"People Will Continue to Suffer If the Virus Is Around": A Qualitative Analysis of Sub-Saharan African Children's Experiences during the COVID-19 Pandemic

"It is important to understand experiences as they are occurring in children’s lives to ameliorate harm."

Childhood is a time of profound cognitive, emotional, and social development. Disasters such as the COVID-19 pandemic can greatly impact children's current and future lives, especially for those in challenging conditions. To hear and understand sub-Saharan African children's experiences, these researchers conducted interviews with 51 children, ages 9 to 13, from Nigeria, Tanzania, and Sierra Leone. Based on the findings, the study offers guidance and recommendations for meeting the needs of children in times of crisis.

The study draws on Bronfenbrenner's ecological systems theory, which describes four levels that interact to affect behaviours: individual characteristics (sex, age), the microsystem (interpersonal interactions such as with family, teachers, and friends), the mesosystem (neighbourhood, school, and community groups), and the exosystem (economics, culture, politics, and mass media). Notably, these influences, particularly the media, can impact children at different system levels. Both directly and indirectly, system factors influence children's thinking, perceptions, and behaviours.

The study was carried out in May 2020. The final study sample consisted of 20 children from Nigeria, 15 from Sierra Leone, and 16 from Tanzania. Most of the children came from low-income households, but inclusion criteria required that the participants had access to a mobile phone; most interviews were done over the telephone to respect social distancing.

The analysis revealed five unique coding themes to capture changes during the pandemic, each with several subthemes. The results are organised to highlight how different spheres of influence affect children's perceptions of COVID-19 while identifying key barriers and facilitators to their lives and health the children identified. To exemplify themes, the researchers provide italicised key quotes from the interviewed children, as well as tabulations of comments.

The exosystem level (vs. individual, microsystem, and mesosystem levels) seemed to have the most striking impact on children's perceptions of the nature and severity of COVID-19. This level includes factors such as:

• The child's exposure to media - While many children expressed that media use was a regular part of their lives, several explained they were spending more time than usual using media. The type of use had changed for some; during the COVID-19 pandemic, they were more frequently using educational media, as well as watching or listening to news programmes. The high and increased media usage was consistent across participants from the three regions.
• Home country - For example, the research team found that:
  • The Sierra Leonean children of this study had the highest levels of knowledge, the most understanding of what their government was doing, and the greatest overall adherence to health protocols. These children also reported the most media use to learn about COVID-19. The researchers suggest that Sierra Leone's coordinated control measures and communication efforts were reflective of the country's proactive approach, as well as its history with the 2014 Ebola outbreak. The 9- to 13-year-olds in our study seemed to be benefiting from these priorities and learned lessons.
  • Tanzanian children in this study were more ignorant and less concerned about this public health crisis. Their apathy could be due to the Tanzanian government's withholding of credible information on COVID-19 cases or fatalities; leaders have urged its citizens to continue usual behaviours. Despite high rates of media use, Tanzanian children had the lowest reported levels of knowledge about COVID-19.
  • In Nigeria, the inconsistent messaging and dissimilar methods of control across the country manifested in the sampled children showing differential levels of fear and understanding of COVID-19. For example, children in Kano reported less media use than children in the other two countries, along with less fear, lower overall knowledge, and little awareness of how their government is responding to the pandemic. Across the three regions, the Nigerian children in the study described the least government trust and were most likely to overtly criticise their officials. Nigeria's lack of consistent health communication and healthcare efforts may have contributed to the sample's overall low government trust. (In contrast, Tanzanian children expressed the highest levels of trust and least criticism. They tended to adhere to the President and mass media's messaging, expressing strong national collectivism and even pride in their country's isolationism. With regard to government trust, historical perceptions of political corruption may play a role - as discussed in the article.)
• Religion - Many participants explicitly offered religious messages of hope. Children discussed how they missed their religious schooling and services. In Tanzania, for example, Christian children may be at greater risk, with President Magufuli's advice to attend church services, saying Jesus would protect them from the spread of COVID-19.

"Researchers and in-country teams agreed that those in power should closely consider comments from study participants discussing those in need, prioritizing food for hungry children, and overall high levels of struggle and stress." The paper offers several specific recommendations based on the children's responses. For example:

• At the individual level, it is important to address and prioritise knowledge and empowerment among girls. The girls (who talked less than boys) in the study worried more about their families and homes and seemed less hopeful about the future. Also, government communication should address children's stress, perhaps adding information and infrastructure to manage stay-at-home directives. Media messages should not only focus on sound science-based information that appeals to the audience but also incorporate age-appropriate messages to help children cope with the information they are receiving.
• At the microsystem level, positive family interactions and dynamics appear protective. The reverse is also true. Community efforts should focus on household and family dynamics, encouraging parents to give their children time to study and cope with various circumstances.
• At the community or mesosystem level, messages to the public should be clear about school plans, supporting practices (e.g., for at-home learning), and strategies for securing the future of children's educational paths. In addition, the media should take advantage of the opportunity to share more educational programming, such as Akili and Me and Ubongo Kids, with children.
• At the exosystem level:
  • The media should carefully consider how they share risk communication. For children as well as other audience members, inconsistent messaging creates knowledge gaps and misconceptions, and even high-quality information is associated with increased fear and worry. The government should work closely with the media to share their actions and encourage openness during crises. As part of the provided information, messages should assure and offer hope. Consistent messaging and transparency throughout the crisis seems to be a key finding that is paramount to children's experiences during a crisis like this one.
  • Prayer seems to be a strong coping strategy during times of crisis, and an effort should be made to allow for safe religious worship regardless of lockdown orders. Given the highly religious lives these children lead, it is important to convey religious messages of hope during disasters. However, religious leaders should be careful not to contradict information from scientific leaders, as was the case in Tanzania when President Magufuli insisted that prayer would keep COVID-19 away. Messages from religious leaders as opposed to political figures should be prioritised at the community level.

The researchers suggest directions for future research, such as identifying the specific policy implications and recommendations that can help influence child health in sub-Saharan Africa.

A 9-year-old Nigerian boy from the study said, "This event has taught us to take care of our health, and that we children are the leaders of tomorrow." The researchers hope that this work will give children a voice to help public health leaders learn from this crisis and protect present and future child health.