Abstract
More than 60,000 deaths from COVID-19 had been confirmed as of the 1st of August 2020. Concerns about physical and psychological wellbeing had increased across the world with women disproportionately being affected. This research was set to explore the triggers of mental health distress among women during COVID-19 lockdown. The research study utilized a qualitative descriptive approach. Forty (N = 40) women were recruited to take part in the research study. A one to one semi structured interview schedule was used to collect data. NVivo Version 11, QSR International Pty was utilized to organize data for analysis. Content analysis was used to identify, describe, and make inferences about the qualitative data generated. Findings from new interviews were compared for consensus and disagreement. Categories were then collapsed and analyzed into clusters from which concepts and themes were developed. The research study found that the triggers for mental health distress among the research participants included domestic violence, loss of employment, stress of managing children indoors, fear of COVID-19 infection, loneliness and poor access to health services. There is need to consider radical sensitive approaches in preventing triggers of mental health distress among women.
Introduction
Societies across the globe have seen increases in concerns about the physical and psychological wellbeing of women since the start of the COVID-19 pandemic (Bradbury‐Jones & Isham, Citation2020). By early April 2020 the World Health Organization reported that over 1 million cases of COVID-19 had been confirmed worldwide (World Health Organisation, Citation2020). The measures taken by governments around the world to protect their citizens included imposing a national lockdown to contain the outbreak and encompassing mass quarantine under stay-at-home ordinances (Lippi et al., Citation2020, p. 85). Families have been forced to retreat indoors without access to the usual sources of support and the important structure that schools provide in looking after and educating children during the day This has resulted in family burden to existing family difficulties.
The new and sudden COVID-19 context has inevitably had a dramatic impact on the wellbeing of entire communities. Media reports throughout the outbreak have painted “an alarming picture” of increased instances of gender based violence which includes acts of intimate partner violence such as rape, harassment, and coercive control (Roesch et al., Citation2020, p. 1). There is a possibility that that many more instances of gender-based violence occur than are reported across the world (Finchilescu & Dugard, Citation2021). Capturing accurate information about levels of suffering during COVID-19 lockdown has been further complicated by social distancing measures and blanket restriction of services from fully operating particularly in more remote or rural communities. Many existing services for women and girls have been “de-prioritized and deemed non-essential” (John et al., Citation2020, p. 65). Women have experienced increased instances of domestic violence with partners who sometimes use these new physical distancing measures “to further isolate affected women from supporting services” (Roesch et al., Citation2020, p. 1). This imposes a dire impact on their psychological wellbeing. There is a void, not only in support, but also in information from women about their experiences and how they are being impacted upon by the conditions of COVID-19 lockdown.
In Zambia, people with mental illness are stigmatized, feared, scorned at, humiliated and condemned (Essien & Asamoah, Citation2020). It is traditionally the duty and responsibility of the extended family to look after the aged and people affected by mental illness. Gender based violence (GBV) is a prevalent issue in Zambia. Women, who depend on their spouses economically, are forced by circumstances to continue living in abusive relationships. The family is considered sacrosanct and the affairs of the family members are private making it difficult to combat GBV and mental health (Nyangweso & Olupona, Citation2019). It is against this background that GBV is regarded as a family affair yet spouse beating has led to depression and death. In terms of psychiatric services, there are close to 560 beds for psychiatric patients across the country while the incidence of mental health are so many (Abi Doumit et al., Citation2019). Common mental disorders in Zambia include acute psychotic episodes, schizophrenia, affective disorders, alcohol related problems and organic brain syndromes. About 70–80% of people with mental health problems rely on traditional health practitioners prior to seeking help from conventional health facilities. The number of frontline mental health workers and professional staff has been declining due to the “brain drain,” retirement, death and low output from training institutions (Matlin et al., Citation2018). In Zambia, gender-based violence has been the focus of health and social care research interest, with increases in reports of violence in marriages seen in recent years (Mathur et al., Citation2018). Many cases are reported to be a result of poverty and “marital differences” (Nsakanya & Judith, Citation2017, p. 392). Of particular interest is the region of Copperbelt where the highest number of gender based violence cases in the country were recorded at 5554 in December 2016 (Nsakanya & Judith, Citation2017). The additional pressure of health anxieties and unexpected rises in unemployment brought about by the COVID-19 lockdown has placed strain on the mental health and wellbeing of many women while exposing existing gender inequalities. Considering the above assertions this study was set to explore the triggers of mental health distress among women during COVID-19 lockdown in the Copperbelt province in Zambia.
Methodology
Study location
The Copperbelt Province covers the mineral-rich Copperbelt, and farming and bush areas to the south of Zambia. It is the backbone of Zambian economy. However, its economic importance was severely eroded by a crash in global copper prices in 1973. The province adjoins Katanga province of the Democratic Republic of the Congo, which is similarly mineral-rich. The main cities of the Copperbelt in Zambia include Kitwe, Ndola, Mufulira, Luanshya, Chingola and Chililabombwe. Roads and rail links extend north into the Congo to Lubumbashi, but the Second Congo War brought economic contact between the two countries to a standstill, now recovering. The province has a population of more than two million people attracted by economic activities.
Research design
The research study utilized a qualitative descriptive approach. The idea was to understand the nature of the problem comprehensively as opposed to providing a conclusive solution to the problem (Josefsson & Gard, Citation2010). Qualitative descriptive study is important when trying to discover the who, what and where, to provide a comprehensive summary of an event (Leech & Onwuegbuzie, Citation2007). The approach aligned with our aim of identifying and exploring the triggers of mental health distress among women during COVID-19 Lockdown. Examining problems like triggers of mental health distress can be enhanced by a conceptual framework that recognizes the systematic factors contributing to the triggers. The study was underpinned by the Silences Framework. The Silences Framework is normally used to research sensitive issues among marginalized groups in communities (Serrant-Green, Citation2011). The utilization of the Silence framework in qualitative research helps to define research goals and methodological choices while connecting to the current literature and expose the Silences not normally shared in communities because of the sensitivity of the topic under research (Collins & Stockton, Citation2018).
Research participants
Forty (N = 40) women were recruited from the Copperbelt Province, to take part in the research study. The women were recruited through faith groups and community organizations. In the first instance the researchers wrote to faith groups and community organization managers inviting their members to take part in the research study. Only those members who expressed interest to take part in the research had their names and contacts passed to the researchers to schedule time for interviews. All the women who took part in the study had children and were aged between 18 and 50. The interviews were stopped after reaching a saturation point which refers to a point when no new data was being generated (Hennink et al., Citation2017).
Data collection
One to one semi-structured interviews were used to collect data. The data were collected between March and July 2020. The interview schedule was designed by the researchers and trialed on four women. Minor adjustments were made to the wording of some questions. The questions focused on triggers of mental health distress during COVID-19 Lockdown. All the early interviews were reviewed by a senior researcher to enhance consistency and provide feedback to the other researchers. The interview format was informal, allowing the participants to lead the conversation on issues they considered relevant and important. The interviews were conducted through online platforms which included Microsoft teams, WhatsApp and Zoom, in line with the ethos of social distancing during COVID-19 pandemic. All interviews were audio recorded. The audio files were uploaded to a secure server within two hours and the original recordings deleted. All the recordings were transcribed verbatim and validated for accuracy and consistency. Personal identifying data were removed, and a reflexive journal was maintained instead. Initial and follow‐up memos, documented thoughts and ideas were explored during data analysis. below shows the semi structured interview guide utilized for the study.
Table 1. Semi‐structured interview guide.
Data analysis
NVivo Version 11, QSR International Pty was utilized to organize data for analysis. Content analysis was used to identify, describe, and make inferences about the qualitative data generated. An integrative approach which included both deductive and inductive was utilized for data analysis (Bradley et al., Citation2007). The inductive approach allowed the researchers to immerse themselves in the data to determine the concepts and themes most relevant to the participants (Hsieh & Shannon, Citation2005). Further deductive analysis was performed to evaluate the concepts and themes.
Following each new interview conducted, initial ideas about concepts and themes were documented in memos. The interviews were then reviewed and areas where the interviewer may have influenced the questioning were documented in a reflective journal to inform the next interview and the final output of the study. Findings from new interviews were compared with the old for consensus and disagreement. Categories were then collapsed and analyzed into clusters from which concepts and themes were developed. Analysis continued until concepts and themes were agreed.
Ethical consideration
The University of Northrise Ethics board in Zambia granted the ethical clearance for the study. Participants who had agreed to take part in the study received an information sheet describing the purpose of the study and risks and benefits of taking part. They had the opportunity to ask questions prior to participating. Furthermore, the research participants signed a consent form indicating their willingness to participate in the interview. Transcriptions and analysis notes were stored on a computer with encrypted password. All the data were anonymised to conceal identification of research participants.
Rigor
Processes to consolidate and enhance trustworthiness described by Elo et al. (Citation2014) were utilized during the preparation, organization and reporting stages of this study. These methods presented a clear strategy to gather, quantify and describe the phenomena being studied, thereby enhancing the validity of the results obtained. All the methods were piloted by the researchers prior to use. The findings were discussed and confirmed by the research participants to ensure credibility of the results.
Results
Following data analysis, the research study found out that the triggers for mental health distress among the research participants included Domestic violence, Loss of employment, Stress of managing children indoors, Fear of COVID-19 infection, Loneliness and Poor access to health services.
Domestic violence
The research participants reported an upsurge of domestic violence during COVID-19 due to prolonged lockdown in closed spaces leading to arguments and possibly stress. This was caused by living in an enclosed place with very limited space to walk around and have self-quiet time normally needed by people to relax.
I am experiencing domestic violence nearly every day since we are spending most of the time with my husband I am subjected to ridicule and sometimes beaten for no apparent reason in front of my children. I am really stressed. We need time to go out of the house and relax somewhere away from each other. A 36-year-old woman with 2 children.
I am used to work on my own pace in the kitchen but these days, my husband determines the pace. My husband always complain that I am slow in everything I do. He does not appreciate me. It is so stressful; he forgets that I am not a machine. When I try to explain to him, he threatens me which is not good for our children. I honestly think that the government need to pass strict laws that prevent women from being abused. A 25-year-old woman with 1 child.
Loss of employment
The research participants reported loss of employment leading to cash flow problems and possibly stress. This was exacerbated by
I lost my job, feel useless was used to contribute to the family income. I am now dependent on my husband who is working 2 weeks per month, he is now getting half of his salary. It is difficult for my children and I to have an abrupt adjustment, especially on the issue of meals. I’ve lost my self-esteem can hardly sleep these days. I think the government need to support us with loans or something. A 39-year-old woman with 2 children.
I lost my job was working in the catering industry and our industry was hit harder than others. I am struggling to make ends meet. The little savings I had is now finished. I have been reduced to nothing. Life is not worthy living. I am thinking of selling my car so that I can get money to start buying and selling clothes, I am also worried of where I am going to get the market? I’m in a dilemma, when I start thinking of it, I have sleepless nights. Honestly the government need to support catering industries with money so that we can keep our jobs……We also need support with mental ……. A 51-year-old woman with 4 children
Stress of managing children indoors
The research participants reported stress and anxiety due to difficulties in managing children at home. It became difficult to keep the children engaged while in an enclosed place leading to stressful incidences for the mothers who had to grapple with other issues triggered by the pandemic.
I’m really stressed of managing my children, no longer afford paying the maid, taking care of toddlers is terrible, it needs someone who’s patient, my 3year-old son is just a nuisance can’t do other tasks, he needs my attention all the time. On the other hand, the 3adolescents are giving me a headache, they do not want to stay indoors, want free time to watch TV programs of their choices yet the father is determining their pace. Most of their time is spent on social media, they do not want to assist in household chores. This is too much for me, I feel like blowing out, I’m really burning out. We need green spaces to take our children to play and relax but all this is not available. A 35-year-old woman with 2 children.
I can’t stay with my 18-year-old daughter for a long period. She is stubborn, if I rebuke her from social media, she threatens me with suicide, imagine from morning to sunset, she locks herself in her bedroom and will be on social media, does not study nor assist with household duties. Yesterday I took her phone as a form of punishment and today she is withdrawn, feel I am failing as a mother. This is affecting me and I’m failing to concentrate, don’t have problems with her older siblings’ wish the lockdown comes to an end so that she can return to school. We need to be helped with skills to manage children while out of school because of lockdown. A 29-year-old woman with 1 child.
Fear of COVID 19 infection
The research participants reported fear of COVID-19 infection to themselves and to their children, leading to stress and anxiety. The anxiety was exacerbated by poor knowledge about the virus and its potential impact.
I’m afraid of getting COVID-19 infection, have flu frequently even before corona virus pandemic, especially in winter. I am anxious, do not want to die of corona. When I think of that, cannot sleep. Who will take care of my children? Aaah! This virus, where did it come from? God help us. Honestly we need more information from health professionals about COVID-19. A 49-year-old woman with 3 children.
I’m diabetic and understands that my body defence system is weak. We are hearing that Covid 19 infection attacks old people and those with compromised immunity. I’m worried about my children, the youngest is 2 years old. A 31-year-old woman with 2 children.
Loneliness
The research participants reported loneliness due to family social isolation, leading to boredom, anxiety, and stress. It became impossible for families to visit each other due to the restrictions imposed by the government.
For the past three months we have not met our friends and relatives…….Its only me, my children and my husband stuck in this house…Honestly I can’t stand it we are feeling lonely and isolated. A 42-year-old woman with 2 children.
My children feel lonely and bored, but we cannot take them anywhere to play because of this lockdown… They miss their friends I just wish this lockdown would come to an end and my children can see their friends again. A 52-year-old woman with 4 children
Poor access to health services
The research participants reported poor access to health services due to poor transportation during lockdown, leading to default in medication concordance for chronic conditions like HIV and hypertension.
Lockdown is affecting my health I am HIV positive, my supply was finished last week but I couldn’t manage to go for resupply because of transport challenges. I went to the health facility to collect my monthly supply yesterday, but I had defaulted treatment for a week. This will affect my health to make matters worse, I am not having a balanced diet. They need to give us supplies of medication that can take us a long time. A 29-year-old woman with 2 children
I have hypertension, failed to collect my medications for this month due to transport challenges’ am afraid of stroke if my blood pressure shoots up A 50-year-old woman with 4 children.
Discussion
Domestic violence is one of the problems that has a long-lasting impact on both the abused parent and the children (Lloyd, Citation2018). Domestic violence in some cases can be exacerbated by infringement of spaces and prolonged periods indoors (Bungay & Guta, Citation2018). The research participants reported that they experienced domestic violence from their partners which in turn impacted on their mental health well-being. There is need for social workers and public health promotion practitioners to enlighten communities on the impact of spending long periods indoors and possibly provide information to prevent domestic violence in situations like this. It is important to note that despite the passing of the 2011 Anti-gender based violence Act in Zambia which aimed at protecting victims, of domestic violence, the problem is still prevalent and attitudes toward gender-based violence are pervasive (Njamba, Citation2015). More importantly the central government need to pass further legislation that can deter partners from engaging in domestic violence. Families need to take time out to exercise and give each other space to prevent episodes of space invasion during lockdown leading to potential chances of domestic violence.
Loss of employment is one of the triggers of mental health distress especially when there is no potential chance of getting another job as in the case of the COVID-19 lockdown era. Such a situation can be worse in female-headed single parent families. On many occasions the most vulnerable industries/businesses are those where the majority of women work like food markets and tourism which were directly affected by lockdown (Gulseven et al., Citation2020). The research participants reported losing employment following COVID-19 lockdown leaving them in dire need for money to buy food for the family. There is need for the central government to roll out supporting packages for people whose jobs were affected by COVID-19 lockdown. This is likely to reduce stress associated with uncertainty of how to support families. Furthermore, there is need for the government to recognize the vulnerability of industries like vending markets and tourism where many women work and support them financially to survive the harsh economic conditions caused by COVID-19 lockdown. There is need to establish a crisis mental health team to work with families and prevent affected individuals from prolonged mental distress.
Young children need open spaces to play as they often have a short attention and listening spun (Smith, Citation2018). In situations where children are kept in squeezed spaces like a house for a long time without going out, they become bored and difficult to manage. The research participants reported stress and anxiety due to difficulties in managing children at home. There is need for the central government to consider establishing larger green spaces which can allow parents to take out their children during prolonged lockdown like the one caused by COVID-19 lockdown. Such green spaces do not only serve the children but also parents and can go a long way in alleviating stress and anxiety through physical exercises (Ewert & Chang, Citation2018). More importantly parents need to be equipped with knowledge and skills to provide children with engaging activities in the absence of school-based activities.
The fact that COVID-19 is not treatable and unknown poses alarm to communities (van de Haar et al., Citation2020). Such an alarm is not new in communities, it was also associated with HIV in the early 80 s before the discovery of high Anti-Retroviral-Therapy (Horter et al., Citation2019). The research participants reported fear of COVID-19 infection to themselves, and to their children leading to stress and anxiety. There is need for reassurance to communities in times of pandemics like COVID-19, to curtail fear and possible panic, emanating from lack of knowledge and poor community-based support. More importantly there is need for the central government to roll out robust awareness programmes to educate communities on how best to protect themselves from COVID-19. There is also a need to establish community based mental health services to work with all people affected by the pandemic during prolonged periods of lockdown.
Loneliness and isolation are triggers of mental health distress for people living alone or lacking interaction with others (Kim et al., Citation2009). Secluded families can also experience loneliness if they are not allowed to leave their homes like in the case of COVID-19 lockdown. The research participants reported loneliness due to family social isolation during COVID-19 lockdown leading to boredom, stress, and anxiety. There is need for the central government to provide family-based activities utilizing green spaces. This will also ensure the possible implementation of social distance maintenance, should there be more than one family utilizing the green space. Such an initiative can provide a safe meeting point for families to interact and avoid loneliness with its associated detrimental mental health impact. Use of virtual interaction for families can also be another effective intervention against triggers of mental health distress stemming from loneliness (John et al., Citation2020, p. 67). Virtual interaction involves the use of real-time online platforms to interact with each other (McBrien et al., Citation2009). Such online platforms may include teams, WhatsApp and zoom, among others. Such platforms can also be used by children to play games with friends and reduce boredom as alluded to earlier on in this discussion. Lessons should be learned from the 2014-16 Ebola outbreak in Sierra Leone where quarantines were imposed (Nic Lochlainn et al., Citation2018). Women experienced higher levels of violence whilst unable to access community support while service centers that were open saw “an increase in women and girls accessing their health, counseling and case management services compared to the months before the crisis.” (John et al., Citation2020, p. 66). This underscores the need for immediate support of women during pandemic periods to improve their mental health and well-being.
Poor access to health services during a pandemic period like COVID-19 can have a dire impact on people or individuals accessing medication for chronic conditions like hypertension, cancer, and HIV (Bailey & Moon, 2009). Such a situation can lead to stress and anxiety on the affected individuals possibly triggering mental health distress. The research participants reported poor access to health services due to poor transport network during lockdown, leading to defaulting in medication for chronic conditions like HIV and hypertension. Such a situation as alluded to above triggered stress and anxiety on the affected individuals. There is need for the central government to provide medication pick up points in communities to prevent people from traveling long distances to collect medication or possibly default medication for serious chronic conditions. More importantly the Ministry of Health needs to waive medication dispensing protocols to incorporate dispensing excess medication to cover longer periods and avoid regular visits to health facilities, by people living with chronic conditions during pandemic periods like COVID-19.
Implications for professionals working with women
There is need for professionals working with women to devise mental health crisis management teams to prevent severe impact of mental health among women during pandemic periods like COVID-19 lockdown. Gender sensitive approaches to engage and support women during pandemic periods need to be considered and implemented when engaging women affected by mental health. More importantly professionals need to raise awareness among women to prevent domestic violence through education and community engagement. There is need to establish a multi-disciplinary approach among professionals when working with women to prevent mental health problems. Such initiative can bring together professionals like social workers, public health professionals, doctors and nurses when attending to mental health distress affecting women during a COVID-19 lockdown.
Limitations
This research study was only conducted in the Copperbelt province, a research encompassing all the provinces in the future, can enable comparisons of the findings. Furthermore, the study only employed a qualitative approach, a study utilizing mixed methods in future can enhance the capturing of both qualitative and quantitative aspects of the topic and enhance generalizability of the findings.
Concluding comments
There is need to consider radical gender sensitive approaches in preventing triggers of mental health problems among women. In doing so there is need to consider robust initiatives to support women during pandemic periods like COVID-19 lockdown where their health and well-being can be compromised or affected by a myriad of mental health triggers. More importantly there is need to pass tough laws against domestic violence as a way to deter violence against women.
Acknowledgment
Our sincere thanks go to all women in the Copperbelt Province, who took part in this study.
Disclosure statement
No potential conflict of interest was reported by the author(s).
References
- Abi Doumit, C., Haddad, C., Sacre, H., Salameh, P., Akel, M., Obeid, S., Akiki, M., Mattar, E., Hilal, N., Hallit, S., & Soufia, M. (2019). Knowledge, attitude and behaviors towards patients with mental illness: Results from a national Lebanese study. PloS One, 14(9), e0222172. https://doi.org/https://doi.org/10.1371/journal.pone.0222172
- Bailey, Z. D., & Moon, J. R. (2020). Racism and the political economy of COVID-19: Will we continue to resurrect the past. Journal of Health Politics, Policy and Law, 45(6), 937–950. https://doi.org/https://doi.org/10.1215/03616878-8641481
- Bradbury‐Jones, C., & Isham, L. (2020). The pandemic paradox: The consequences of COVID-19 on domestic violence. Journal of Clinical Nursing, 29(13–14), 2047–2049. https://doi.org/https://doi.org/10.1111/jocn.15296
- Bradley, E. H., Curry, L. A., & Devers, K. J. (2007). Qualitative data analysis for health services research: Developing taxonomy, themes, and theory. Health Services Research, 42(4), 1758–1772.
- Bungay, V., & Guta, A. (2018). Strategies and challenges in preventing violence against Canadian indoor sex workers. American Journal of Public Health, 108(3), 393–398. https://doi.org/https://doi.org/10.2105/AJPH.2017.304241
- Collins, C. S., & Stockton, C. M. (2018). The central role of theory in qualitative research. International Journal of Qualitative Methods, 17(1), 160940691879747. 1609406918797475. https://doi.org/https://doi.org/10.1177/1609406918797475
- Elo, S., Kääriäinen, M., Kanste, O., Pölkki, T., Utriainen, K., & Kyngäs, H. (2014). Qualitative content analysis: A focus on trustworthiness. SAGE Open, 4(1), 215824401452263. https://doi.org/https://doi.org/10.1177/2158244014522633
- Essien, B., & Asamoah, M. K. (2020). Reviewing the common barriers to the mental healthcare delivery in Africa. Journal of Religion and Health, 59(5), 2531–2555.
- Ewert, A., & Chang, Y. (2018). Levels of nature and stress response. Behavioral Sciences, 8(5), 49. https://doi.org/https://doi.org/10.3390/bs8050049
- Finchilescu, G., & Dugard, J. (2021). Experiences of gender-based violence at a South African university: Prevalence and effect on rape myth acceptance. Journal of Interpersonal Violence, 36(5–6), NP2749–NP2772. https://doi.org/https://doi.org/10.1177/0886260518769352
- Gulseven, O., Al Harmoodi, F., Al Falasi, M., & ALshomali, I. (2020). How the COVID-19 pandemic will affect the UN sustainable development goals? Available at SSRN 3592933.
- Hennink, M. M., Kaiser, B. N., & Marconi, V. C. (2017). Code saturation versus meaning saturation: How many interviews are enough? Qualitative Health Research, 27(4), 591–608.
- Horter, S., Bernays, S., Thabede, Z., Dlamini, V., Kerschberger, B., Pasipamire, M., Rusch, B., & Wringe, A. (2019). “I don’t want them to know”: How stigma creates dilemmas for engagement with Treat-all HIV care for people living with HIV in Eswatini. African Journal of AIDS Research: AJAR, 18(1), 27–37.
- Hsieh, H. F., & Shannon, S. E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15(9), 1277–1288. https://doi.org/https://doi.org/10.1177/1049732305276687
- John, N., Casey, S. E., Carino, G., & McGovern, T. (2020). Lessons never learned: Crisis and gender-based violence. Developing World Bioethics, 20(2), 65–68. https://doi.org/https://doi.org/10.1111/dewb.12261
- Josefsson, K. A., & Gard, G. (2010). Women’s experiences of sexual health when living with Rheumatoid Arthritis-an explorative qualitative study. BMC Musculoskeletal Disorders, 11(1), 240–248.
- Kim, J., LaRose, R., & Peng, W. (2009). Loneliness as the cause and the effect of problematic Internet use: The relationship between Internet use and psychological well-being. Cyberpsychology & Behavior: The Impact of the Internet, Multimedia and Virtual Reality on Behavior and Society, 12(4), 451–455. https://doi.org/https://doi.org/10.1089/cpb.2008.0327
- Leech, N. L., & Onwuegbuzie, A. J. (2007). An array of qualitative data analysis tools: A call for data analysis triangulation. School Psychology Quarterly, 22(4), 557–584. https://doi.org/https://doi.org/10.1037/1045-3830.22.4.557
- Lippi, G., Henry, B. M., Bovo, C., & Sanchis-Gomar, F. (2020). Health risks and potential remedies during prolonged lockdowns for coronavirus disease 2019 (COVID-19). Diagnosis (Berlin, Germany), 7(2), 85–90. https://doi.org/https://doi.org/10.1515/dx-2020-0041
- Lloyd, M. (2018). Domestic violence and education: examining the impact of domestic violence on young children, children, and young people and the potential role of schools. Frontiers in Psychology, 9, 2094. https://doi.org/https://doi.org/10.3389/fpsyg.2018.02094
- Mathur, S., Okal, J., Musheke, M., Pilgrim, N., Kishor Patel, S., Bhattacharya, R., Jani, N., Matheka, J., Banda, L., Mulenga, D., & Pulerwitz, J. (2018). High rates of sexual violence by both intimate and non-intimate partners experienced by adolescent girls and young women in Kenya and Zambia: Findings around violence and other negative health outcomes. PLoS One, 13(9), e0203929. https://doi.org/https://doi.org/10.1371/journal.pone.0203929
- Matlin, S. A., Depoux, A., Schütte, S., Flahault, A., & Saso, L. (2018). Migrants’ and refugees’ health: Towards an agenda of solutions. Public Health Reviews, 39(1), 1–55. https://doi.org/https://doi.org/10.1186/s40985-018-0104-9
- McBrien, J. L., Cheng, R., & Jones, P. (2009). Virtual spaces: Employing a synchronous online classroom to facilitate student engagement in online learning. International Review of Research in Open and Distributed Learning, 10(3), 1–15.
- Nic Lochlainn, L. M., Gayton, I., Theocharopoulos, G., Edwards, R., Danis, K., Kremer, R., Kleijer, K., Tejan, S. M., Sankoh, M., Jimissa, A., Greig, J., & Caleo, G. (2018). Improving mapping for Ebola response through mobilising a local community with self-owned smartphones: Tonkolili District, Sierra Leone, January 2015. PloS One, 13(1), e0189959. https://doi.org/https://doi.org/10.1371/journal.pone.0189959
- Njamba, P. (2015). An evaluation of the communication strategies used in anti-gender-based violence campaigns: A case of the young Women’s Christian Association in Linda Township of Lusaka.
- Nsakanya, H., & Judith, N. (2017). Determining the causes and impacts of gender-based violence in Kalulushi Ward of Copperbelt Province of Zambia.4(6), 388–395.
- Nyangweso, M., & Olupona, J. K. (Eds.). (2019). Religion in gender-based violence, immigration, and human rights. Routledge.
- Roesch, E., Amin, A., Gupta, J., & García-Moreno, C. (2020). Violence against women during COVID-19 pandemic restrictions. BMJ (Clinical Research ed.), 369(May), m1712–3. https://doi.org/https://doi.org/10.1136/bmj.m1712
- Serrant-Green, L. (2011). The sound of ‘silence’: A framework for researching sensitive issues or marginalised perspectives in health. Journal of Research in Nursing, 16(4), 347–360. https://doi.org/https://doi.org/10.1177/1744987110387741
- Smith, H. V. (2018). Cooking the books: What counts as literacy for young children in a public library? Literacy, 52(1), 31–38. https://doi.org/https://doi.org/10.1111/lit.12121
- van de Haar, J., Hoes, L. R., Coles, C. E., Seamon, K., Fröhling, S., Jäger, D., Valenza, F., de Braud, F., De Petris, L., Bergh, J., Ernberg, I., Besse, B., Barlesi, F., Garralda, E., Piris-Giménez, A., Baumann, M., Apolone, G., Soria, J. C., Tabernero, J., Caldas, C., & Voest, E. E. (2020). Caring for patients with cancer in the COVID-19 era. Nature Medicine, 26(5), 665–671. https://doi.org/https://doi.org/10.1038/s41591-020-0874-8
- World Health Organisation (2020). Coronovirus timeline. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/interactive-timeline/