COVID-19 pandemic management at a hospital in Somalia: A qualitative study

Abstract

Background

COVID-19 pandemic management in the hospitals is important for the prevention practices of health staff. Studies assessing COVID-19 pandemic management in Somali hospitals are limited. This study aimed to evaluate the management of the COVID-19 pandemic at De Martino Public Hospital in Mogadishu, Somalia, to enhance pandemic management strategies in hospitals.

Methods

In this phenomenological study, in-depth interviews were conducted with 29 key participants at De Martino Hospital, including 5 managers, 12 healthcare workers, and 12 patients. Additionally, on-site observations were carried out at the hospital. The study was conducted in 2022, and thematic content analysis was used to analyze the interview data.

Results

The interviews revealed seven themes: infrastructure, prevention, communication, awareness, fear, management, and finance. The study found that the hospital generally managed the COVID-19 pandemic well. However, public awareness was deemed inadequate. Observations indicated a lack of triage procedures at the entrance. The results also highlighted a shortage of budget and poor infrastructure for COVID-19 management in the hospital.

Conclusions

Effective COVID-19 pandemic management is crucial for reducing disease transmission. It is important to implement entry regulation measures, particularly screening triage procedures. Public education is needed to encourage the adoption of COVID-19 infection prevention and control practices. Additionally, sufficient funding should be allocated to ensure that hospitals have the necessary materials, equipment, and human resources for improved management of the COVID-19 pandemic and similar epidemics.

1. Introduction

The COVID-19 pandemic affected the whole world by different means. However, it affected African countries more severely in terms of morbidity and mortality considering the weak capacity of their health systems. ¹ Health care institutions were among the most affected. ²

African continent was not well prepared to manage the COVID-19 pandemic, ² espicially the testing ability was not adequate, as 62% of all tests performed in only 5 countries as of Dec 31, 2020. ³ Somalia had no testing capacities for COVID19 during the first few months of the epidemic and the samples were transported to Kenya Medical Research Institute (KEMRI). Somalia doesn’t have a strong system for surveillance and response for diseases including COVID-19. ⁴

Confirmed patients with COVID-19 are the main sources of infection and transmission of COVID-19 to others. COVID-19 is primarily transmitted via air droplets and direct contact. ⁵ Transmission of SARS-CoV-2 from the contaminated environment to human through aerosol and fomite is also possible and the virus can remain viable and infectious in aerosols and on surfaces. ⁶

During the COVID-19 pandemic or the emergence of other infectious diseases, infection prevention and control (IPC) practices in the hospitals are of great importance, ⁷ as hospitals are relatively closed environments with dense populations and high patient influx, creating a suitable environment for COVID-19 transmission. Infections among healthcare workers (HCWs) have been associated with aerosol transmission in hospitals. ⁸ Therefore, a sound policy is essential for managing the pandemic process.

Protecting HCWs is important for the continuity of healthcare delivery. ⁹ To prevent HCWs from contracting COVID-19, public health plans should be upheld during the pandemic to reduce disease transmission. Adequate HCW capacity should be ensured and planned for the pandemic, ¹⁰ the number of healthcare assistants should be minimized, non-essential medical procedures should be postponed, and only urgent surgeries should be scheduled at the end of the day to lower the risk of hospital-acquired infections. ⁵ Many HCWs have factors that increase their susceptibility to severe COVID-19 infection or death, such as chronic diseases; thus, managers should decide whether these workers should be reassigned to lower-risk areas. Additionally, healthcare facility managers should implement vaccination programs against COVID-19. ¹¹

The planning should contain establishing a ventilation system and installation of air conditions in the different parts of the hospital. Proper organizing procedures, such as separation between outpatient clinics and inpatient wards of the hospital are essential during the pandemic. ¹⁰ Adequate supplies of Personal Protective Equipment (PPE) should be ensured and HCWs should be trained in using it. The environmental hygiene of hospitals and the personal hygiene of HCWs should be maintained. ¹² Hand washing and Hygiene (HH) is especially mandatory for HCWs, both for themselves and for the patients’ safety. ¹³ Proper treatment equipment for COVID-19 patients should be used and equipment should be disinfected strictly. ¹⁰ Contact reduction measures, isolation of COVID-19 cases and quarantine of their contacts or quarantine of staff caring for them should be implemented in the hospitals. ¹⁴

A surveillance system should be established in the hospital. Contact tracing, active case finding and testing are essential for COVİD-19 IPC. ¹⁵ Triage strategies (eg. documentation of patient and co-patient information, temperature check and screening for COVID-19 symptoms) should be adopted and supervision activities should be strengthened. ⁵ Regular check-ups for HCWs should be maintained to initiate the diagnosis quickly and treat them properly. Daily screening of medical and non-medical staff, followed by immediate testing and isolation would be effective. ¹⁰

Healthcare facility managers should motivate health workers to comply with the IPC measures. Managers should arrange appropriate working hours and provide rest times and should ask HCWs’ opinions regarding their occupational health and safety. Managers should establish a good relationship between managers and different staff members in the hospital and facilitate the cooperation between staff. ¹⁶ Combining vaccination programs with rigorous IPC measures, monitoring and communication, seems to be more effective in protecting HCWs. ¹⁷

The results of this study will provide valuable insights for policy makers and managers, in ensuring the safety of HCWs in hospitals during pandemics. Evaluating COVID-19 pandemic management in hospitals is crucial for IPC. There are some findings on COVID-19 IPC practices in different global regions, especially in Africa. However, research on this topic in Somali hospitals is limited. Therefore, this study aimed to assess COVID-19 pandemic management at De Martino Public Hospital in Mogadishu, Somalia, using a qualitative method. The goal is to enhance pandemic management and COVID-19 IPC practices in hospitals.

2. Methods

2.1. Study design and place

The study utilized a qualitative phenomenological design and was conducted at De Martino Public Hospital in Mogadishu, Somalia’s capital city. This hospital is one of the country’s most important facilities dedicated to COVID-19 patients.

The phenomenological framework guided both the development of the research questions and the analytical process by centering on the lived experiences of patients and healthcare workers affected by the COVID-19 pandemic. This approach prioritized understanding how participants perceived and made sense of the challenges surrounding access to health services and infection prevention measures within their specific social and cultural contexts. Accordingly, the research questions were designed to elicit detailed narratives about personal experiences, barriers, and coping mechanisms, rather than to quantify service utilization. During the analysis, phenomenology informed the thematic interpretation by focusing on how the essence of participants’ experiences shaped their access to healthcare and their responses to COVID-19 infection risks. This framework also enabled the researcher to uncover the underlying meanings within these experiences, such as feelings of exclusion, vulnerability, and resilience. At the same time, the findings are schematized in detail under the headings that the three categories have in common (see Figure 1).

Figure 1.

Experiences and perceptions of participants.

Two methods were employed in the study: in-depth interviews and observation. In-depth interviews were conducted to gather comprehensive information about COVID-19 pandemic management from key individuals, while the observational method was used to examine practices and reinforce the research findings.

2.2. Study sample

In the in-depth interviews, the sample size was determined based on the principles of phenomenological qualitative research, where the focus is on depth rather than breadth of understanding. Recruitment continued until data saturation was achieved—that is, when no new themes or insights emerged from additional interviews. In this study, data saturation occurred after 29 interviews, which provided sufficient variation and richness to comprehensively explore participants’ lived experiences related to access to healthcare and infection prevention during the COVID-19 pandemic.

To ensure adequate representation, purposive sampling was employed to include participants from diverse categories of healthcare workers, such as physicians, nurses, technicians, and managers, as well as patients who had different levels of interaction with the healthcare system during the pandemic. Efforts were made to achieve balance in terms of professional role, gender, and work setting (hospital departments). This approach ensured that a wide range of perspectives and experiences were captured, reflecting the heterogeneity of those affected by COVID-19–related healthcare challenges. In addition, this situation is determined as a limitation in the last paragraphs of the discussion section.

Participants were categorized based on key demographic and professional characteristics, including gender, and professional role. Within each category, purposive sampling was used to recruit participants who had direct experience with healthcare delivery or service use during the COVID-19 pandemic. Recruitment continued until data saturation was reached within and across categories to ensure diversity and depth of perspectives.

Key individuals were selected from three categories within the hospital: managers, HCWs, and patients, in accordance with the study’s objectives. Twelve HCWs were interviewed, divided into three categories (doctors, nurses, and other HCWs), with four individuals in each category, selected based on gender. Additionally, twelve hospitalized patients from various departments were interviewed, also based on gender. Three managers and two deputy managers were interviewed without considering gender.

2.3. Inclusion and exclusion criteria

Inclusion criteria: being a key informant, manager, healthcare professional (physician, nurse, etc) or patient who can dedicate sufficient time to the interview and is relevant to the topic.

Exclusion criteria: having any mental or physical health condition that would impede conducting the interview.

2.3.1. Data collection

The in-depth interviews were conducted using semi-structured forms, which were developed based on a literature review. Different forms were prepared for the three participant categories: hospital managers, healthcare workers and patients (Supplementary file 1).

Written informed consent was obtained prior to the interviews. They were informed about the study’s objective and method and that their participation was voluntary and that they would not be paid or charged.

The anonymity of the participants was ensured using codes not names. Eg. Doctor No.1. Similarly the confidentiality was maintained by not disclosing any information about the interviews. Participants were asked to choose their suitable time and comfortable method of online interview. They were also told to attend the interview alone in a quite isolated place. In addition, participants were not asked about their personal identifiers during the interview process. After data collection, all participant information, sound recordings and transcriptions were stored in a secure computer for reference until data analysis.

All interviews were conducted online between October and November 2022. A pilot study was conducted initially to refine the interview process. The interviews collected personal information, as well as participants’ experiences and perceptions related to COVID-19 IPC practices in the hospital. Voice recordings were made with the participants’ consent. The average duration of the interviews was 25 minutes (maximum 57, minimum 6). After data collection began, new emerging questions were added to the survey forms.

On-site observations were conducted using an observation form adapted from the World Health Organization, Western Pacific Region’s COVID-19 Infection Prevention and Control: Preparation Checklist for Long-Term Care Facilities with some modifications according to the suitability of the hospital and using literature guides. ¹⁸

The observation form was intended to include hospital information and data on COVID-19 IPC measures. On-site observations were conducted in November 2022, with each observation taking place over the course of a single day.

The observation was participatory where participants were not aware of. However, consent was obtained from the hospital administration. Multiple observations were carried out at hospital entrance, outpatient polyclinics and emergency and inpatient departments using different checklists. Observations made at different times and from different angles in the same location can yield differences. Therefore, the observations were diversified and used to better understand the results obtained from the interviews.

2.4. Analysis

For analysis, the audio recordings of the interviews were transcribed into text. The texts were then manually analyzed for thematic content. This process involved coding, creating lists of codes, and identifying common codes. Each interview was coded by at least 2 researchers. Then the codes were revised by all authors and discrepancies were resolved. As the interviews continued, it was concluded that saturation had occurred because no new codes were emerging. Once all interviews were completed, the researchers reviewed the transcriptions and reached a consensus decision that data saturation had been achieved. After the analyses were completed, the researchers unanimously concluded that data saturation had been reached. Subsequently, code categories and themes were developed. The findings were illustrated using quotes represented by numbers.

For the observation analysis, a simple content analysis of the checklist was conducted.

2.5. Trustworthiness

Consolidated criteria for Reporting Qualitative research (COREQ) checklist was applied in the study to ensure validity and reliability (Supplementary file 2). Triangulation was used in data collection to enhance credibility; for the qualitative research; interviews were conducted with different key groups, including hospital staff, managers, and patients, and were complemented by an observational method. Participatory type of observation helps reduce bias in the study. Participant confirmation and expert review were also employed; after transcribing the recordings, participants were contacted for clarification on unclear points. During thematic content analysis, each interview was coded by at least 2 researchers, and then the codes and emerging themes were discussed with the authors.

3. Results

Simple characteristics of the participants are presented in Table 1. Participants were patients, managers and HCWs from different departments or units of the hospital (internal medicine, maternity, pediatric, surgery, emergency, intensive care unit, oxygen technique, operation room and cleaning services). The participants ranged in age from 18 to 60 years with the average of 31.5 years.15 participants were males and 14 were females making 51.7% males and 48.3% females.

Table 1.

Characteristics of the participants.

Polyclinic or unit	Category	Gender	Number of participants
Internal medicine	Managers	Male	-
		Female	1
	Patients	Male	3
		Female	1
Maternity	Health care providers	Male	-
		Female	3
	Managers	Male	1
		Female	-
	Patients	Male	-
		Female	5
Surgery	Patients	Male	3
		Female	-
Emergency	Health care providers	Male	-
		Female	1
	Managers	Male	-
		Female	1
Intensive care unit	Health care providers	Male	2
		Female	-
Oxygen technique	Health care providers	Male	2
		Female	-
Cleaning	Health care providers	Male	-
		Female	2
Operation room	Health care providers	Male	1
General	Manager	Male	2
Pediatric	Health care providers	Male	1

Experiences and perceptions of HCWs, managers and patients are illustrated in Figure 1. The common opinion about COVID-19 preventive measures included adequate cleaning services, information posters, social distancing measures, PPE and HH supplies and adequate ventilation in the rooms. However, public awareness, testing facility and medicine were inadequate. Good management and communication was common opinions shared by managers and HCWs. HCWs and patients shared inadequate PPE use and HH and low encouragement of public for vaccination. While HCWs focused on vaccine and cleaning training, managers focused on test and screening training. On the other hand, HCWs mentioned about free services while patients said that services were good.

In this study, 7 main themes emerged from the interviews: infrastructure, prevention, communication, awareness, fear, management, and finance. The themes and their related codes are presented in Table 2.

Table 2.

Themes and codes identified from the interview.

Themes	Codes	n = 29	Repeated times
Infrastructure	Hospital cleanliness is good	21	28
	Ventilation is good	20	21
	Patient rooms are good (Fans and air conditions)	18	19
	COVID-19 tests are insufficient	18	22
	The hospital works well (The biggest ICU and referral hospital)	16	20
	Lack of materials (Lab materials, medicine)	14	18
	Oxygen stock is adequate	11	20
	COVID-19 tests are adequate	10	10
	Insufficient of the isolation rooms	5	5
Prevention	Success in COVID-19 prevention and control	18	20
	Personal Protective Equipment (PPE) is adequate and well used	16	36
	Prevention is adequate	15	27
	Hand Hygiene (HH) supplies are adequate and well used	15	19
	Feeling of the importance of prevention	14	19
	Social distancing is adequate	14	18
	There is mask wearing requirement	13	13
	Social distancing is not adequate	11	15
	No prevention or weak prevention	10	15
	Isolation procedures are good	10	18
	Vaccination procedures are easy	10	10
	Encouraging people to take COVID-19 vaccines are inadequate	10	10
	Masks and gloves are the most common PPE	10	10
	There is no mask wearing requirement	9	9
	Vaccine taking is mandatory for HCWs	9	10
	There is COVID-19 IPC committee	9	9
	PPE use is inadequate	8	12
	People are motivated to take COVID-19 vaccines	7	7
	HCWs are encouraged to be vaccinated	6	6
Communication	The communication between HCWs is good	16	18
	The communication between administration and HCWs is good	15	16
	People have the opportunity to ask questions and share their concerns	12	12
	The communication between HCWs and the public is good	5	5
Awareness	Posters for community are adequate	16	27
	Public awareness is not adequate	14	25
	Public awareness is adequate	12	21
	Training and education of HCWs is good	13	24
	Posters are not adequate	6	6
	People do not read the posters	6	6
	HCWs’ training is inadequate	4	5
Fear	Fearing from COVID-19	13	18
	Not fearing from COVID-19	9	15
	Feeling of COVID-19 end	7	8
Management	Management is good	13	25
	Ministry of Health deficiencies	9	10
	The motivation provided is high	11	13
	Work shifts are good	8	8
	Workload is high	7	8
	There is resting time	7	7
	The motivation provided is low	6	7
	There is no resting time	3	3
Finance	Salary problems	12	23
	Budget is insufficient	6	9
	COVID-19 budget is not controlled by the administration	4	4
	Salary is sufficient	4	4

Codes are summarized as coding tree in Figure 2. Hospital infrastructure and environment affect staff to produce good services which in turn affects patients. Ministry of health has relation with budget and hospital management that both related to salary and motivation. Hospital management affects communication in the hospital that relates to public awareness and staff training. Fear helps patients and staff to practice IPC, including proper isolating of infected patients, taking vaccination, maintaining social distance and using PPE and hand washing.

Figure 2.

Coding tree.

Seven emerging themes and related quotations are presented below:

3.1. Infection prevention and control

Most participants reported adequate IPC practices and success in implementing them, particularly regarding the use of PPE and hand washing practices. Masks and gloves were cited as the most commonly used PPE, with disinfectant being the most frequently used HH product. Many participants emphasized the importance of practicing COVID-19 IPC; only one participant deemed it unimportant.

However, some participants, mostly HCWs expressed concerns about the lack of prevention or weak prevention practices. Some HCWs and patients reported inadequate PPE use and handwashing. Three HCWs expressed hope for the end of COVID-19, while two linked this hope to the level of prevention measures taken. Overall, COVID-19 IPC in the hospital was considered good, although some participants noted it was weaker than before. Some staff highlighted the role of the COVID-19 committee, mentioning that the hospital has a dedicated IPC committee that activates in emergency situations or assigns at least one person for IPC.

“Most of what needs to be done to reduce COVID-19 infection is done in the hospital. However, people are not as careful as before” (Nurse No.20).

“In this hospital, to fight against COVID-19, hands are washed, masks are used, people are very careful and care is taken about cleanliness. All this is enough”(Patient No.7)

Most participants mentioned that social distancing in the hospital was adequate, and some of them, mostly HCWs said the opposite. Managers emphasized existing marked places to help social distancing. Similarly, most participants mentioned that wearing masks at the hospital entrance was mandatory, while some of them said it was not mandatory.

Most HCWs and managers agreed that the implementation of isolation procedures in the hospital was adequate, with the majority stating that visitors were not allowed to see COVID-19 patients. However, two individuals mentioned that the isolation procedures were inadequate due to a lack of control over visitors not wearing PPE.

Regarding COVID-19 vaccines, many participants agreed that the process of getting vaccinated was straightforward. Most hospital workers, including managers and healthcare workers (HCWs), concurred that vaccination was mandatory for hospital staff, and some mentioned that workers were encouraged to get vaccinated. However, many participants noted that the general public was not encouraged to get the COVID-19 vaccine, while some said that people were motivated to do so.

“There is currently no social distancing; only social distancing can be maintained from persons with respiratory disease until their conditions are confirmed. The measures have weakened now; they arre not like that in the past. Vaccines are given in a dedicated section in the hospital and there are different COVID-19 vaccines, the vaccine is free and easily accessible. Hospital staff are encouraged to take the vaccine and all of them have been ordered to take the vaccine”(Manager No.22).

3.2. Fear of COVID-19 infection

Most participants reported that they fear being infected with COVID-19. On the contrary, some participants reported that they do not fear COVID-19 infection. Also, some participants, more than half of them are patients thought that COVID-19 had already ended. In addition, some participants mentioned that fear of COVID-19 has decreased, so the IPC practice has decreased.

“COVID-19 still exists. I am afraid of COVID-19 and I do prevention”(Patient No.12).

“For me, there is a big difference between the past and now regarding COVID-19; In the past, when I was caring for a patient, I was using three sterile gloves and one non-sterile glove for a total of 4 together, I was using 1 surgical mask and 1 N95 mask, and when using PPE, I was using it fully, starting from the hat and covering my entire length. I was doing these because of fear, not from lack of training” (Manager No.18).

“Currently only masks and gloves are used regularly and only hand sanitizer is used for hand washing which only the person who wants it uses. However, there is no fear like before. There are currently no COVID-19 cases in the hospital, because the Ministry of Health announced that there are no COVID-19 cases in the country and the society is behaving normally. There is no specific fear of COVID-19 in the hospital”(Nurse No.23).

3.3. Hospital management

Most HCWs and managers reported that the hospital’s management of COVID-19 IPC was good, often citing effective supervision activities. However, they also highlighted negatives related to the Ministry of Health, including issues with salary payments.

“There is an IPC committee. There is also a daily activity person who monitors IPC procedures in all departments every morning”(Manager No.24).

“The management made hand washing sites everywhere, put water and shampoo next to it, and took very good precautions. The hospital has a committee working day and night to carry out COVID-19 related affairs”(Paramedical No.27).

Most hospital workers reported that the motivation provided in the hospital was good. Approximately half mentioned material incentives, while the other half referred to non-material or spiritual motivation. However, some HCWs expressed that the motivation in the hospital was lacking. The workers highlighted effective work organization as a motivational factor. They generally agreed that work shifts were satisfactory, with only one participant dissenting.

Similarly, most agreed that there was adequate rest time for hospital workers, with only three individuals disagreeing. Despite this, a high workload was acknowledged by the hospital workers, with only two persons indicating that the workload was low.

“The hospital administration implemented various motivational initiatives. For example, it tried to reduce the workload and organized trips for employees to help them relax after working for a certain period.. However, in the event of a COVID-19 wave or an increase in workload and patient admissions, opportunities for rest naturally decreased”(Doctor No.2).

3.4. Communication

Most hospital staff reported that communication among HCWs was good, as was the communication between HCWs and managers. However, two HCWs stated that the communication between HCWs and managers was not satisfactory; one of them cited managers’ low autonomy and inability to make independent decisions in certain matters as barriers to effective communication. Many participants mentioned that the public could share their concerns and ask questions to HCWs, with only one participant reporting the opposite. Five participants, including three HCWs, specifically noted good communication between HCWs and the public, while one HCW mentioned that this communication was not effective, stating that people do not adhere to the informed prevention measures.

“The communication between hospital staff is very good. Health care workers help each other. There is a WhatsApp group containing the necessary personnel and information is shared through there”(Doctor No.2).

“Our communication with healthcare professionals is good; They meet our needs and follow us”(Patient No.6).

“There is good communication between us and the administration. If we need something from the administration, we tell the committee between us and the committee delivers it to management”(Paramedical No.28).

3.5. Public awareness and staff training

Regarding public awareness, most participants reported that COVID-19 posters around the hospital were adequate, with social distancing being the most emphasized measure. However, they also noted that public awareness was generally inadequate. Some participants, primarily patients, felt that the posters were insufficient, while others believed that public education was adequate. A few participants thought that the posters were ineffective because people tend not to read them. Some patients mentioned that they did not read the posters either because they were in pain upon admission or because they were illiterate. Three HCWs stated that people did not practice what they were educated.

“Since we came to the hospital we have not talked to the HCWs and they have not talked to us about COVID-19. Also, we were not given information about the COVID-19 vaccine” (patient No.5).

“Posters posted during the COVID-19 period are currently helping us in regard with giving information. But the society needs verbal awareness, because our society listens but does not read; Therefore, I can say that the thing needed to be done in COVID-19 prevention and control is to raise awareness” (Nurse No.17).

Most managers and HCW participants believed that the training of HCWs was adequate, although they mainly referred to past training sessions. They mentioned that HCWs were primarily trained on PPE use, handwashing, and social distancing. However, four HCWs, including three nurses, felt that the training was inadequate.

“If I talk about training, there are some institutions that give seminars to hospital employees raising awareness about COVID-19. Currently, there is not much training as the number of infections has decreased. I was specifically trained on how to prevent illness, how to wear PPE and how to put on and take off gloves, and how to use shoes” (Paramedical No.26).

3.6. Hospital services and infrastructure

Most HCW and patient participants reported that the hospital was good, with some noting that the services were both satisfactory and free of charge. It is worth mentioning that the focus of the study participants was primarily on the hospital environment and infrastructure. The majority mentioned that hospital cleaning and ventilation were good, although two individuals reported that cleaning was not so good, and one person mentioned poor ventilation. Additionally, they said that rooms have fans and air conditions. HCWs mentioned improvements in the environment due to enhancements in infrastructure, such as the installation of air conditioning systems. Managers paid attention to the location of the hospital regarding ventilation.

“The hospital is very good, staff make great efforts to provide services such as dressings, they always come after a short time to follow us. I've been at this hospital before and now after I was injured, I requested to be taken to this hospital. Cleaning is always done at short intervals. There is no problem with cleaning and bed service. The room is cool, very good; windows open and clean” (Patient No. 11).

“During the 1st wave, the weather was very hot at that time and there were no air conditioners. Some health workers had a hard time using PPE. After that air conditioners were installed” (Doctor No.1).

However, participants reported a lack of testing facilities, though some, mostly patients, stated that COVID-19 testing was adequate. Many participants reported shortage of supplies, especially lab supplies and medicines, only one participant reported the opposite. Many HCWs and managers agreed that the hospital has adequate oxygen stock; they mentioned that oxygen stock was improved later and they talked about the challenges encountered before. A notable portion of hospital workers; 3 managers and 2 HCWs noted the insufficiency of isolation rooms.

“There were and still are big problems in terms of materials, there are no continuing supplies such as medicine, except PPE” (Manager No.25).

3.7. Finance

Many participants, primarily managers, believed that the hospital’s budget for COVID-19 was inadequate, with only one patient stating it was sufficient. Managers also reported that the budget was managed by the Ministry of Health rather than hospital managers, and they did not know about the details.

“The Ministry of finance knows better about budget data, we only focus on patient needs and internal works such as oxygen and intensive care rooms. Due to the lack of hospital economy, some supplies are missing; there are too many patients and the government is weak and cannot provide these supplies” (Manager No.19).

Most hospital workers mentioned that they have salary problems, including irregular payments, no salaries, unfair distribution, and insufficient amounts. They specifically mentioned that their salaries were cut. Three hospital workers, including two HCWs, stated they did not receive extra salaries allocated for their work on COVID-19. However, two managers and two HCWs claimed that their salaries were sufficient.

“There is no regular salary in the hospital. I haven't received any salary for a year; I even pay myself for transportation. Hospital workers were not paid even for working during COVID-19 era and they are still waiting” (Nurse No.21).

During the observation, there were 5 staff members at the hospital entrance, 8 staff members at the outpatient polyclinics, and 5 staff members at the Emergency department. The Emergency department had 7 beds, with only 2 patients present at the time of observation. The inpatient wards had a total of 20 staff members, 115 beds in the inpatient department, and 84 patients were residing there.

The observed COVID-19 IPC measures are presented in Table 3. Observations determined that the hospital effectively managed the COVID-19 pandemic, such as ensuring adequate PPE and HH materials, implementing social distance measures, establishing ventilation systems and practicing adequate cleaning, disinfection and waste disposal procedures. Observations also found that HCWs adhered to adequate IPC practices, such as using PPE and practicing HH. However, the hospital lacked proper entry regulation measures, particularly in triage procedures. There was also a shortage of isolation rooms. Additionally, due to insufficient COVID-19 resources, residents and staff were observed sharing some equipment and items after disinfection. The study also identified gaps in public awareness, noting that only suspected cases were informed about the virus, excluding other patients.

Table 3.

COVID-19 IPC at De Martino Hospital: Results of the observation.

Domain	Variable	Yes/No
Entry regulation	A temperature check for all persons entering the facility is developed	No
	A health declaration form for all persons entering the facility is filled	No
	A mask-wearing for all persons entering the facility is required	Yes
Equipment and supplies	Adequate hand hygiene materials (e.g. Alcohol-based hand rub) are available	Yes
	Adequate supplies of medical mask are ensured for HCWs and they use	Yes
	Adequate supplies of gloves are ensured for HCWs and they use	Yes
	Adequate supplies of gowns are ensured for HCWs and they use	Yes
	Quality PPE in various sizes is provided	Yes
	Adequate wash basins are available	Yes
	Adequate supplies for proper hand washing, including water, soap are ensured	Yes
Isolation	Secure space in the facility is ensured to isolate residents suspected of COVID-19 (e.g. a single isolation room with bathroom is maintained)	No
	Ensure dedicated equipment for the care of isolated resident	Yes
	All resident and staff personal equipment and belongings are well differentiated (e.g. Labeled), and not shared	No
A safe and healthy environment	Separation of at least 1.5–2 meters between all patients is maintained	Yes
	Markers are placed where patients may queue or sit (e.g. on the floor)	Yes
	Areas are well-ventilated (i.e. windows kept open, where possible)	Yes
Cleaning, disinfection and waste disposal	Cleaning staff clean and disinfect the environment (e.g. floor, patient room, toilets) at least daily, with a focus on frequently touched surfaces (e.g. door knobs, switches, tables, etc.)	Yes
	Safely dispose of infectious waste in appropriate rubbish bags and safely handle rubbish bags with appropriate PPE	Yes
	The number of shared items is reduced and shared items are cleaned and disinfected after every use between residents/patients and staff	Yes
Public awareness	COVID-19 information is visible to visitors including:-Signs and symptoms of COVID-19-How to prevent infection, including hand and respiratory hygiene, physical distancing	Yes
	COVID-19 information is provided for residents and their families including:-Signs and symptoms of COVID-19-How to prevent infection, including hand and respiratory hygiene, physical distancing	Yes
	Residents and their families are requested to inform staff immediately if they have any symptoms	Yes

4. Discussion

Infection prevention and control practices, and especially personal protection of healthcare workers are very important during COVID-19 or other infectious diseases epidemics; because protecting them is a priority to sustain healthcare delivery.^7,19 In low-resource countries like Somalia where the number of HCWs falls significantly short of the Sustainable Development Goals, ensuring the protection of these workers is vital. ²⁰ The most important resource is the manpower. So HCWs and managers will be the most worth resource during adverse health events like COVID-19 pandemic. This study is an example of infection prevention and control in low resource countries.

The study found adequate COVID-19 pandemic management in the hospital, but public awareness was insufficient. This lack of awareness may be due to low fear of COVID-19 and low risk perception among the community in the later stages of the pandemic. Fear of COVID-19 infection may lead to a better understanding of the importance of IPC practices. It was reported from China that the perceived risk of COVID-19 significantly improved IPC behaviors among healthcare professionals in hospitals. ¹³ Additionally, fear among the general population and HCWs can aid in the implementation of IPC measures. ¹⁰ A study reported that HCWs’ adherence to IPC measures increased during the first wave of COVID-19, decreased post-lockdown, and then rebounded during the second wave. ²¹ Furthermore, the encouragement for hospital visitors to get vaccinated against COVID-19 was reported to be low, which may be primarily related to low public awareness. This finding aligns with a study conducted in an Indian hospital. ¹⁰ Hospital managers should focus on providing information to patients, their companions, and visitors, as well as placing posters with images and using speakers to remind people of the pandemic’s risks and preventive measures at the hospital entrance. Public awareness is crucial for ensuring adherence to IPC guidelines. Managers must ensure that the public is informed about the pandemic, its vulnerability and severity, causes of the disease, transmission risks, symptoms of infection, and prevention methods. ¹⁰ The interviews highlighted the significant role of hospital administration in the fight against COVID-19, including supervisory activities, enhancing communication within the hospital, and providing training and motivation. Effective management may lead to better adherence to COVID-19 IPC practices in the hospital. Factors that facilitate HCWs compliance with IPC guidelines for respiratory infectious diseases include support and motivation from managers, workplace culture or social norms, the type and frequency of training received, access to and availability of resources such as PPE and HH supplies, clear and consistent guidelines, and strong communication. ²²

The interviews revealed that the hospital services were good and free of charge, with commendable cleanliness, likely due to sufficient cleaning staff, their training, and supervision. However, the interviews also highlighted inadequate COVID-19 infrastructure, despite some improvements. There were shortages in laboratory supplies and medicines, as well as insufficient COVID-19 tests and isolation rooms. Some participants, particularly patients, reported that COVID-19 testing was adequate, which may indicate a lack of awareness about testing standards. Challenges such as lack of oxygen and electricity issues were addressed by making oxygen available and installing fans and air conditioners, resulting in improved care and a better environment. Fortunately, there were no significant shortages in PPE and handwashing supplies. Weak COVID-19 infrastructure is a common issue in Africa, mainly due to economic constraints and low spending. However, hospitals with higher capacities in terms of beds and other resources can more effectively control disease transmission. Therefore, hospital managers should invest in improving infrastructure, such as enhancing testing facilities and increasing the number of isolation rooms. ²³

The interviews revealed that an adequate budget was not allocated for COVID-19 IPC in the hospital, which may be a primary cause of weak infrastructure. Healthcare workers reported salary issues, such as lack of payment, irregular payments, unfair wages, and insufficient salaries, potentially leading to burnout. These issues were primarily attributed to the Ministry of Health. Additionally, managers emphasized their lack of autonomy in managing the budget. Burnout may be more prevalent among HCWs in countries with vulnerable health systems, where budgets for healthcare expenditures are limited, or where administrators have restricted budgetary autonomy. Healthcare workers may feel undervalued due to not receiving salaries commensurate with their risky work and experiencing injustices in payments, further exacerbating burnout. ²⁴

The study’s findings are consistent with a qualitative study conducted in Kenyan hospitals, which used interviews and reported improved cleaning standards and challenges in funding and infrastructure for COVID-19 IPC, including inadequate ventilation and limited installation of fans. ²⁵ However, unlike the Kenyan study; our study did not identify challenges with HH supplies, indicating some improvements in this area.

The hospital was observed to lack proper entry regulation measures, particularly triage procedures. This is consistent with a study at an Indian hospital, which reported a lack of frequent screening of COVID-19 symptoms among caregivers and staff as a triage strategy. ¹⁰ Studies showed that entry regulating measures to protect residents, staff or visitors and prevent introducing the virus into the facility is beneficial. ¹⁴ Triage strategies should be used to reduce contact between the susceptible population and potential sources of infection. ⁵ Temperature checks for the staff at the beginning of every shift and temperature checks for any patient before admitting should be practiced to control the infection. Daily screening of COVID-19 symptoms for healthcare workers before and after every shift and documentation of screening reports should be performed. ¹⁰ However, mask wearing regulations at the hospital entrance is an advantage. Personal protective measures, such as wearing masks, especially by HCWs are important components of COVID-19 IPC. ²⁶

The observation method also detected inadequacy of isolation rooms as the interview method. Additionally, residents and staff were observed to share some equipment and items after disinfection due to the inadequate COVID-19 resources. These results are consistent with those from a study of 9 observed hospitals in Sierra Leone, which reported a lack of triage procedures at the entrance and infrastructure problems. ²

The identification of diverse cases reflects the variability and complexity of participants’ and staff experiences and perceptions during the COVID-19 pandemic. These contrasting perspectives highlight how contextual, institutional, and individual factors shaped participants’ views on prevention practices, social distancing, and the adequacy of public awareness. For instance, the coexistence of views such as “prevention is adequate” and “prevention is not adequate” suggests differing access to resources, institutional support, and levels of compliance with infection control measures across healthcare settings. Similarly, variations in opinions regarding social distancing and public awareness indicate that participants’ assessments were influenced by their social environments, workplace conditions, and exposure to health education campaigns. The differing perceptions about healthcare workers’ training — from “adequate” to “not adequate” — point to unequal opportunities for professional development and variability in institutional preparedness for managing COVID-19. Likewise, the contrast between fearing and not fearing COVID-19 reflects differences in perceived vulnerability, coping strategies, and trust in protective measures. Finally, the variation between high and low motivation and resting time among health staff underscores how psychological resilience, workload, and recognition influenced workers’ morale during the pandemic. Collectively, these diverse cases emphasize that the impact of COVID-19 on healthcare and patients experiences cannot be generalized; rather, it must be understood through the multiple, context-dependent realities of individuals.

4.1. Limitations of the study

The study has some limitations; the interview method may be subject to response bias, but participant observation could enhance the objectivity of the study. Both methods may not cover all variables to be assessed. However, the two methods might complement each other and assess as many variables as possible. The findings of this study may not be generalizable to other COVID-19 care hospitals. Nevertheless, it may be generalizable to the entire hospital since the study observed different important sites and interviewed key persons from different categories, despite difficulty in obtaining extensive information from the patient category due to some illiterate participants and challenges in reaching some patients for confirmation after discharge. In addition, the sampling method might have possibilities of bias since it is mainly relied on subjective judgment rather than statistical calculation.

4.2. Strengths of the study

Although response bias and limited generalizability are inherent to qualitative research, several measures were taken to mitigate these issues. To reduce response bias, participation was voluntary and confidentiality was assured, encouraging honest and open sharing of experiences. Interviews were conducted by native/local? from the same country and trained researcher who used neutral, open-ended questions to minimize interviewer influence. While the findings are not intended to be statistically generalizable, purposive sampling ensured diversity in gender, workplace, and professional roles, thereby enhancing the transferability of the results to similar contexts. The phenomenological framework prioritized understanding how participants perceived and made sense of the challenges surrounding access to health services and infection prevention measures within their specific social and cultural contexts. During analysis, phenomenology guided the thematic interpretation by focusing on how the essence of participants’ experiences shaped their access to healthcare and their responses to COVID-19 infection risks. This framework also enabled the researchers to uncover the underlying meanings within these experiences, such as feelings of exclusion, vulnerability, and resilience. Furthermore, the findings were systematically organized and illustrated under the thematic headings that reflected commonalities across the three participant categories.

5. Conclusions

Pandemic management is essential to minimize the rate of disease transmission. Hospitals should prioritize infection prevention and control. Adequate capacity of HCWs should be ensured and planned for COVID-19 pandemic. Entry regulation measures, such as screening triage procedures, should be implemented. Patients, their companions, and hospital visitors should be informed about COVID-19 IPC practices, using strategies like automatic sound warnings or posters with attractive images at the entrance. Sufficient funding should be allocated to acquire necessary hospital materials, equipment, and meet human resource needs for improved COVID-19 pandemic management in hospitals. The Ministry of Health and donor organizations should contribute to this process, with the Ministry of Health granting hospital managers some autonomy in managing the funds. These points can be useful in the managing of future similar epidemics.

Supplemental material

Supplemental material - COVID-19 pandemic management at a hospital in Somalia: A qualitative study

Supplemental material for COVID-19 pandemic management at a hospital in Somalia: A qualitative study by Abdullahi Ibrahim Janay, Belgin Unal, and Bulent Kilic in Journal of Public Health Research.

Supplemental material

Supplemental material - COVID-19 pandemic management at a hospital in Somalia: A qualitative study

Supplemental material for COVID-19 pandemic management at a hospital in Somalia: A qualitative study by Abdullahi Ibrahim Janay, Belgin Unal, and Bulent Kilic in Journal of Public Health Research.