductive Health Survey (I-SHARE-1): A Multi-Country Analysis of Adults from 30 Countries Prior to and During the Initial COVID-19 Wave

Background

The COVID-19 pandemic forced billions of people to shelter in place, altering social and sexual relationships worldwide. In many settings, COVID-19 threatened already precarious health services. However, there is limited evidence to date about changes to sexual and reproductive health (SRH) during the initial wave of COVID-19 disease. To address this gap, our team organized a multi-country, cross-sectional online survey as part of a global consortium.

Methods

Consortium research teams conducted online surveys in 30 countries. Sampling methods included convenience, online panels, and population-representative. Primary outcomes included sexual behaviors, partner violence, and SRH service utilization, and we compared three months prior to and three months after policy measures to mitigate COVID-19. We used established indicators and analyses pre-specified in our protocol. We conducted meta-analyses for primary outcomes and graded the certainty of the evidence using Cochrane methods. Descriptive analyses included 22,724 individuals in 25 countries. Five additional countries with sample sizes <200 were included in descriptive meta-analyses.

Results

Respondents were mean age 34 years; most identified as women (15160; 66.7%), cis-gender (19432; 86.6%) and heterosexual (16592; 77.9%). Among 4546 respondents with casual partners, condom use stayed the same for 3374 (74.4%) people and 640 (14.1%) people reported a decline. Fewer respondents reported physical or sexual partner violence during COVID-19 measures (1063/15144, 7.0%) compared to the period before COVID-19 measures (1469/15887, 9.3%). COVID-19 measures impeded access to condoms (933/10790, 8.7%), contraceptives (610/8175, 7.5%), and HIV/STI testing (750/1965, 30.7%). Pooled estimates from meta-analysis indicate during COVID-19 measures, 32.3% (95% CI 23.9-42.1) of people needing HIV/STI testing had hindered access, 4.4% (95% CI 3.4-5.4) experienced partner violence, and 5.8% (95% CI 5.4-8.2) decreased casual partner condom use (moderate certainty of evidence for each outcome). Meta-analysis findings were robust in sensitivity analyses that examined country income level, sample size, and sampling strategy.

Conclusion

Open science methods are feasible to organize research studies as part of emergency responses. The initial COVID-19 wave impacted SRH behaviors and access to services across diverse global settings.

Intersectional tension: a qualitative study of the effects of the COVID-19 response on survivors of violence against women in urban India

OBJECTIVES

There is a concern worldwide that efforts to address the SARS-CoV-2 pandemic have affected the frequency and intensity of domestic violence against women. Residents of urban informal settlements faced particularly stringent conditions during the response in India. Counsellors spoke with registered survivors of domestic violence in Mumbai, with two objectives: to understand how the pandemic and subsequent lockdown had changed their needs and experiences, and to recommend programmatic responses.

DESIGN

Qualitative interviews and framework analysis.

SETTING

A non-government support programme for survivors of violence against women, providing services mainly for residents of informal settlements.

PARTICIPANTS

During follow-up telephone counselling with survivors of violence against women who had previously registered for support and consented to the use of information in research, counsellors took verbal consent for additional questions about the effects of COVID-19 on their daily life, their ability to speak with someone, and their counselling preferences. Responses were recorded as written notes.

RESULTS

The major concerns of 586 clients interviewed between April and July 2020 were meeting basic needs (financial stress, interrupted livelihoods and food insecurity), confinement in small homes (family tensions and isolation with abusers) and limited mobility (power imbalances in the home and lack of opportunity for disclosure and stress relief). A major source of stress was the increased burden of unpaid domestic care, which fell largely on women.

CONCLUSION

The COVID-19 pandemic has increased the burden of poverty and gendered unpaid care. Finance and food security are critical considerations for future response, which should consider inequality, financial support, prioritising continued availability of services for survivors of violence and expanding access to social networks. Decision-makers must be aware of the gendered, intersectional effects of interventions and must include residents of informal settlements who are survivors of domestic violence in the planning and implementation of public health strategies.

Tele-Case Work Consultation to Woman Survivor of Domestic Violence During COVID 19 Pandemic

The COVID-19 pandemic and subsequent lockdown to mitigate the spread of the COVID-19 have resulted in social isolation, reduced social support system, and increased domestic violence (DV) cases against women and children. The governments and NGOs have taken several measures to prevent DV by starting helpline, WhatsApp numbers, and counseling services during the lockdown to safeguard the women. This paper describes a case scenario of how we offered tele-case work consultation during the lockdown period due to the COVID-19 pandemic, the procedure adopted, and preventive measures followed while providing a tailor-made psychosocial intervention to a DV survivor. It also discusses the strengths and challenges while offering tele-consultation and possible steps to overcome the technological barriers to mental health professionals.

PROXEMICS, COVID-19, AND THE ETHICS OF CARE IN SOUTH AFRICA

In South Africa, lockdown and its excesses have opened up questions on the limits of an ethics of care, whose ethics are privileged, how care is delivered, and what care means. We show how an ethics of proxemics and its operationalization as distance highlight everyday inequalities and limit the provision of care. Constraints on physical distancing in line with public health measures intended to limit the spread of the coronavirus echo the controls enforced under apartheid, showing how inequality is both embodied and legally entrenched.

Impact of COVID-19 pandemic on chronic diseases care follow-up and current perspectives in low resource settings: a narrative review

Coronavirus is a respiratory disease that spreads globally. The severity and mortality risk of the disease is significant in the elderly, peoples having co-morbidities, and immunosuppressive patients. The outbreak of the pandemic created significant barriers to diagnosis, treatment and follow-up of chronic diseases. Delivering regular and routine comprehensive care for chronic patients was disrupted due to closures of healthcare facilities, lack of public transportation or reductions in services. The purpose of this narrative review was to update how patients with chronic care were affected during the pandemic, healthcare utilization services and available opportunities for better chronic disease management during the pandemic in resources limited settings. Moreover, this review may call to the attention of concerned bodies to make decisions and take measures in the spirit of improving the burden of chronic diseases by forwarding necessary recommendations for possible change and to scale up current intervention programs.

Changes in traumatic mechanisms of injury in Southern California related to COVID-19: Penetrating trauma as a second pandemic

BACKGROUND

The COVID-19 pandemic resulted in a statewide stay-at-home (SAH) order in California beginning March 19, 2020, forcing large-scale behavioral changes and taking an emotional and economic toll. The effects of SAH orders on the trauma population remain unknown. We hypothesized an increase in rates of penetrating trauma, gunshot wounds, suicide attempts, and domestic violence in the Southern California trauma population after the SAH order.

METHODS

A multicenter retrospective analysis of all trauma patients presenting to 11 American College of Surgeons levels I and II trauma centers spanning seven counties in California was performed. Demographic data, injury characteristics, clinical data, and outcomes were collected. Patients were divided into three groups based on injury date: before SAH from January 1, 2020, to March 18, 2020 (PRE), after SAH from March 19, 2020, to June 30, 2020 (POST), and a historical control from March 19, 2019, to June 30, 2019 (CONTROL). POST was compared with both PRE and CONTROL in two separate analyses.

RESULTS

Across all periods, 20,448 trauma patients were identified (CONTROL, 7,707; PRE, 6,022; POST, 6,719). POST had a significantly increased rate of penetrating trauma (13.0% vs. 10.3%, p < 0.001 and 13.0% vs. 9.9%, p < 0.001) and gunshot wounds (4.5% vs. 2.4%, p = 0.002 and 4.5% vs. 3.7%, p = 0.025) compared with PRE and CONTROL, respectively. POST had a suicide attempt rate of 1.9% and a domestic violence rate of 0.7%, which were similar to PRE (p = 0.478, p = 0.514) and CONTROL (p = 0.160, p = 0.618).

CONCLUSION

This multicenter Southern California study demonstrated an increased rate of penetrating trauma and gunshot wounds after the COVID-19 SAH orders but no difference in attempted suicide or domestic violence rates. These findings may provide useful information regarding resource utilization and a target for societal intervention during the current or future pandemic(s).

LEVEL OF EVIDENCE

Epidemiological, level IV.

COVID-19 and the rise of intimate partner violence

Stay-at-home policies have been implemented worldwide to reduce the spread of the SARS-CoV-2 virus. However, there is a growing concern that such policies could increase violence against women. We find evidence in support of this critical concern. We focus on Peru, a country that imposed a strict nationwide lockdown starting in mid-March and where nearly 60% of women already experienced violence before COVID-19. Using administrative data on phone calls to the helpline for domestic violence (Línea 100), we find that the incidence rate of the calls increased by 48 percent between April and July 2020, with effects increasing over time. The rise in calls is found across all states and it is not driven by baseline characteristics, including previous prevalence of violence against women. These findings create the need to identify policies to mitigate the negative impact of stay-at-home orders on women's safety.

International Sexual Health And REproductive health (I-SHARE) survey during COVID-19: study protocol for online national surveys and global comparative analyses

BACKGROUND

COVID-19 may have a profound impact on sexual health, reproductive health and social life across the world. Shelter in place regulations that have extended across the globe may influence condomless sex, exacerbate intimate partner violence and reduce access to essential reproductive health services. Population representative research is challenging during shelter in place, leaving major gaps in our understanding of sexual and reproductive health during COVID-19. This International Sexual Health And ReproductivE health (I-SHARE) study protocol manuscript describes a common plan for online national surveys and global comparative analyses.

METHODS

The purpose of this cross-sectional study is to better understand sexual and reproductive health in selected countries during the COVID-19 pandemic and facilitate multinational comparisons. Participants will be recruited through an online survey link disseminated through local, regional and national networks. In each country, a lead organisation will be responsible for organising ethical review, translation and survey administration. The consortium network provides support for national studies, coordination and multinational comparison. We will use multilevel modelling to determine the relationship between COVID-19 and condomless sex, intimate partner violence, access to reproductive health services, HIV testing and other key items. This study protocol defines primary outcomes, prespecified subanalyses and analysis plans.

CONCLUSION

The I-SHARE study examines sexual and reproductive health at the national and global level during the COVID-19 pandemic. We will use multilevel modelling to investigate country-level variables associated with outcomes of interest. This will provide a foundation for subsequent online multicountry comparison using more robust sampling methodologies.

Implicaciones del porte legal de armas en salud pública: Una mirada desde el caso colombiano

La Organización Mundial de la Salud (OMS) define la violencia como el uso de la fuerza física de manera exagerada contra sí mismos o con miembros de una comunidad. Cada acto de violencia en sí, genera un aumento del riesgo de muerte, de esta manera, se estima que 9 de cada 10 muertes violentas no se encuentra asociada al conflicto armado.  

Expresiones de la violencia basada en género, en el marco del confinamiento por COVID-19

La violencia basada en género (VBG) es un reto actual para la consecución de la equidad de género y la garantía de una vida libre de violencia para las mujeres. Una vez que la emergencia por la expansión del virus COVID-19 inició, con las subsecuentes medidas de confinamiento adoptadas por distintos países, han aumentado los casos de VBG. La siguiente pesquisa lleva a cabo una revisión de textos provenientes de fuentes académicas, ONG y pronunciamientos oficiales acerca de la incidencia de las medidas de confinamiento sobre la VBG,  especialmente para el caso iberoamericano. Desde una aproximación cualitativa, los resultados muestran expresiones, factores de riesgo y estrategias de mitigación para la prevención y atención de la VBG en el marco del confinamiento por COVID-19.

COVID-19 Resilience for Survival: Occurrence of Domestic Violence During Lockdown at a Rural American College of Surgeons Verified Level One Trauma Center

Background As the early peak phase in the coronavirus outbreak has intensified, stay-at-home mandates requiring identified individuals as nonessential were advised to remain home to prevent community transmission of the disease. Further mandates escalated isolated environments such as school closures, social distancing, travel restrictions, closure of public gathering spaces, and business closures. As citizens were forced to stay home during the pandemic, the crisis created intensifying stressors and isolation, which fostered an environment for increased domestic violence.  Methods A retrospective review of all emergency department (ED) patients that presented to an American College of Surgeons (ACS) verified rural level one trauma center with associated diagnostic coding for assault was conducted during the Coronavirus 2019 (COVID-19) lockdown, integral dates March 16, 2020 to April 30, 2020. In particular the identification of proportional assaults that presented to the ED after school closures (March 16, 2020) was compared to the previous year (March 16, 2019 to April 30, 2019). The data collected included patient characteristics, grouping by mechanism, grouping by a specific mechanism, and domestic violence perpetrators.  Results A statistically significant (p = 0.01) increase in assaults was found during the COVID-19 lockdown, particularly during the period after school closures.  Conclusions Although overall trauma volume was reduced during the COVID-19 stay-at-home mandates, a significant increase in domestic violence assaults was observed. Largely the assaults were perpetrated against white men by partners and unspecified nonfamily members, which were predominantly penetrating injuries.

Impact of the societal response to COVID-19 on access to healthcare for non-COVID-19 health issues in slum communities of Bangladesh, Kenya, Nigeria and Pakistan: results of pre-COVID and COVID-19 lockdown stakeholder engagements

INTRODUCTION

With COVID-19, there is urgency for policymakers to understand and respond to the health needs of slum communities. Lockdowns for pandemic control have health, social and economic consequences. We consider access to healthcare before and during COVID-19 with those working and living in slum communities.

METHODS

In seven slums in Bangladesh, Kenya, Nigeria and Pakistan, we explored stakeholder perspectives and experiences of healthcare access for non-COVID-19 conditions in two periods: pre-COVID-19 and during COVID-19 lockdowns.

RESULTS

Between March 2018 and May 2020, we engaged with 860 community leaders, residents, health workers and local authority representatives. Perceived common illnesses in all sites included respiratory, gastric, waterborne and mosquitoborne illnesses and hypertension. Pre-COVID, stakeholders described various preventive, diagnostic and treatment services, including well-used antenatal and immunisation programmes and some screening for hypertension, tuberculosis, HIV and vectorborne disease. In all sites, pharmacists and patent medicine vendors were key providers of treatment and advice for minor illnesses. Mental health services and those addressing gender-based violence were perceived to be limited or unavailable. With COVID-19, a reduction in access to healthcare services was reported in all sites, including preventive services. Cost of healthcare increased while household income reduced. Residents had difficulty reaching healthcare facilities. Fear of being diagnosed with COVID-19 discouraged healthcare seeking. Alleviators included provision of healthcare by phone, pharmacists/drug vendors extending credit and residents receiving philanthropic or government support; these were inconsistent and inadequate.

CONCLUSION

Slum residents' ability to seek healthcare for non-COVID-19 conditions has been reduced during lockdowns. To encourage healthcare seeking, clear communication is needed about what is available and whether infection control is in place. Policymakers need to ensure that costs do not escalate and unfairly disadvantage slum communities. Remote consulting to reduce face-to-face contact and provision of mental health and gender-based violence services should be considered.