Documentation of older people’s end-of-life care should cover the care given and provide an overview of their entire situation. Older people approaching the end of life often have complex symptoms, live with bodily losses, and face an unknown future in which existential aspects come to the forefront. Knowledge of the existential aspects recorded in palliative care documentation is sparse and merits improvement. This knowledge is relevant to the development of more holistic documentation and is necessary in order to promote reflection on and discussion of documentation of the sensitive existential considerations arising in palliative care. The aim of this study was to describe the documentation of existential aspects in the patient records of older people receiving specialized palliative care.Data were obtained from a retrospective review of the free-text notes in 84 records of randomly selected patients aged ≥75 years enrolled in specialized palliative care units who died in 2017. The notes were analysed using an inductive qualitative content analysis.autonomy concerning loss of freedom and self-determination, social connectedness concerning loneliness and communion, emotional state concerning anxiety and inner peace, and state of being concerning despair and hope. The notes on existential aspects were, however, not recorded in a structured way and no care plans related to existential aspects were found.The notes documented existential aspects in terms of connotations of well-being and ill-being. Documented existential aspects were related to the patients’ Existential aspects concerning both ill-being and well-being were sparsely and unsystematically documented in older people’s patient records, but when notes were extracted from these records and analysed, patterns became evident. Existential aspects form an important basis for delivering person-centred palliative care. There is a need to develop structured documentation concerning existential aspects; otherwise, patients’ thoughts and concerns may remain unknown to healthcare professionals. Clinical record-keeping is integral to delivering safe, high-quality healthcare and is fundamental to clinical practice , 2. WHO The literature describes existential aspects encountered towards the end of life in terms of both suffering  and wellResearch shows that living towards the end-of-life entails facing loss and adapting to a new and unknown existence in which the person strives for balance by calibrating and adjusting expectations in order to maintain physiological and existential well-being , 14. ThiAdvanced care plans, which are prepared by both non-palliative-care–trained HCPs and specialized palliative nurses, are documents covering the physical, social, psychological, and spiritual domains and stating individuals’ goals and preferences for future treatment and care. A study of such plans in specialized palliative care found that they were most concerned with the physical domain, much less with the social and psychological domain, and least with the existential domain . This isThe aim of this study was to describe the documentation of existential aspects in the patient records of older people who had received specialized palliative care.This study was a retrospective review of free-text notes in patient records, analysed using inductive content analysis as described by Elo and Kyngäs . The dat> 75 years who had received end-of-life care in an in-patient ward and/or in their own home and had died between 1 January and 31 December 2017. Every eighth patient record meeting the criteria was randomly selected in each of the three geographical areas, resulting in 92 electronic patient records. The decision to select every eighth medical record of older people who died in 2017 (n = approximately 750) [The sample in this study was derived from 11 palliative units providing specialized palliative care in three geographical areas in southern Sweden. The inclusion criteria were patient records of people aged ely 750)  was baseely 750) ; it was In terms of total capacity, the 11 palliative units serve patients of all ages, providing palliative care for approximately 280 patients at home and 70 in palliative in-patient wards. About 1650 patients die in these specialized palliative care units yearly, of whom about 54% are aged ≥75 years, representing approximately 750 deceased people in 2017 [Data were collected by the first author by identifying the free-text notes concerning existential aspects in the patients’ records. A random selection of about 5% of the extracted data was independently reviewed by two of the four co-authors (BHR and IB). As others have noted, the concepts “spiritual” and “existential” are used interchangeably in the literature; with no single commonly accepted definition of these concepts , we From the patient records, the free-text notes concerning existential aspects were analysed using qualitative content analysis, in a method incorporating the phases of preparation, organization, and categorization . The preThe notes understood as treating existential aspects conveyed connotations of both ill-being and well-being and were represented in all four categories Table . An inciloss of freedom and wellbeing in terms of self-determination.The notes mentioned existential aspects related to personal autonomy, concerning ill-being in terms of loss of freedom expressed the hardship of not being able to move around or take care of oneself and of having to depend on others for help. The notes described feelings of frustration at not being able to do things one could do in the past: “Is not afraid of death, but thinks it is hard that she now needs help as she has always managed by herself” .Notes relating to The notes described situations in which lack of energy hindered the older people from doing what they wanted to do, and some notes described a process of coming to accept the present reality. The state of being tired and powerless made the patients sad. Other notes referred to the experience of feeling unsafe going outdoors, due to lack of bodily energy; this meant that patients did not dare to go outside, instead staying at home and becoming isolated. Notes also described feelings of frustration expressed, for example, when the older people were not informed of their condition, were “asked to pee in a diaper”, or met other people who did not understand their current life situation.self-determination recorded the patients’ desire to take care of themselves as much as possible, for example, taking prescribed medications themselves and contacting municipal homecare services by themselves to discuss the kind of help they needed. Expressions such as “wants to manage as much as possible”, “wants to ask for help themselves”, and “wants control” were found in the notes. Although the patient’s body was gradually deteriorating and weakening, the notes described a patient as “using the aids available to make everyday life easier and to save energy”. Other notes stated that patients preferred not to talk about the future and imminent death at all, or that an older person had “learned to push away emotions and move on”. Although notes described one older person as preferring not to talk about death, several notes stated that s/he was aware that the end of life was near. The notes revealed that the patient wished to be involved in her/his own care, for example, by participating in care decisions and being able to refuse offered care. The notes also articulated the importance for the patients of deciding on the physical care of their bodies. The notes stated that it was important for all HCPs to know their patients’ individual desires when, in the future, they were no longer able to express their wishes.The notes concerning loneliness and wellbeing in terms of communion.The notes mentioned existential aspects related to social connectedness, specifically ill-being in terms of loneliness, expressed in the records in various ways. For example, notes mentioned patients not wanting to be alone, wanting to have people around, wanting to move to a nursing home because of a lack of social interaction, and feeling lonely even when with other people, revealing feelings of emptiness and boredom. Furthermore, notes described how an older person simply lay down waiting for the next visit, while other notes described an older person’s longing for company during meals. The following note recorded a patient’s feeling of loneliness and desire for someone to be nearby: “Is feeling worried after her son left, feeling lonely and wanting someone to check on her regularly” .The documentation of the older people’s ongoing lives contained notes about feelings of Notes also revealed that the patients were missing significant others who had died. Other notes described an older person who gripped hold of the HCPs so as not to be left alone. Furthermore, notes described patients who, despite expressing feelings of loneliness, rejected invitations to sit in the living room with other people.communion related to older people being with their family and HCPs in their own homes or in the palliative in-patient wards. These notes described activities such as talking, being together, and celebrating events as well as the patients’ moods, for example: “was in a good mood” and “was laughing and joking”. In some notes, HCPs described conversations in which the older people were allowed to take their time and talk about whatever they wanted. Other notes indicated that they spent time communicating with their children via Skype and spent time with their pets, even in the in-patient ward, which was described as making them happy and satisfied. The following quotation from a note recorded the type of activity and mood described by an older person who had celebrated a baptism: “Attended a baptism on the weekend and endured participation in church. Feels satisfied by that” .Notes identified as expressing The notes in this category also spoke of the older people as receiving good support and help from family, describing the family and/or HCPs as being present and watching at their deathbeds.anxiety and wellbeing in terms of being at peace.The notes mentioned existential aspects related to emotions, concerning ill-being in terms of anxiety were always followed by explanations as to why such feelings were expressed. The anxiety could concern being worried and stressed about having to move to a nursing home or could be because other patients were straying into their room in the in-patient ward. Notes also described the patients’ experiences of unpleasant symptoms, for example, fears about “not getting enough air” and that the problem could worsen in the future. The notes about anxiety also concerned fear of dying. Documented feelings of anxiety were often related to nightly events such as nightmares and sleeplessness caused by intrusive thoughts: “The patient is very anxious, is afraid to fall asleep due to fear of not waking up” .The notes related to Feelings of anxiety in the present were often caused by thoughts about the past or future, rather than about the situation here and now. The notes revealed the patients’ worries about what would happen to their families when they were dead. Notes also described anxiety about a future of anticipated pain, severe symptoms, and insufficient help. The notes described interventions such as HCPs offering contact with other professions, usually social workers and physicians, and/or contact with religious representatives for further conversations. The notes reported conversations with the older people in which suggestions were offered about, for example, how to relieve anxiety by soft-touch massage. Other interventions for calming anxious patients were “getting tucked in”, “getting help to listen to music”, and “sitting beside a dying person”.being at peace were varied and referred to the past, present, and expected future life. Notes describing the present life told of “coming to peace”, “sleeping well”, “having a good time”, “feeling well”, and “being in good spirits”. Further notes contained information about the patients “accepting their situation, wanting to take advantage of the day and do nice things with their family”. Notes related to the past life could describe a patient as “being satisfied with the life lived” and, in relation to the future, as “not feeling any fear or anxiety about having to die soon” because s/he “has planned and arranged for their family and know they will be safe”. Even though the patients felt safe and peaceful, the notes documented their wishes for support from HCPs: “Is not anxious about what’s ahead but wants support at the end of life” .Notes related to despair and wellbeing in terms of hope.In the notes, existential aspects related to state of being were found, and concerned ill-being in terms of despair revealed that the dying older people were living with severe problems. These notes often recorded the words of the patients who felt that life was not worth living. Their present life was described as a “meaningless existence”, associated with the impossibility of living the way they wished to live. Notes also recorded an increased sense of boredom, sadness, and tiredness, making it difficult to find joy or any quality of life, leading to a desire to end one’s life. The notes about patients wanting to die or to shorten their lives were worded in various ways: “unable to live”, “does not want to live any longer”, “wishes for euthanasia”, and “crying and expressing a desire to shorten life”. Some notes described older people “becoming panicky” or screaming “I want to die”, but went on to report that they eventually calmed down.The notes related to hope reported patients’ wishes to live for a while longer, even though they were aware that death was imminent. Other notes described the hopefulness of older people striving to live in the present and “take the days as they come”, “focus on the present”, and “take advantage of the times of well-being”. Other notes focused on the future and expressed patients’ hopes of being able to celebrate upcoming birthdays, and expressions such as “hopes to get better” and “wants to fight on”, and reports of patients’ wishes to continue life-prolonging treatments were found. Notes described how the patients wished to go outdoors and “looked forward to sitting in a wheelchair” or “longed for the spring” or “to get home and be able to go outside in their garden” when in the in-patient ward. Some notes described patients’ feelings of joy experienced between periods of suffering. Furthermore, the notes also revealed hopes of letting go of life. The notes described patients’ wishes for a death that “will be fast and be painless” and that they will be supported by HCPs and not left alone. One note described a patient’s hope “to fall asleep and never wake up again”.The notes related to The results indicate that the documentation of existential aspects in older people’s patient records within specialized palliative care covered elements of both ill-being and well-being. Yet, the notes were sparse and unsystematic, were intermixed with other kinds of documentation, could not be identified by specific keywords, and did not result in any documented care plan shared with the patients. However, when the notes were extracted and analyzed, patterns of well-being and ill-being became evident. The existential aspects related to ill-being were loss of freedom, loneliness, anxiety, and despair and could be described as existential suffering or its causes . The exiOur study identified some notes indicating supportive care interventions related to the older person’s ill-being as well as well-being, interventions such as “tucking in” the patient, giving soft-touch massage, helping the patient listen to music, having conversations, and sitting beside the dying person to relieve her/his anxiety. The notes also indicated that these interventions were experienced as supportive, as the patients were described, for example, as “sleeping well”, “having a good time”, and “laughing and joking”. Several other studies show that supportive care interventions relieve existential suffering , 36. ComDocumentation of existential aspects in patient records is a sensitive matter, as it records personal wishes, moods, and thoughts that older people might not want to share with all HCPs. This ethical dilemma must be considered when information on existential aspects is documented in patient records and could be a reason why notes on existential aspects are sparse in patients’ records , 24. On The strengths of this study are that it was conducted in a context in which HCPs are supposed to pay attention to existential aspects, and that the patient records were randomly selected and include variation concerning age, gender, place of care, and diagnosis. In line with our pre-understanding, all authors were involved in the analytical process and continued discussion until consensus was reached, increasing the credibility of the results . RegardiExistential aspects concerning both ill-being and well-being were sparsely and unsystematic documented in older people’s patient records, but when the notes were extracted and analysed, patterns became evident. The extracted notes described both ill-being and well-being and revealed that HCPs do document older people’s existential suffering and existential health. Alleviating existential distress should be a care priority when frail older people reach the end of life; this presupposes open collaboration between the older people and HCPs, leading to a shared care plan. Although HCPs do document existential aspects in older people’s patient records, it is unknown how well these notes help them deliver high-quality care to individual older people. There is a need to feature existential aspects in patient records to ensure holistic care at the end of life. Future research should consider to what extent the documentation of existential aspects in patient records accurately reflects conversations on these matters and informs the care provided to older people in specialized palliative care.


Global health research and education curricula should be decolonized. The “global” in global health helps question ethnocentrism and account for heterogeneity across borders and cultures. It prioritizes the generation and cultivation of different skills, knowledges, practices, and the agility required to deal with a diverse and globalized world and its health. It recognizes that even everyday concepts such as “healthy” or “pain” or “drugs” can be defined and acted upon differently across the globe. Knowing and understanding these differences and bringing them into health research and curriculum matter. What about decolonializing approaches? Why should global health education be decolonized as well as being global? Below I unpack what “decolonizing” can mean for global health education and research, and argue that it needs to (1) recognize the legacies of coloniality in health outcomes; (2) address racial inequalities in health without racializing disease; and (3) increase racial literacy in health education and research. Decolonization should be considered not as a loss but as a gain for global health – it has the potential to make research and curricula more rigorous, leading to better health outcomes.I define decolonized global health education and research as that which goes beyond valorizing diversity and is able to think through the consequences of the facts of difference and diversity, including racialized attitudes. It takes racism and ethnic injustices seriously, and makes sufficient and explicit references and adjustments in its theorization and practices of health to ethnicity, racism, and global interconnectedness. Hence, I argue that whilst the “global” questions ethnocentrism, the “decolonial” lens makes us aware of, and considers, racial inequalities and injustices to do with health. Below I outline what I see as three core issues that decolonized education and research approaches in global health need to consider.th century race science. The modern world is largely shaped by colonialism, empires, slavery, and racialized (that is differentiated according to race) hierarchies ooling people in race silos is akin to zoologists grouping raccoons, tigers and okapis on the basis that they are all stripey.” Yet, race, like other social constructs, for example money, continues to have a real and significant impact on people’s lives. Health education and health research need to thus focus on structural racism – racism is a system which ensures an unequal distribution of resources and penalties between racial groups. Health outcomes are shaped by this, but health interventions can also reproduce racialized outcomes and poor health advice if uninterrupted. For example, despite being known as a “Black illness,” sickle cell disease is not race-bound but related to areas where malaria is dominant; in fact the highest rates in the world are located in India [Second, decolonizing means that racial divisions and their impact on health should be understood structurally without “racialization of disease.” In social sciences, race is studied in India .th century race science. These racial group categories are themselves hugely varied, socially and historically defined, and since they maintain problematic conceptions of human variation, can lead to essentialism and stereotypes and thus to poor science [White, Asian, Latino, and Black are racial categories born in colonialism and from 19 science . Additio science .Third, decolonizing global health means that we develop racially literate health research and curricula. Racial literacy here means that racial inequalities are regarded as one of the core social determinants of health . This ha51011Above I outlined three core issues, issues which are indicative but not exhaustive, that a decolonized global health program could start prioritizing. Paying attention to these can help make health research and teaching more robust, accurate, and interconnected, and also produce better health outcomes for populations. Such interconnectedness also requires interdisciplinarity, including learning from the many years of scholarship in social sciences on race and racism. Last, but not least, often the onus to decolonize curricula and research falls on the shoulders of those minoritized just as gendering curricula has typically fallen on female staff members’ “to do list.” Instead, decolonizing should be taken seriously by everyone, as not to do so makes poor sense not just in education and research but also in health outcomes.


Introduction: The number of older people in China who require formal care is increasing. In response, China is creating a service delivery mode of health and social care combination for older people—community-based adult services (CBAS) integrated with medical care—in some provincial capital cities, such as Changsha. However, the needs of most older people for this service delivery mode are not well understood. Aim: To assess older people’s awareness of and demand for CBAS integrated with medical care and to determine influencing factors. Methods: Semi-structured guideline interviews were conducted with 20 older people (aged 65+ years) from two communities at different economic development levels and from a nursing home in Changsha, China. Interviews were analyzed using qualitative content analysis. Results: The specific needs that older adults expect from CBAS integrated with medical care involve daily care, primary care, self-management guidance, rehabilitation therapy services, and mental health services. Contrary to expectations, most interviewees showed low awareness of and demand for CBAS integrated with medical care. Individual, family, and community factors influence older people’s demand, as do exogenous variables such as gender and number of children. Discussion: The influencing mechanism of older people’s demand for CBAS integrated with medical care is complex and multifaceted. To implement and promote CBAS integrated with medical care, attention should be given to older people’s individual needs, family backgrounds and community environment improvement. Furthermore, improving awareness of integrated care and increasing ageing-in-place opportunities for more older adults is essential and urgent. China is witnessing the rapid growth of ageing . More th“Yiyang Jiehe” in Chinese [Yiyang Jiehe”.Conversely, the implementation of integrating health care and social care for older adults in China is a recent development. Since 2013, the State Council has promulgated “Several Opinions on Accelerating the Development of the Aged Care Service Industry”, proposing to add medical care service to traditional aged care service and develop a healthy old-age care service industry named  Chinese . In JuneAfter nearly a decade of development, four primary modes of integrating medical care and ageing services have been formed in China. The first mode is “constructing hospital in nursing home”: a professional medical care team is set up in the nursing home to integrate the older adults care and health care functions . The secAs the fourth mode of China’s integrated care and a move to defragmentation of aged care services in community settings, CBAS integrated with medical care aims for a “person-centered” approach that connects the healthcare system with other human service systems for older adults . In thisTo improve the quality of life and happiness of older adults, it is essential to understand older adults’ awareness of, attitudes towards, and factors influencing their demand for services . HoweverDue to the lack of previous studies, we conducted a pilot qualitative study to answer the following research questions: 1. How well do older people currently know about CBAS integrated with medical care and what services do older people need? 2. What factors influence the demand for CBAS integrated with medical care among older adults? Furthermore, we hope that this pilot study will contribute to promoting CBAS integrated with the medical care model across the country and will provide a reference for decision-making to accelerate the development of ageing services in China.A qualitative descriptive design  was adopHunan province is one of the most aging provinces in south central China, and Changsha  is a pilot city experimenting with older adult services integrated with medical care, with the financial support of the central government. There are 272 service centers for CBAS integrated with medical care . The tarThe sample included 8 men and 12 women, fourteen of the participants had partners, and the other six were widowed. The mean age was 74 years (65–89 years). All participants were from Hunan, China. Five participants’ monthly incomes were less than RMB 1000 (approximately USD 143), six received RMB 2500–4000 (approximately USD 357–571) per month, five received RMB 4000 to 5500 (approximately USD 571–786) per month, and four received over RMB 5500 (approximately USD 786) per month. Seventeen of the participants were covered by social security healthcare insurance, and three were not covered. Six participants had one child, four had one son and one daughter, six had two sons or two daughters, three had one son and two daughters, and one had no children. The sample characteristics of the 20 interviewees are shown in The data collection has been approved by the Clinical Medical Ethics Committee of Xiangya Hospital, Central South University (No. 202011184). Informed consent was obtained from all respondents involved in the study. We collected information by conducting face-to-face semi-structured interviews in November and December 2020. Prior to the interviews, the study participants gave written consent to be audio-recorded. All materials were prepared in simplified Chinese. To examine the participants’ definitions and perceptions of CBAS integrated with medical care, every participant was asked six open-ended interview questions , which was indicated by information redundancy .To improve the reliability of the study, it is necessary to demonstrate a link between the results and the data . TherefoBecause the knowledge of CBAS integrated with medical care is fragmented, an inductive approach to analysis is more appropriate . Thus, wAfter a process of reflection and discussion, we identified the factors influencing older adults’ demand to participate in CBAS integrated with medical care  required CBAS integrated with medical care, whereas the other 12 (60%) did not. The factors affecting the needs of older people with CBAS integrated with medical care can be described by three categories: individual-level factors, family-level factors, and community-level factors  wellness, (b) economic capability, (c) individual opinion, (d) experiences, and (e) willingness to pay.Physical condition and self-care ability determined the degree of demand for services among older people, which greatly affected their living arrangements. Older people often regarded poor physical conditions as a signal to seek CBAS integrated with medical care. Y19 described his experience as follows: “I am in good health now. I can take care of myself, can prepare food by myself. In addition, I have no chronic diseases and do not need to take medicine.” Similarly, L03 shared, “Only when we cannot walk or move will we know .” He explained,Before the age of 70, my body (was well with no major diseases) did not need these services at all. Currently, my wife can handle the housework and cooking well, and there is no special requirement of help from others.However, older people with chronic diseases or poor physical conditions often require CBAS integrated with medical care. S10 complained, “I have lumbar spine pain. It will not work without taking medicine… (in the community) some check-ups and treatments are needed for older people.” This description was in stark contrast with those of Y19 and L03.The assessment of the economic capability of older individuals was mainly based on the observation of monthly income and payment for healthcare expenses. Older people with better economic capability were more willing to accept CBAS integrated with medical care. For example, L02, who retired from the Health Bureau, had a monthly retirement salary of RMB 5000 and employee medical insurance. She said that what she most expected was CBAS integrated with medical care, and she was not willing to go to a nursing home. By contrast, older people with low retirement wages or living on state subsidies were reluctant to participate in community pension service projects. H09 stated, “I only have money from the country, approximately 300 yuan every month…  is a good project, but if you do not pay, you can’t receive services. I will insist on taking blood pressure medicine… No need , no matter how good it is, it costs money.”This topic involved many aspects of older people’s personal thoughts and concepts, including views on ageing, expectations for retired life, concerns for future health and food and housing, and opinions about providers of CBAS integrated with medical care. L03 espoused the traditional Chinese concept of ageing: “raise children for old age.” He believed that the responsibility for providing for him should rest on his son rather than on society. He asked us, “Why go to other places to age? My son can take care of me.” Similarly, W11 also said that when she could no longer take care of herself, her son would continue to care for her. However, in general, more people expected to grow old in the community and worried about their future health. L02 reflected, “Everyone has their own personality. It is not very good to go to a nursing home in an unfamiliar situation. Therefore, I think it is better to stay at home in the community… In addition, once you’re old, you have to think about your health problems.” Moreover, L04 also thought it was better to grow old in the community. She explained patiently,In the case of ageing at home, the next generation is too busy to rely on them. In the case of ageing in community, the community should be well prepared to carry out activities suitable for older people… it’s the best way to meet the needs  of older people in the community. We can go to the senior center during the day to have a meal and participate in activities until we go home and sleep at night.In addition, L03, who lived at home, said, “Community will not support us.” Another older person, L13, had to live in a nursing home because the community services and infrastructure were unsatisfactory. She declared, “It is impossible to provide  in our community!” Both of these older people had a negative attitude towards providers of CBAS integrated with medical care.Older people’s past and current experiences affected their needs, as did their impressions and judgements of community services for older people. Insufficient publicity of CBAS integrated with medical care, which led to an insufficient understanding among the older population, was the largest influencing factor. We found that more than half of the older adults surveyed did not understand the current status of CBAS integrated with medical care services and developments. L02, who was retired from the Health Bureau, was affected by occupation and she was the individual who knew the most about CBAS integrated with medical care in our study. Although every community in Changsha now has an activity center for older people, experience with the center is limited due to insufficient publicity. P18 pointed out, “I have lived here (in the community) for four years and just learned that there is a community service center here.” Because of insufficient publicity, he lowered his expectations of CBAS integrated with medical care. Some older people had heard negative comments about nursing homes from friends, and they were more willing to enjoy older people care services in the community after being affected. H09 said, “I have a friend. He and his wife lived in a nursing home for five or six years. After a long time, they still said that living in a nursing home was uncomfortable.”Older people living in nursing homes described having richer experiences and ideas when they compared their original community life with their current institutional life. X08 explained why she did not continue living in the community.First, the community environment is not good, and the air is polluted. I live here (a nursing home) with clean air. Second, living in the community, I have to do everything by myself, such as hygiene, grocery shopping, and cooking (I do not want to do these things anymore), so I just live here.L04 was more willing to live in the community after joining a community charity organization. She emphasized, “…The organization I joined also does not advocate nursing homes because older people living there are very lonely.”Older people’s willingness to pay for a certain number of consumer goods or services, such as CBAS integrated with medical care, directly affected their needs. In our study, there were more older people who were willing to pay than those who were unwilling to pay. However, L04 believed that her willingness to pay depended on the situation. She explained, “It depends on whether the value is equal and whether the service content, charging standards, and charging items meet my expectations.”Family-level factors were reflected in five aspects: living arrangements, marital status, distance to adult children, family members’ attitudes, and informal support from family. These five aspects influenced one another and were inseparable. For example, most older people did not live alone but lived with their spouses or children, or even lived with three generations, including their spouses, children, and grandchildren. They received informal support from their spouses or children and provided some informal assistance to their children and grandchildren . These older people generally had a lower need for CBAS integrated with medical care. Y19 was a typical example. He lived with his wife and youngest daughter. He usually took care of his grandson for his daughter while she was at work and took on the task of cooking at home. He said that he had no time and no need for CBAS. Moreover, among those who interacted with their children more frequently and received more support from their children, their children were usually opposed to their parents living in nursing homes. L01, who lived only one street away from her son, mentioned more than once that her son was very nice to her. She recalled, “At that time, I went to the nursing home and paid a little money, but when I came back home and told them (her adult children), they were opposed to me living in a nursing home.” Therefore, she needed only spiritual comfort from CBAS, and she wanted to participate in only some cultural and entertainment activities in the community.M15, whose wife had died and whose son worked somewhere else, truly wanted to live in the community. With no one to take care of him, he had no choice but to choose a nursing home. He said, “I need . After all, my son does not live with me. Living in the community, we are familiar with each other, so I can play chess with other older people…but the community where I live does not have CBAS.” Such older people who lacked a partner or children living near them were forced to choose a nursing home. In fact, they truly needed CBAS integrated with medical care.Poor infrastructural facilities in the community made older people feel that their communities were not suitable for ageing, so they chose nursing care at home. L13 complained many times that the community where she lived did not have elevators and did not have any community staff to visit. However, poor infrastructure also contributed to increased demand among older people. L02 also complained, “Our community is not good.” She believed that the community needed to provide CBAS integrated with medical care. Some older people were not satisfied with the doctors and staff in the community. L05 suggested that the community should be equipped with more professional doctors in the future, and L04 also stressed that “ (Community staff) have to work harder and to care about what is needed for older people.”Older people were also concerned about service fees. Since most older people had a small retirement salary and were unwilling to increase the financial burden on their children, they expressed dissatisfaction with the known excessive prices and unknown price concerns. S10 often needed rehabilitation in the community because of lumbar spine pain. She said, “The community  is very expensive now, (price) has increased from 200 yuan to 800 yuan.” The increasing price of services at the community hospital deterred her from purchasing medical services in the community. L02 also reflected, “The price of community services is high now we have to buy medicine every month, and it is slightly tight with our monthly retirement salary.” Moreover, they hoped that the community would increase the number of unpaid services for older people.According to the matrix coding performed in NVivo 12.0, the 12 direct factors influencing older adults’ demand for CBAS differed by gender. Compared with females, males focused less on service fees, family members’ attitudes, informal support from families, marital status, and distance to adult children. Individuals of both sexes focused on experiences, wellness, personal opinions, community situation, and economic capability  focused more on the distance to their adult children when considering their life after retirement. They paid more attention to service fees, individual opinion, marital status, wellness, economic capability, living conditions, community situation, and willingness to pay but cared less about informal family support than older people with more than one child. Older people with more than one child placed a greater emphasis on experiences and wellness  among all categories, so formal caregivers must capture older adults’ individual information to provide comprehensive nursing support. Based on the sub-category of wellness and economic capability, older people with poor health or better economic capability needed community care services more than those with better health or poor economic capability, which is consistent with the findings of a sample of 7320 older people in Lanzhou, China . PreviouDespite the well-known benefits of CBAS, the literature continues to report that older people and their caregivers underutilize these services . UnderutPrevious studies have mostly highlighted family factors as an important factor influencing the integrated care of older people . InteresYang Er Fang Lao, a part of the Confucian cultural sphere in East Asia), children’s attitudes play a key role in the choice of older people’s retirement options, and the more supportive their children are, the more they agree with adult services with medical care, and the more willing they are to participate in them [At the same time, our research also found that older people’s need for CBAS with medical care services is also influenced by the attitudes of their spouse or children. If an older person still has a spouse rather than being solitary, they will usually take into account the views of their significant other when ageing in the community or a nursing home, and they will prefer to be served in the community rather than in a nursing home if their children have committed to visiting them regularly in the future or reject to them ageing in a facility. Research from Shanxi Province, China, also proves that influenced by the traditional Chinese concept of “raising children for old age”  , which iYang Er Fang Lao), make the model more in line with the cultural context of China and East Asia. Fourth, ABMHSU is applicable to a wider range of scenarios and populations, but the theoretical model in this study can only be used to analyze the factors influencing the integrated care for older people in the community.Both models focus on the impact of environmental and personal characteristics on the needs of people for integrated health care services, highlighting three types of factors: individual, family, and community, and suggesting different dimensions and factors along which policy makers and health service researchers can optimize health service utilization behavior and transform health service systems. Meanwhile, there are four differences between the two models. First, the theoretical model of this study takes the demand of older adults for CBAS integrated with medical care as a result, and the ABMHSU regards the demand as a core factor. Second, the theoretical model of this study has advantage in effectively identifying and controlling subtle behavior influencing factors, as it uses the number of children and gender as exogenous variables whereas the ABMHSU takes the two as sub-factors of the core factor “personal characteristics”. Third, an important innovation of this theoretical model compared to the ABMHSU is that it adds two sub-factors—“individual opinion” and “experiences” to the individual factors. Individual concepts and cognition such as “raising children for old age”  and informal caregivers (referring to family members). Some older people with dementia or disability often cannot express their demands independently and comprehensively, but their caregivers can reflect their needs to some extent. In addition, the cross-sectional study design is also a limitation of this study. With the gradual establishment and implementation of CBAS integrated with medical care across China, we will add the perspective of the caregivers to future studies to gain a more comprehensive understanding of the needs of older people. And the influence mechanism of the older people on the demand for the integrated care services could be further clarified through longitudinal quantitative studies in the future.The adoption of a pilot qualitative study provided a novel perspective for our research, and the new topics continuously emerging from the interviews enabled us to understand older adults’ needs and feedback. Whether older people need CBAS integrated with medical care is primarily determined by personal factors, but family and community situations also play a role. As a pilot city of CBAS integrated with medical care, Changsha has made some progress in promoting the service, but it still needs to do more to meet the demands of the older adults. Since integrated care is a new thing for older Chinese people, improving the awareness of integrated care in older adults is essential and urgent. It is incumbent upon community service providers and policy makers to work together to improve the fit to increase ageing-in-place opportunities. Furthermore, this pilot study provides new knowledge of gerontological nursing by showing the characteristics of older people’s demands and the influencing factors of community-based integrated care in resource-limited settings such as Changsha, Hunan Province, China.


Background: By 11 March 2022, there were 450,229,635 coronavirus disease (COVID-19) cases and 6,019,085 deaths globally, with Nigeria reporting 254,637 cases and 3142 deaths. One of the essential healthcare services that have been impacted by the pandemic is routine childhood immunization. According to the 2018 National Demographic and Health Survey, only 31% of children aged 12–23 months were fully vaccinated in Nigeria, and 19% of eligible children in the country had not received any vaccination. A further decline in coverage due to the pandemic can significantly increase the risk of vaccine-preventable-disease outbreaks among children in Nigeria. To mitigate such an occurrence, it is imperative to urgently identify how the pandemic and the response strategies have affected vaccination services, hence, the goal of the study. Methods: The research method was qualitative, including in-depth interviews of healthcare workers and focus group discussions (FGDs) with caregivers of children aged 0–23 months. We selected one state from each of the three zones of Nigeria: northern, central, and southern. Within each state, 10 local government areas and 20 healthcare facilities were purposively selected. In each facility, 10 healthcare workers were invited for interviews. Overall, 517 healthcare workers were interviewed. For the focus group discussion, 30 communities were selected. Within each selected community, six consenting caregivers were included. Overall, 180 caregivers participated. The data were analyzed using thematic inductive content analysis. Results: Three significant impacts that were observed are: difficulties in accessibility to immunization services, declining immunization demand and uptake among caregivers due to varying factors, and erosion of vaccine confidence among both caregivers and healthcare workers. Movement restriction and lockdown had numerous major impacts, such as decreased general healthcare service delivery, increased transportation costs, fewer engagements that promote vaccine uptake, and cessation of mobile vaccination campaigns that target hard-to-reach communities. Moreover, misinformation, conspiracy beliefs about the pandemic and COVID-19 vaccines, and risk perception negatively influenced general vaccine confidence. Conclusion: The results of this early impact study show that immunization was directly affected by the pandemic and provide insights into areas where interventions are needed for recovery. This isOne of the essential healthcare services that have been impacted by COVID-19 is routine immunization . CoveragNigeria, with a DTP3 coverage of 57%, is among those projected to have the highest number of COVID-19 cases . AccordiExperience from previous disease outbreaks such as the 2014–2016 Ebola virus epidemic in West Africa, have shown that exacerbation of morbidity and mortality often occur because of the interruption of healthcare services . In 2015In the WHO African Region, in addition to service disruption, demand for services was also affected, mainly due to rumors about COVID-19 vaccines . In thisThe Strategic Advisory Group of Experts on Immunization (SAGE) working group defined three factors, complacency, convenience and confidence (the 3C model), that influence vaccine hesitancy . In thisTo avoid a surge in VPD and child mortality in Nigeria, it is urgent for policymakers to identify how the COVID-19 pandemic and response strategies are affecting childhood vaccination uptake, including access to and public confidence in vaccines. This will help to mitigate further disruption of immunization services in Nigeria. In addition to confidence and other behavioral insights, structural factors impacted by the lockdowns (a pandemic response strategy) could potentially become an even bigger contributor to increased incidences of VPD .The relationship between COVID-19 and the immunization system is complex, and several mechanisms through which the pandemic can affect immunization services have been proposed . HoweverThe study used a mixed qualitative method including in-depth interviews (IDIs) and focus group discussions (FGDs). This design enabled the collection of different but complementary data types from two primary sources, i.e., caregivers and HCWs. The IDIs targeted HCWs, while FGDs focused on caregivers. Nigeria was chosen because it is one of the countries in Africa most impacted by the pandemic, and it had also introduced measures in response to the pandemic. The study was conducted in Kaduna, Plateau, and Osun states. Within each state, 10 local government areas (LGAs) were purposively selected, and 2 healthcare facilities that offer immunization services in each of the LGAs were included in the IDIs. Six caregivers of children aged 0–23 months or adolescent girls in 10 communities in each of the states participated in FGDs.A simplified quota sampling approach was used to select caregivers and HCWs. The selected states were a mix of those with historically high and low immunization coverage levels based on predefined inclusion criteria and consideration of geographical representation, such as states that implemented a lockdown as part of their COVID-19 pandemic response strategy, facilities that offered immunization services for at least one year before the pandemic, and caregivers of children aged 0–23 months or adolescent girls. The states selected were: Kaduna (Northern Zone), Plateau  and Osun (Southern Zone).The participants in the IDIs came from 20 health facilities that offer immunization services in 10 purposively selected LGAs per state. A maximum of 10 consenting HCWs were interviewed in each health facility, and in those who did not have 10 HCWs, all eligible HCWs were interviewed. Overall, a total of 517 HCWs were interviewed. At least 6 consenting caregivers of children aged 0–23 months or adolescent girls participated in the FGDs in 10 communities per state, resulting in a total of 180 participants from 30 communities. The samples were purposively guided to keep the focus on the characteristics of the populations that were of interest to the study.Prior to data collection, study participants were provided with an information sheet on the study, stating the goals and expected outcomes, to enable risk analysis, if any. Informed consent was obtained from all study participants. The data collection was conducted between 3 August and 30 September 2021. Guides were used to lead the IDIs and FGDs. The IDIs, which lasted an average of 20 min, explored HCWs’ opinions regarding factors that affected caregivers’ demand for childhood vaccination services among caregivers during the COVID-19 pandemic. The IDIs and FGDs were audio-recorded after obtaining consent from the participants. Both the interviewer and interviewee maintained a distance of at least 1.5 m and wore face coverings, as required by the COVID-19 guidelines. Between six and nine participants were present at each FGD, which explored caregivers’ opinions on the impacts of the pandemic on vaccination services. All qualitative data were transcribed verbatim and stored in a password-protected drive.The IDI and FGD guides explored topics such as: knowledge about COVID-19 (“Tell me what you know about COVID-19?”); knowledge of childhood diseases and immunization (“What childhood diseases are common in this community and what do you feel about immunizing your children?”); effect of the pandemic and the response strategies on access to childhood immunization (“How did the COVID-19 pandemic and response strategies affect people in your community and were you able to vaccinate your children during the pandemic? If not why?”); effects of the pandemic on the general healthcare system ; sources of vaccination information (“How do you get information about vaccines and vaccination?”); and main reasons for low vaccination uptake during the pandemic (“what are the reasons that caregivers were able or not to receive immunization for children?”).The data were analyzed using thematic inductive content analysis. Main themes were identified after analyzing each individual transcript and then categorized based on the aggregation of subject outcomes. Transcribed data were coded as follows: the IDIs were coded as HCW001 and HCW002, while the FGDs were coded as FGD001 and FGD002. The analysis resulted in the development of themes and sub-themes based on the impacts of the pandemic on vaccination services.Healthcare service delivery, including immunization, was negatively affected by the pandemic from: both demand (caregivers) and supply (HCWs/facilities) perspectives. Fewer HCWs were able to go to work due to the pandemic (supply side), and caregivers were reluctant to go for immunization due to the pandemic (demand side). Some caregivers assumed that immunization services were not available in the facilities, and others were afraid of going to the facility because of infection risks. In addition, HCWs were reluctant to go to the facility because of the non-availability of consumables and vaccination materials:“The lockdown affected people and most caregivers were not able to visit the healthcare facilities, even here there are no vaccines and other drugs to administer, due to the COVID-19 pandemic”—HCW (Narayi PHC). “We are just trying to improvise now, at least to see how we can maintain the clients” HCW (Rayfield PHC). “People are scared of coming to the hospital because they read what is happening about the pandemic”—Caregiver .It was difficult for caregivers who had pre-existing health conditions to go through all of the rigorous COVID-19 protocols at health facilities without inducing health crises. The rigor of the protocols at health facilities, such as wearing a face mask, social distancing, washing of hands, 1.5-m distancing, etc., created an overcrowded space and long waiting times, which induced fatigue in caregivers. They strictly avoided healthcare facilities, and, therefore, their children were not vaccinated. However, this behavior or fear of crowds was not limited to caregivers, since HCWs also expressed concerns:“It is difficult for clients who are suffering from other illnesses to come and follow all the sanitary protocols—HCW . “Some healthcare facilities were not giving PPE to protect HCWs against COVID-19. so, we were exposing ourselves to so many dangers in crowded situations” HCW . “There are not even enough face masks in the hospital, we are just managing, and I will come and expose myself because of what?” HCW .One of the response strategies introduced by the Nigerian government was restricting the movement of persons, goods, and services. HCWs and caregivers, in particular, found it difficult to access healthcare facilities due to lockdown or movement restrictions. In some cases, there was a dusk-to-dawn curfew. The majority of IDI and FGD respondents cited the restriction of movement owing to lockdown as the major barrier to caregivers’ access to immunization services:“We are restricted in offering immunization services. So, it is one of the major reasons for decline in services”—HCW . “…it affected immunization services because we had total lockdown and transportation was not easy. So HCWs were found it difficult to come to work”—HCW . “The caregivers were not able to reach healthcare facilities due to the lockdown”—Caregivers . “Our children did not take immunization because we feared going out”—Caregivers . “Since there was a ban, no movement of vehicle or motorcycle due to the lockdown, this affected the ability of many caregivers to go to the healthcare facilities”—HCW .Due to a decrease in social interaction and gatherings, immunization campaigns and other supplementary activities that promote vaccination demand were halted. This created the impression that even healthcare facilities and services such as immunization were not exempted from the shutdown caused by the pandemic:“Unlike before where ceremonies are done with huge gatherings, now it is no longer the same”—Caregiver The cost of transportation increased rapidly when the lockdowns and movement restrictions were imposed by the federal government of Nigeria. As a result, it was expensive and difficult to commute to work. The lockdown and subsequent absence of commercial transportation triggered hyperinflation. The majority of the FGD and IDI participants cited transportation-related issues as a major barrier to service provision at healthcare facilities. This was not limited to caregivers only, since there was an absence of vehicles to transport vaccines:“…It affected healthcare services because of transportation. Some patients wanted to come to the facility but because they are far away, it was difficult for them to come due to problems of transportation” - HCW . “The healthcare facility was opened but most parents were not able to come because of transportation issues, especially costs”—Caregivers .“I have a patient who told me that she could not afford the transport fare to take her child to the facility…the charges are unbearable”—HCW (Imo PHC). “There was no vehicle for them to transport the vaccine from cold store and distribute to facilities”—HCW (Sekona PHC).Caregivers could not access immunization services due to the non-use of use of PPE or face coverings such as masks by HCWs. Lack of PPE, which is necessary for the protection of HCWs was frequently described as a barrier against positive risk perception by caregivers and consequently affected service provision in the facilities.“We, the HCWs are not well equipped. There was no provision of PPE for us to protect ourselves”—HCW . “Caregivers are afraid of coming to the healthcare facilities. Before attending to the caregivers, we need to wear the required PPE, because they are scared” – HCW . “Many caregivers came to the facilities without their face masks, so we tell them to return home to get them, but many never return” – HCW (Eleyele PHC); Caregivers (FGD: Okefia community).Participants of the FGDs singled out the violent actions of law enforcement agents trying to enforce the lockdown order as a barrier to accessing immunization services:“Amotekun, police, soldiers, they stopped us from going or coming to hospital”—Caregivers . “They can’t come out because the police arrest the people who don’t stay at home”—HCW (Sekona PHC).Immunization services for house visits were halted. The services were completely cancelled in many areas, especially in hard-to-reach (H2R) areas that relied upon household-to-household outreach or mobile campaigns for immunization. Most of the participants agreed that pre-pandemic mobile campaigns, especially those targeting H2R communities, were efficient. However, since the pandemic and lockdown, it has been difficult for HCWs to reach these needy communities:“The reason is that people don’t like to come to the hospital. We had to go and educate people about the importance of vaccination. So, due to the Lockdown, going from house to house is no longer feasible”—HCW (Chikun PHC). “We are appealing to the Government to provide ways of receiving the vaccines easily, in such a way that HCWs don’t even have to travel” – Caregivers .A major sub-theme that emerged as a barrier to immunization demand was safety. Caregivers described fears ranging from the facilities being at high risk of COVID-19 transmission, fear that HCWs were super spreaders, and confidence in the safety of the COVID-19 vaccines themselves. Caregivers reported fear of contracting the virus and fear that they could be forcefully vaccinated against COVID-19; hence, caregivers stayed away or avoided healthcare facilities altogether:“We are afraid of contracting the disease from the HCWs. We will go to get immunization for our children after the lockdown is relax and COVID-19 is gone”—Caregivers (IROJO community). “People were not able to come down because of fear. Since it is a hospital, caregivers argue that other patients visiting might carry infection…they say ‘eh no dey show for face’. They don’t know much about the virus and that is one of the fears they have that prevents them coming to the facility“—HCW . “Some were thinking that we have added COVID-19 vaccine into the immunization services, so they refused to come” – HCW (Ologunna PHC).Some of the participants described COVID-19 as a nickname of the country where the first case was reported and assigned its symptoms to malaria, cold, and cough. This limited knowledge may not only be for COVID-19 but could be for vaccine-preventable-diseases, in general. Not only does limited knowledge affect risk perceptions, but it can also encourage skepticism about vaccine preventable diseases:“I don’t really know much about COVID-19 but what I heard is that it is like someone who feels malaria symptoms in their body, like weakness, cold, too much coughing and he can’t control himself…”—Caregivers (FGD: Ologunna community)“It is a virus that does not belong here but where it was first reported in Wuhan (China)” – HCW .Due to disinformation and misinformation about the COVID-19 pandemic and COVID-19 vaccines, especially through social media, caregivers were afraid that they might be wrongfully considered positive for COVID-19, when they visited a health facility for childhood immunization. The fear stemmed from rumors that people were being taken to isolation centers for quarantine if they showed interest in vaccination activities or even went near healthcare facilities.“Most of our patients thought that when they come to the healthcare facility, we might create another scene by saying we would move them to the isolation center, so most of the caregivers who were supposed to bring their children for immunization were scared” – HCW (Oja-timi PHC). “Some of us think that if we go to the facility, our children might be vaccinated with COVID-19 vaccine”—Caregivers .The financial difficulties created by the inflation caused by the COVID-19 pandemic, either directly through the economic effect on cost of living or indirectly due to the resultant increase in the prices of services such as transportation, were described by participants as a barrier to caregivers’ demand for immunization services. The pandemic impacted both global and national economies, thereby affecting costs of everyday goods and services, including transportation, which is vital for access to vaccination facilities:“They don’t have money…some have no money for transportation” – HCW (Ologunna PHC). “It really affected them because some people could not find a motorcycle to transport them to the clinic, and even if they found one, they can’t afford it, because it is double the price before the pandemic and lockdown started”—HCW . “All the COVID-19 sanitary protocols put in place made me stay home because it would have cost me a lot of money”—Caregivers (FGD: Ologunna community). “People didn’t want to go because they were short of food stuff……. we that don’t have money to buy food, how can we go for vaccination?”—Caregivers (FGD: Olodan community).Vaccines are stored centrally, and they need to be distributed to healthcare facilities, particularly in rural areas, where the majority of healthcare facilities are situated. Due to the pandemic, the central storage facilities and the services were shut down, although, in some areas, the services were very sporadic. Similarly, refrigerators in healthcare facilities where vaccines are temporarily stored prior to being administered were without power, and with no alternative source of power, this meant that the cold chain of vaccines was not respected, and therefore, immunization services were disrupted: this hampered the preservation of vaccines and disrupted services. Therefore, a lack of alternative sources of power such as solar disrupted immunization uptake.“Electricity contributed to low uptake, because during the lockdown, some healthcare facilities didn’t have the electric power needed for vaccines storage. I think this is the things that really affected immunization services”—HCW . “We don’t have anywhere to store vaccine during power cut, such as solar powered refrigerators, so caregivers didn’t bring their children for immunization”—HCW (Ologunna PHC). “Some facilities in rural areas where there are no solar refrigerators to store the vaccines were unable to provide immunization services”—HCW .Due to strict adherence to COVID-19 sanitary protocols at healthcare facilities, such as social distancing and the use of nose and mouth coverings/masks, the numbers allowed in the vaccination area were reduced, thereby leading to longer waiting times, and this hampered the provision of services in the facilities: “We were not allowed to sit together as we used to before the pandemic started, and we were spending longer than before”—Caregivers (FGD: Imo community). “All of the HCWs were saying if you don’t use face masks, you can’t enter, even when we don’t have any, we had to go away to get a mask before they would see us” – Caregivers .HCWs did not trust the information that they received on COVID-19. The absence of proper training of HCWs on the COVID-19 pandemic was obvious. In addition, the poor attitude of HCWs affected immunization services. They were not motivated, and their hazard and pandemic-related allowances were not paid, which resulted in low morale and a poor attitude to work:“Not all HCW trusted the information provided that said once you practice the precautionary measures like social distancing, use of PPE and practicing personal hygiene like handwashing, you would be unlikely to be infected and when the COVID-19 vaccine also comes, you can take the vaccine and the chances of being infected are slim…if you are infected, the chances of severity are slim” – HCW . “They did not pay our allowances, so we are not motivated”—HCW .The caregivers’ risk perception limited attendance at immunization services because they were afraid of being infected with COVID-19. In previous outbreaks, fear of being infected was reported as the prominent suicide stressor. Therefore, the severity of the disease has become a concern, because it worsens emotional, cognitive, and behavioral responses:“People were even scared of going to the hospital because of reading what was happening and fear that hospitals were super spreader centers”—Caregiver This study assessed immunization service uptake and the effects of policy strategies and measures taken to prevent community transmission in the context of the COVID-19 pandemic in Nigeria. Three significant factors were affected, i.e., accessibility to immunization service, a significant reduction in immunization demand and uptake among caregivers, and a lack of trust by caregivers and HCWs .The results showed that accessibility to immunization services was a big barrier during the pandemic for the majority of participants, as were lockdown and restriction of movement, curfews, inflation, increased cost of transportation, economic recession due to the pandemic, suspension of mobile immunization campaigns to H2R communities, and lack of PPE for HCWs. Some of these factors were to be expected in a pandemic situation. However, the lack of provision of PPE, the lack of knowledge and training for HCWs, and the lack of alternative outreach measures for H2R communities created an impression of the absence of pandemic preparedness. Further, those involved in the healthcare system decision-making process in Nigeria were unprepared. In addition, they were not consulted on how the lockdown measure would impact healthcare services, including immunization. This may partially explain why many healthcare facilities were closed during the lockdown and demonstrates the vacuum or disconnect between public health decision-making structures  and policymakers or politicians in Nigeria. Public health policy must rely on the advice of health professionals and behavioral experts, especially during pandemics and health emergencies, but the evidence suggests that this was not the case in Nigeria.Secondly, demand for and uptake of immunization declined due to the pandemic, and countermeasure-related-factors, such as fear of contracting the virus and fear of the forceful vaccination of caregivers against COVID-19, fake news, misinformation and disinformation, poor knowledge, the lack of appropriate storage infrastructure (such as solar-powered refrigerators in facilities), the high-handedness of law enforcement agents, long waiting hours by caregivers, and the increased indirect personal costs of accessing care, such as the need to buy PPE and sanitizers and transport for each visit, contributed to the disruption of routine immunization uptake. These are largely consistent with some of the main reasons proposed by experts, to date, for the disruption of immunization services, primarily highlighting a combination of vaccine demand and supply factors [The knowledge gap during the pandemic in Nigeria not only impacted the risk perception of the disease but also compounded existing vaccine hesitancy in general. Associating malaria with COVID-19 or thinking that the two diseases were the same by both caregivers and HCWs, as seen in this study, highlights a significant knowledge gap in Nigeria. This accentuates a previous study across Nigeria that showed that caregivers misunderstood VPD to include malaria . In a stThe lockdown exposed and worsened existing immunization inequities and uptake barriers. However, the risk of visiting healthcare facilities for immunization still outweighs the consequences of COVID-19 infection. A recent benefit–risk analysis modeling the impact of missed childhood vaccinations in Africa found that the benefit of averting vaccine-preventable infections far outweighed any possible COVID-19 morbidity and mortality associated with immunization clinic visits .The confidence of HCWs and caregivers in the healthcare system was tested during the pandemic, and both contributed to the negative impacts on immunization services. HCWs’ attitudes were poor, and they were not motivated due to the lack of payment of their hazard and pandemic-related allowances, “They did not pay our allowances, so we are not motivated” – HCW . Further, the general mistrust of COVID-19 information shows a lack of confidence in the healthcare system or in training, as well as a significant lack of knowledge of diseases. “Not all HCW trust the information…about the Coronavirus and COVID-19 vaccine” – HCW . In addition, caregivers’ perception of the risk of infection was a major drawback to immunization uptake. Perceived inadequate infection prevention and control measures in healthcare facilities, including the lack of adequate PPE and other consumables, and measures, such as HCW training, may have created hesitation among caregivers and made the general population reluctant to access healthcare services, including immunization services. Interventions targeting confidence and safety in the healthcare system will be key for the recovery of uptake to the level in the pre-pandemic situation.The results from this study demonstrate the gap in immunization messaging, highlighting the need for improved efforts at behavior change communication policies that convey key messages targeting caregivers to emphasize the importance of attending routine vaccination services, despite the COVID-19 pandemic and the response strategies for infection prevention ,26. EffeAlternative immunization delivery mechanisms such as using private pharmacies (as vendors) may be worth consideration. This will facilitate vaccine delivery closer to caregivers’ homes, thereby overcoming challenges of distance and transportation .The non-probabilistic nature and representativeness of the study sample was a limitation observed, even though the included HCWs and caregivers were quasi-randomly selected from healthcare facilities. However, a sense of representation of the regions was achieved by equally distributing the study centers in the north, central, and south regions. In addition, the sample was made large to accommodate for saturation for a large population such as Nigeria.As the COVID-19 pandemic persists, further studies are needed to understand in-depth causality between the pandemic, measures to counter the pandemic, and low immunization coverage in order to inform comprehensive vaccination intervention programs. Additionally, further research would be helpful to understand how these study results, in terms of accessibility, uptake, and confidence in immunization services, may have affected attitudes toward COVID-19 vaccine acceptance in Nigeria.The goal of this study was to generate systematic context-specific evidence on the impacts of the COVID-19 pandemic on immunization services and uptake. A reduction in the accessibility of immunization services, low demand for immunization, and lack of confidence in the immunization system are the main discoveries of this study. The results explain not only how the COVID-19 pandemic negatively affected immunization services but also how it brought the health system to a near collapse. The national lockdown was the factor that had the most pronounced negative impact on immunization services in Nigeria during the COVID-19 pandemic. The restriction of movement led to a general decrease in healthcare service delivery, including immunization services. The restriction in movement also led to an increase in the cost of transportation and a decrease in immunization outreach activities. All of these amplified the already fragile vaccine confidence levels in some quarters. However, we also found that there are positive spinoffs from the pandemic. These include good sanitary practices such as frequent hand washing and cough hygiene.This study contributes new knowledge on the early impacts of COVID-19 on immunization services and expands the current understanding of the extent of its influence by elucidating individual, social, and context-related factors affecting access, confidence, and uptake. The evidence generated can be useful for in-country immunization stakeholders and partners to inform the formulation and design of new strategies to minimize immunization system disruptions during COVID-19.


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