UNIPH Quarterly Epidemiological Bulletin January-March 2021 volume 6 Issue 1

EDITORIAL TEAM

Dr. Alex Riolexus Ario |
Director, Uganda National Institute 
of Public Health, MoH

Dr. Allan Niyonzima Muruta|
Commissioner, Integrated Epidemiology, 
Surveillance and Public Health 
Emergencies, MoH

Paul Mbaka|
Asst. Commissioner Health Services, 
Division of Health Information, MoH

Lilian Bulage |
Scientific Writer, Uganda Public 
Health Fellowship Program, MoH

Dr. Benon Kwesiga |
Field Supervisor, Uganda Public 
Health Fellowship Program, MoH

Daniel Kadobera |
Field Supervisor, Uganda Public Health 
Fellowship Program, MoH

Dr. Josephine Namayanja |
PHFP Fellow, National Animal Disease 
Diagnostics and Epidemiology Centre 
(NADDEC), MAAIF

Peter Omms Oumo |
PHFP Fellow, National Malaria Control 
Division, MoH 

Dr. Richard Migisha |
PHFP Fellow, Neglected Tropical 
Diseases, MoH

Inside this Issue;

Upcoming Health Events and News
_______________________________________________________________________________________________________

1. World Immunization Week 2021,
last week of April (Vaccines have brought us closer, and will bring us closer again) While the world focuses on critically important new vaccines to protect against COVID-19, there remains a need to ensure routine vaccinations are not missed.

Many children have not been vaccinated during the global pandemic, leaving them at risk of serious diseases like measles and polio. Rapidly circulating misinformation around the topic of vaccination adds to this threat.

In this context, this year’s campaign will aim to build solidarity and trust in vaccination as a public good that saves lives and protects health.

2. World Malaria Day, April 25
On 21 April, WHO will publish a new report highlighting successes and lessons learned among the “E-2020” group of malaria-eliminating countries.

Despite the challenges posed by the COVID-19 pandemic, a number of these countries reported zero indigenous malaria cases in 2020, while others made impressive progress in their journey to becoming malaria-free.

Ahead of World Malaria Day slated for 25 April, country leaders, frontline health workers and global partners will come together in a virtual forum to share experiences and reflections on efforts to reach the target of zero malaria.

The event will be co-hosted by WHO and the RBM Partnership to End Malaria on 21 April.

3. World No-Tobacco Day, May 31 (Commit to quit)
The Member States of the World Health Organization created World No Tobacco Day in 1987 to draw global attention to the tobacco epidemic and the preventable death and disease it causes.

This yearly celebration informs the public on the dangers of using tobacco, the business practices of tobacco companies, what WHO is doing to fight the tobacco epidemic, and what people around the world can do to claim their right to health and healthy living and to protect future generations.

The COVID-19 pandemic has led to millions of tobacco users saying they want to quit!

Psychological Impact of COVID-19 on Healthcare Workers during the Early Phase of the Epidemic in Uganda, April-May 2020

Richard Migisha1*, Benon Kwesiga1, Lilian Bulage1, Daniel Kadobera1, Steven N. Kabwama1, Elizabeth Katana1, Alex Ndybakyira1, Ignatius Wadunde1, Aggrey Byaruhanga1, Geofrey Amanya1, Alex Riolexus Ario1,4, 1 Uganda Public Health Fellowship Program Kampala, Uganda 4 Ministry of Health, Kampala, Uganda

Background
After confirming the first COVID-19 case in Uganda on March 21, 2020 [1], the number of confirmed COVID-19 cases increased to 212 with no deaths as of May 24, 2020. Although no health care workers (HCW) in Uganda had been diagnosed with the disease at that time, there were widespread reports globally about HCWs who had contracted the disease and died [2, 3], and heightened tension and fear were anticipated among HCWs in Uganda. To understand more about potential psycho- logical distress among HCWs in Uganda and design appropriate interventions, we assessed risk perception and immediate psychological state among HCWs with regard to the COVID-19 outbreak.

Results
Socio-demographic characteristics of study participants in tertiary referral hospitals during the early phase of COVID-19 epidemic in Uganda, April-May 2020.

Among 335 HCWs who received questionnaires, 328 (98%) completed and returned them. Respondents’ mean age was 36 (SD±9.9) years and ranged from 18-59 years; 172 (52%) were male and 242 (74%) were in the direct contact group. Approximately one-third (35%) were nurses, one quarter (26%) were support staff, 14% were doctors, and 9% were clinical officers (Table 1). Approximately half reported ever providing direct care to suspected (57%) or confirmed (46%) COVID-19 cases (Table 1).

Table 1: Socio-demographic characteristics of respondents during a study to assess psychological impact of COVID-19 on hospital-based healthcare workers in the early phase of COVID-19 epidemic, Uganda

Level of perceived risk towards COVID-19 among healthcare workers in tertiary referral hospitals during the early phase of COVID-19 epidemic in Uganda, April- May 2020
The mean risk perception score derived from the concern statements was 42 (SD±12) and ranged from 479 points (Figure 1). For the direct contact group (n=242), the mean score was 42 (SD±12) while for the indirect contact group the mean score was 43 (SD±11).

Of the 328 respondents, 293 (89%) said they would feel endangered if a colleague contracted COVID-19, 265 (81%) felt they were at risk of contracting COVID-19 at the workplace, 233 (71%) felt anxious at workplace, and 194 (59%) felt the outbreak had increased their workload (Table 2). With regard to training and PPE, 139 (42%) reported not receiving adequate training on infection prevention and control (IPC) at their workplace, while 185 (56%) felt there was not enough PPE available at the workplace. Thirty-nine percent felt being absent from the workplace would reduce their risk of contracting COVID-19, while 23% contemplated changing their jobs due to COVID-19 risk. With regard to social aspects of COVID-19 and healthcare work, 196 (60%) were worried about transmitting the infection to their family members; 175 (53%) felt family members would not look after them if they contracted the infection; and 147 (48%) felt family members were avoiding them because they were HCWs. Of note, three-quarters (76%) felt they could easily disclose to family members if they contracted COVID-19, compared with only 21% who were comfortable disclosing to colleagues at work (Table 2)

Table 2: Concerns of healthcare workers (HCWs) with regard to COVID-19 outbreak during the early phase of the epidemic, Uganda, April-May 2020

Psychological distress assessment among healthcare workers in tertiary referral hospitals during the early phase of COVID-19 epidemic in Uganda, April-May 2020
The mean GHQ-12 distress score of the HCWs was 12 (±7.2); 144 had a GHQ-12 score >12, for a prevalence of psychological distress of 44% (95%CI: 38-49%). The most commonly-reported indicators from the GHQ-12 questionnaire with score >1 were not enjoying day-to-day activities (54%), being under stress (50%), not feeling reasonably happy (43%), and feeling unhappy and depressed (40%) (Table 3).

Table 3:  Descriptive statistics for GHQ-12 items among healthcare workers in tertiary referral hospitals during the early phase of the epidemic, Uganda, April-May 2020 (N=328)

Factors associated with psychological distress among healthcare workers in tertiary referral hospitals during the early phase of COVID-19 epidemic in Uganda, April-May 2020

In bivariate analysis, compared to respondents with low risk perception, the prevalence of psychological distress was 2.3 (95%CI: 1.3-4.1) and 4.0 (95%CI: 2.2-7.4) times higher among those with moderate and high risk perception, respectively. None of the demographic factors including age, sex, duration in service, HCW category by patient contact (direct vs indirect contact), or working hours were significantly associated with psychological distress. In the multivariate model, compared to HCWs with low risk perception, the prevalence of psychological distress was significantly higher among those with moderate (aPR=2.2, 95% CI: 1.2 – 4.0) and high (aPR=3.8, 95% CI: 2.0 – 7.0) risk perception towards COVID-19

Conclusion

Nearly half of HCWs surveyed in the early phase of the COVID-19 epidemic in Uganda reported psychological distress. Attention needs to be given to the psychological health of HCWs and follow-up studies in different phases during and after the COVID-19 pandemic. Perceived personal risk of COVID-19 was associated with psychological distress; reducing risks might enhance HCWs’ physical and psychological well-being. This might be accomplished by ensuring sufficient PPE and access to training on infection prevention and control, improving morale, addressing stigma in the workplace and in the community, and rendering more psychosocial support by employers and supervisors. Follow-up qualitative interviews might help further elucidate the nature and extent of the psychological impact of COVID-19 on HCWs.

References
1. Migisha, R., et al., Early cases of SARS-CoV-2 infection in Uganda: epidemiology and lessons 
learned from risk-based testing approaches–March-April 2020. Globalization and Health, 2020. 
16(1): p. 1-9.

2. Bandyopadhyay, S., et al., Infection and mortality of healthcare workers worldwide from 
COVID-19: a scoping review. medRxiv, 2020.

3. Moorthy, A. and T.K. Sankar, Emerging public health challenge in UK: perception and belief on 
increased COVID19 death among BAME healthcare workers. Journal of Public Health, 2020. 42(3): 
p. 486-492.

4. Health, M.o. UPDATE ON THE COVID-19 OUTBREAK IN UGANDA. 2020 [cited 2020 May 25, 2020]; 
Available from: 
https:// www.health.go.ug/covid/document/update-on-the-covid-19-outbreak-in-uganda-12/.
5. Dai, Y., et al., Psychological impact of the coronavirus disease 2019 (COVID-19) outbreak 
on healthcare workers in China. medRxiv, 2020.

6. Goldberg, D.P., The detection of psychiatric illness by questionnaire. Maudsley monograph, 
1972. 21.

7. Lai, J., et al., Factors associated with mental health outcomes among health care workers 
exposed to coronavirus disease 2019. JAMA network open, 2020. 3(3): p. e203976-e203976.

8. Wong, T.W., et al., The psychological impact of severe acute respiratory syndrome outbreak on 
healthcare workers in emergen- cy departments and how they cope. European Journal of Emergency 
Medicine, 2005. 12(1): p. 13-18.

9. Nickell, L.A., et al., Psychosocial effects of SARS on hospital staff: survey of a large 
tertiary care institution. Cmaj, 2004. 170(5): p. 793-798.

10. Ho, C.S., C.Y. Chee, and R.C. Ho, Mental health strategies to combat the psychological 
impact of COVID-19 beyond paranoia and panic. Ann Acad Med Singapore, 2020. 49(1): p. 1-3

A cluster of COVID–19 at a secondary hospital, Kampala, Uganda, during phase four of the epidemic

Elizabeth Katana1, 2, Alex Ndyabakira1, 2, Aggrey Byaruhanga1, Daniel A. Okello2, Ivan Kimuli4, Maureen Kesande3, Daniel Kadobera11Uganda Public Health Fellowship Programme, Kampala, Uganda2Directorate of Public Health and Environment, Kampala Capital City Authority (KCCA), Kampala, Uganda3Infectious Diseases Institute, Kampala, Uganda4Makerere University Lung Institute, Kampala, Uganda

Summary

As of August 03, 2020, Uganda had confirmed 1,203 cases with 5 deaths and several health workers had been confirmed with a cumulative total of 250.Following the reports of several clusters of cases at hospitals in Kampala, we described the cases of COVID–19 identified at a secondary hospital in Kampala during phase 4 of the epidemic. We conducted a descriptive study of cases that had a con-firmed PCR positive test for COVID–19 at a secondary hospital in Kampala, August 19, to September 15, 2020. We de-scribed cases by demographic characteristics, symptoms, mortality, and distribution of overtime. Of the 32 confirmed cases, whose mean age was 39.1, ranging from 20 to 72 years, majority 21 (66%) were males, 25 (78%) were asymptomatic, 16 (50%) health workers, 17 (53%) were either health workers rotating in the ICU or patients admitted in the ICU at the time of sample collection, and mortality was 6%, occurring in the ICU. An equal proportion of health workers and patients were confirmed positive for COVID–19 at the hospital in the one–month period. Most cases were asymptomatic and either health workers rotating in the Intensive Care Unit (ICU) or patients admitted in the ICU at the time of sample collection. We recommended enforcement of Standard Operating Procedures, continued surveillance and vigilance in the most at–risk hospital departments including the ICU.

Results

Descriptive characteristics of confirmed COVID–19 cases at a secondary hospital in Kampala, August –September 2020We identified 32 confirmed cases at the secondary hospital from August 19, to September 15, 2020. Of the 32 confirmed cases, whose mean age of was 39.1, ranging from 20 to 72 years, majority 21 (66%) were males, 25 (78%) were asymptomatic, 16 (50%) health workers, 17 (53%) were either health workers rotating in the Intensive Care Unit (ICU) or patients admitted in the ICU at the time of sample collection, and 2 (6%) were de-ceased, with the death occurring in the ICU. The outbreak started on August 20, 2020, almost three months after the first health worker in Uganda had been confirmed positive at Lira hospital in May 2020. The index case was a symptomatic patient who was seen and tested from the emergency room of the secondary hospital on August 19, 2020. COVID–19 was suspected in the emergency room and the sample was collected immediately. The index case was isolated at the secondary hospital before being referred to a tertiary facility after COVID–19 confirmation. None of the 31 cases was a con-tact to the index case. Almost two weeks later, on August 31, the first health worker was tested and confirmed positive from the wards of the secondary hospital. More health workers tested positive in the subsequent days with cases peaking between September 8thand 14thand predominantly from the ICU, though none of them was a contact to the first confirmed health worker (Figure 1).

Through interviews and observations, we documented the following strategies implemented by the hospital in response to the COVID–19 Outbreak

Establishment of a COVID–19 task force: This was set up at the hospital to oversee COVID–19 related functions including Personal Protective Equipment (PPE) usage and stocks, facility–based contact tracing, maintaining the surveillance system including temperature checks and symptom monitoring, trainings for health workers, mandatory testing, and adherence to the Standard Operating Procedures (SOPs).

Minimizing of staff rotation between hospital departments: The same group of health workers routinely rotated be-tween the hospital departments. Predominantly, one group rotated between the ICU, and theatres while another be-tween the out and inpatient departments. The hospital to review the rotation strategy in a way that reduced rotation of health workers between departments for at least a period of 3 weeks and enforce testing before rotations to other departments. Of note, some of the health workers took shifts in other city hospitals which made these efforts difficult.

Enforcement of mask use and physical distancing procedures at the hospital: Through observation, physical distancing was a challenge at the facility due to very limited waiting space at the OPD, nevertheless physical markings were put on seats to minimize crowding. Some health workers and patients were observed wearing masks incorrectly, a team of health workers on the hospital COVID-19 task force was assigned with ensuring compliance to mask use by both health workers and patients. The cafeteria being small, the health workers were encouraged to take their meals in shifts that could allow fewer people into the cafeteria at every hour.

Closure of the ICU: The ICU was deep cleaned, fumigated, and closed for two weeks, patients requiring intensive care were referred to Mulago National Specialized Hospital. Enforcement of adherence to SOPs in other departments including the theatre was ensured.

Infection Prevention and Control (IPC) trainings: A dedicated IPC committee with representatives from all the hospital departments was formulated and weekly IPC trainings for all the health workers were initiated. The trainings focused on ensuring that the health workers were routinely equipped with knowledge on the standard and required practices with regards to the COVID-19 preventive measures including hand washing, physical distancing, and mask use. The trainings also covered general IPC practices that should be observed in specific departments including the ICU, theatre, and wards. They also covered other general hospital IPC practices including waste management and disposal, quality control, scrubbing and draping, among others.

Mandatory COVID–19 testing: A test and treat policy was initiated for all the patients requiring an admission regard-less of symptom status with the sample collection done by the hospital and the testing costs met by the patients while all health workers were required to test bi weekly with the costs met by the hospital management. The hospital developed a partnership with a COVID–19 testing laboratory to offer testing at a subsidised fee.

Immediate referral of confirmed COVID–19 cases: Upon confirmation of a positive PCR test for COVID–19 infection, cases including health workers were referred to a tertiary hospital for COVID–19 management.

Contact tracing and listing: a team on the hospital COVID–19 task force was entrusted with ensuring contacts were listed and traced with assistance from the surveillance teams from KCCA and MOH. However, it was noted that, given the high volume of patients seen at the hospital as well as movement and rotation of patients and staff between departments, and immediate referral of confirmed cases to tertiary hospital, it was difficult to list and test all the possible contacts of a confirmed case.

Limitations

Given the nature of the study design (a descriptive study), without analytical approaches, we were not able to establish why the outbreak occurred or how it came to be. However, this study casts light on the problems that can be faced by secondary hospitals in future similar out-breaks.

Conclusion

An equal proportion of health workers and patients were confirmed positive for COVID–19 at the hospital in the one–month period. Most cases were asymptomatic and either health workers rotating in the Intensive Care Unit (ICU) or patients admitted in the ICU at the time of sample collection.

Recommendation

We recommended enforcement of Standard Operating Procedures (SOPs), continued surveillance and vigilance in the most at risk hospital departments including the ICU.

References.

1. MOH, Uganda. Press Release Archives [Internet]. COVID–19 | Ministry of Health. [cited 2021 Apr 5]. Available from: https://www.health.go.ug/covid/category/press–release/
2.  Abbas M, Robalo Nunes T, Martischang R, Zingg W, Iten A, Pittet D, et al. Nosocomial transmission and outbreaks of coronavirus disease 2019: the need to protect both patients and healthcare workers. Antimicrob Resist Infect Control. 2021 Jan 6;10(1):7.
3. Hospital outbreak of COVID–19 in South Africa [Internet]. The Centre for Evidence–Based Medicine. [cited 2021 Mar 28]. Available from: https://www.cebm.net/study/covid–19–hospital–outbreak–of–covid–in–south–africa/
4.  Maki DG, Crnich CJ, Safdar N. Nosocomial Infection in the Intensive Care Unit. Crit Care Med. 2008;1003–69.
5. Infection Control in the ICU [Internet]. Infection Control Today. [cited 2021 Mar 28]. Available from: https://www.infectioncontroltoday.com/view/infection–control–icu

Hale M, Dayot A. Outbreak investigation of COVID–19 in hospital food service workers. Am J Infect Control. 2021 Mar;49(3):396–7.

Incidence of preterm births admissions on the rise in Uganda: Implications for the health care system

Authors: Job Morukileng1, Wilberforce Mugwanya2, Robert Mutumba2, and Maureen Katusiime11Uganda Public Health Fellowship Program, Kampala, Uganda.2Ministry of Health Uganda, Reproductive Health Department, Kampala, Uganda

Summary

Premature birth is a growing concern globally. Complications of preterm births are the single largest cause of neonatal deaths and the second leading cause of deaths among children aged <5 years globally. There is paucity of literature on the current trend of preterm births in Uganda. In this study, we described the trends and distribution of preterm births in Uganda between 2015-2019 for advocacy and targeting of interventions.

We conducted a countrywide descriptive analysis of preterm birth admissions data,2015–2019 period Uganda. Preterm birth is defined as birth that occurs before 37 weeks of gestation. We abstracted data from the District Health Information System(DHIS2), disaggregated into national, regional, and district levels. We calculated the annual incidence rates by dividing the number of preterm births admissions by the total live birth (LB). We obtained the mean annual incidence rates by adding yearly incidence rates for the five years of study and dividing by five. We used line graphs to demonstrate the trend of incidence at nation-al and regional levels and used choropleth maps to show district level distribution of incidence. We tested significance of the observed trends using logistic regression.

Nationally, the incidence rate of preterm births admissions/1,000 LB has significantly been increasing (OR=1.3, CI=1.32–1.33) by an annual average of 45.6%. Consistent with the national trend, the incidence rate significantly increased in all the four regions of Uganda. However, the central had the highest mean annual incidence of 12/1000 livebirths while the north and east had the lowest mean annual incidence rate of 7/1000 livebirths. We also ob-served minimal regional clustering in the distribution of incidence in Uganda.

The incidence of preterm births admissions is on the rise and is distributed across the country. As incidence rises, the Ministry of Health needs to understand the level of readiness of the health facilities to manage preterm births and plan accordingly as well as conduct further studies to understand contributors to the in-creasing trend for focused interventions.

Background

Premature birth is a growing concern globally[1]; with many countries reporting increasing trend [2]. Preterm Birth is birth that occurs before 37 weeks of pregnancy, sub–categorized as extremely preterm (<28 weeks), Very preterm (28 to <32 weeks)and moderate to late preterm (32 to <37 weeks)[3]. Every year, an estimated 15 million babies are born too early and approximately 1 million children die each year due to complications of preterm birth globally[4]. 

Whereas60–85%of preterm births occur in Africa and South Asia[3, 5], preterm birth is a global problem. In lower income countries(LICs), 12% of babies are born too early compared with 9% in higher–income countries(HICs). Within countries, poorer families are at higher risk of pre-term birth. Disparities exist in survival rates of preterm babies around the world[3]. In LICs, half of the babies born at or below 32 weeks die due to failure to provide feasible, cost–effective care, such as warmth, breastfeeding support, and basic management of infections and breathing difficulties while in HICs, almost all these babies survive[6]. 

Although the causes of preterm birth are unknown in about 50% of the cases, preterm birth can be caused by problems with the fetus, the mother, or both. Among the causes are the placental abruption, incompetent cervix, hormonal imbalances and infections. Untreated urinary infections and bacterial vaginosis are said to double the risk of premature birth. Other risk factors for premature birth are anemia, slow maternal weight gain, too soon or too late pregnancy, stressful work habits, smoking, drinking alcohol, and using drugs like cocaine [7].

Maternal risk factors for pretermbirth include having a previous premature birth, being pregnant with twins or multiples babies and chronic conditions such as diabetes and high blood pressure[3]. Many mothers of twins and multiple babies go into premature labour spontaneously; about half of all twin pregnancies deliver at 36 weeks or less and a half of triplets deliver before 32 weeks of pregnancy[7]. Others may need to have premature labour induced because of complications during pregnancy or caesarean birth, whether for medical or non–medical reasons[3].

Uganda has a high preterm births rate of 14per 1000 live births[4]. These preterm births are directly responsible for8/27 neonatal deaths per 1,000 live births in Uganda[8] and remains among the top three causes of death during the neonatal period in Uganda[9]. Preterm birth underlies neonatal complications such as immature lungs, difficulty regulating body temperature, infections, poor feeding and slow weight gain. These complications lead to death or longer, more more intense nursery care and some times surgery[10], implying that these babies need to be delivered under the care of a skilled health care provider to increase their chances of survival. However, in Uganda, 1 in 4 deliveries do not occur in a health care setting or under skilled health care personnel. Nevertheless, among babies delivered by skilled health care personnel, only 1 in 2 receive postnatal check–up within two days of delivery[11]. Survival rates for preterm babies are critically reduced if delivery occurs out-side the health care facility. Current, local data are crucial to inform priorities and drive scale–up up of effective interventions for preterm birth. However, there is paucity of literature about the current trends of premature births and its distribution in Uganda. We described the trends and distribution of preterm births in Uganda between 2015–2019 for advocacy and targeting of interventions.

Temporal trends of incidence rate of preterm births admissions, Uganda, 2015–2019

At the national level, there were a total of 2,678 preterm Birth admissions and 914,387 LBs in 2015; 7,508 preterm birth admissions and 959,078 LBs in 2016; 10,561 preterm birth admissions and 1,040,265 LBs in 2017; 13,662 preterm birth admissions and 1,123,279 LB in 2018 and 15,391 preterm birth admissions and 1,176,931 LBs in 2019. The mean nation-al incidence of preterm birth admissions in Uganda was 9.4/1,000 livebirth. The incidence has steadily been increasing by an average of 45.6% annually from 2015 to 2019 (OR=1.3, CI=1.32–1.33) (Figure 1).

Figure 1: Trend of preterm births admissions/1,000 Live Births, Uganda, 2015-2019

Temporal trend of incidence rate of preterm birth ad-missions at regional level, Uganda, 2015–2019

Consistent with the national trend, we observed a statistical-ly significant (Table 1) increase in the incidence rates of preterm birth admissions/1,000 LB/year in all the four regions of Uganda, with eastern region being the only region to register a declining incidence between 2018 and 2019.

Central region registered the highest mean annual incidence rate of 12 preterm birth admissions/1,000 LB over the 5years, while eastern and northern regions registered the lowest mean incidence rate of 7 preterm birth admissions/1,000 LB in the five years (Figure 2).

Spatial distribution of preterm births admission inci-dence rates at the district level, Uganda, 2015–2019

The geographic distribution of preterm birth admis-sions/1,000 LB in Uganda indicates minimal clustering of high burdened districts in particular regions. Nevertheless, we observe more of the districts with >30 preterm birth admissions/1,000 LB/year in the western and central regions. The years with the highest burden were 2017, 2018, and 2019 (Figure 3).

References

1. World Health Organization, Born too soon: the global action report on preterm birth. 2012.
2. Martin, J.A., et al., Births: final data for 2005. National vital statistics reports, 2007. 56(6): p. 1–103.
3. Soon, B.T., The global action report on preterm birth. Geneva: World Health Organization, 2012.
4. Blencowe, H., et al., National, regional, and world-wide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications. The lancet, 2012. 379(9832): p. 2162–2172.
5. Beck, S., et al., The worldwide incidence of preterm birth: a systematic review of maternal mortality and morbidity. Bulletin of the World Health Organization, 2010. 88: p. 31–38.
6. WHO. Preterm birth factsheet, accessed 30/09/2020, available at https://www.who.int/news–room/fact–sheets/detail/preterm–birth. 19 February 2018.
7. About kids Health. Preterm Babies, accessed on 30/09/2020, available at https://www.aboutkidshealth.ca/Article?contentid=1758&language=English. ND.
8. Ministry of Health, Situation analysis of newborn health in Uganda: current status and opportunities to improve care and survival. Kampala: Government of Uganda. Save the Children, UNICEF, WHO; 2008. Accesed on 1/10/2020, available at https://www.healthynewbornnetwork.org/hnn–content/uploads/Situation–Analysis–of–Newborn–health–in–Uganda.pdf
9.  Kananura, R.M., et al., The neonatal mortality and its determinants in rural communities of Eastern Uganda. Reproductive health, 2016. 13(1): p. 13.
10. Ministry of Health, Reproductive Maternal, New-born and Child Health Sharpened Plan for Uganda, accessed on 30/09/2020, available at http://speed.musph.ac.ug/wp–content/uploads/2015/05/Committing–to–Maternal–and–Child–Survival_A–Promise–Renewed.pdf November 2013.
11. Uganda Bureau of Statistics (UBOS) and ICF, Uganda Demographic and Health Survey 2016. Kampala, Uganda and Rockville, Maryland, USA: UBOS and ICF. 2018.

.Wagura, P., et al., Prevalence and factors associated with preterm birth at kenyatta national hospital. BMC Pregnancy and Childbirth, 2018. 18(1): p. 107

Level and determinants of adherence to and satisfaction with use of face masks as one of the COVID-19 preventive measures in the first stage of the outbreak, Uganda.

Authors: aBob O. Amodan1, Lilian Bulage1, Elizabeth Katana1, Alex Riolexus Ario1,21Uganda Public Health Fellowship Program, Kampala, Uganda2Uganda National Institute of Public Health, Kampala, Uganda

Summary

Before confirmation of the first case of COVID–19 in Uganda, the President banned all public gatherings, and encouraged the public to use masks, observe physical distancing, and strict hygienic rules. We assessed the level of adherence and determinants of adherence to and satisfaction with masks use. We abstracted data from the International Citizen Project (ICP) survey that assessed adherence to preventive measures and their impact on the COVID–19 outbreak conducted between 16thand 30thApril 2020.

Of the 1,726 respondents (mean age: 36 years) 59% were males. Only 566/1,726 (33%) adhered to face masks use. Determinants of adherence to face masks use included: Worrying about own health (Adj.PR: 1.1, 95%CI: 1.02–1.1) and being satisfied with face masks use as an appropriate COVID–19 preventive measure (Adj.PR: 1.4, 95%CI: 1.3–1.5). Staying with siblings (Adj.PR: 0.94, 95%CI: 0.91–0.97), and Living in cities/towns other than Kampala (Adj.PR: 0.94, 95%CI: 0.91–0.97) reduced the likelihood of adherence to mask use (AOR: 0.75, 95%CI: 0.61–0.93). Only 520/1,726 (30%) were very satisfied with masks use. Being female (AOR: 1.2, 95%CI: 1.1–1.5) increased satisfaction likelihood, while experiencing violence or discrimination at home (AOR: 0.47, 95%CI: 0.23–0.99) was associated with lower mask use satisfaction. Relatively low proportions of respondents adhered to or were very satisfied with face masks use. Behavior change programs targeting men, those who experienced violence or discrimination, families with siblings, and people living outside Kampala City Centre need to be intensified to improve the level of adherence to and satisfaction with use of masks.

Introduction

The Coronavirus Disease 2019 (COVID–19) caused by the Severe Acute Respiratory Syndrome Coronavirus–2 (SARS–CoV–2) was declared a pandemic by the World Health Organization (WHO) on March 11 2020 [1]. Countries were urged to institute preventive strategies including personal protective, environ-mental and social distancing interventions to minimize viral transmission [2].
The Ugandan government progressively implemented several stringent public health measures to prevent and contain local COVID-19 epidemic. On March 18th 2020, the government banned all public gatherings, closed the airport and points of entry, closed schools and all learning institutions and encouraged the public to use masks, observe physical distance, not to cough, sneeze without covering or spit in public, and to observe strict hygienic rules (hand washing with soap and water or using sanitizers, regularly disinfecting surfaces such as tables and door handles among others) [3].
Uganda’s first case of COVID–19 was reported on 21thMarch, 2020, and on 25thMarch, 2020, a partial lockdown was instituted following a ban on public transport. A 14–day total lockdown was instituted on March 30th2020 with a nationwide curfew from 7pm to 6.30am; the use of private cars was equally banned, except for essential services. The total lockdown was later extended until on June 2nd2020 when a phased easing of the restrictions commenced. At the start of the phased lifting, there were fewer than 300 confirmed COVID–19 cases in Uganda, very low community transmission and no deaths had been recorded due to COVID–19 [4]. Due the economic hardships and collateral impact of the total lockdown, there was strong public pressure on the government to lift some of the lock-down restrictions [5]
However, the level of adherence to key recommended preventive measures for COVID–19 including public use of face masks had not been evaluated. Understanding the level of adherence to and satisfaction with face mask use was essential for the containment of the COVID–19 epidemic in the long–term. There was need to determine if the public adherence to face mask use was good or bad, and subsequently devise ways to ensure it is maintained or improved as its level of adherence influences the effectiveness of containing the spread of COVID–19. Face mask usage by the public has remained controversial and hotly contested in most countries including Uganda with researchers questioning its potential for protection on both the public and individual levels [6].Early in the epidemic some experts advised against com-munity wide use of face masks citing their risk for self–contamination and depletion of stocks for the health workers and symptomatic cases who may have needed them most [7]. We assessed the level and determinants of adherence as well as the population’s satisfaction with respect to the use of face masks as one of the key recommended COVID–19 preventive measures.

Results

Characteristics of study participants

A total of 1,726 persons participated in the study; mean age of 36 years (range = 12 to 72). Less than half (41%) of respondents in the category 29–39 years participated in the survey. Majority of the respondents [59%, (1,015/1,726)] were males. Only [47/1,726 (3%)] respondents were non–Ugandans. Half (50%) of the respondents had attained tertiary education. Kampala suburb had the highest number [40%, (688/1,726)] of respondents. Seventeen percent of the respondents had known underlying conditions. Level of adherence to use of face masks as one of the COVID–19 preventive measures in first stage of the out-break, Uganda.

Of 1,726 respondents, only 566 (33%) adhered to face mask use. Face mask use was similar by sex [52% for males versus 48% for females). Thirty nine percent (219/566) of those who used face masks were in the age group of 29–39 years. Of the 566 who adhered to face mask use, 80 (86%) did not live alone. Adherence to mask use among those who lived as a couple was 30% (14/566). Level of adherence to face mask use decreased with low level of education i.e. those who had no education or studied up to primary level (3/566, 0.53%) versus those with tertiary level education (281/566, 50%) adhered to face mask use. Face mask use was highest [45% (253/566)] among Kampala suburbs. Nineteen percent (107/566) of those with underlying conditions adhered to mask use (Table 1).

Determinants of adherence to use of face masks as one of the COVID–19 preventive measures in first stage of the outbreak, Uganda

In multivariable analysis, respondents who worried about their own health (Adj. PR: 1.1, 95% CI: 1.02–1.1), and those with high satisfaction in use of face masks (Adj. PR: 1.4, 95% CI: 1.3–1.5) were more likely to adhere to use of face masks as one of the preventive measures against COVID–19
Staying with siblings (Adj. PR: 0.94, 95% CI: 0.91-0.97), and Living in cities/towns other than Kampala (Adj. PR: 0.94, 95% CI: 0.91-0.97) reduced the odds for adherence to mask use (AOR: 0.75, 95% CI: 0.61-0.93).Sex, age, wealth index, marital status, getting COVID-19 information from leaders or health workers, being a health worker, living with siblings at home and possession of a TV set were not associated with use of face masks.

Level of satisfaction with use of face masks as one of theCOVID-19 preventive health measures in first stage of the outbreak, Uganda

Of the 1,726 respondents, 520 (30%) were very satisfied with use of face masks as one of the appropriate COVID-19 preventive measures. Majority (51%) of those who were very satisfied with mask use were males. Fifty-two percent of those who were very satisfied with mask use were living as couples (Table 2).

Determinants of level of satisfaction with face masks as one of the COVID–19 preventive measures in first stage of the outbreak, Uganda

In multivariable analysis, females (AOR: 1.2, 95% CI: 1.1–1.5), and those in highest wealth index quintile (AOR: 1.7, 95% CI: 1.2–2.4) were very satisfied with mask use. Respondents who reported violence or discrimination at home during the lockdown period (AOR: 0.47, 95% CI: 0.23–0.99), and those moderately not worried about loved ones’ health (AOR: 0.75, 95% CI: 0.57–0.99) were less likely to be very satisfied with mask use. Age, marital status, living with parents or spouse, possession of a TV set, working condition, worry about one’s health or self, working condition and ever suffering violence were not associated with satisfaction to use a mask

Limitations

The study was conducted online, and this required access to smart phones and internet connectivity for participation in the survey. The study could have therefore enrolled only educated people with a certain social standing and thus the findings could have overestimated the level of adherence and satisfaction.

Table 1: Level of adherence to use of face masks as one of the COVID–19 preventive measures in first stage of the outbreak, Uganda

Table 2: Level of satisfaction with use of face masks as one of the COVID–19 preventive measures in first stage of the outbreak, Uganda

Conclusion

Relatively low proportions of respondents adhered to use of face masks. The proportion of respondents who were very satisfied with use of face masks was also low. Behavior change programs need to be intensified to improve the level of adherence and satisfaction with use of masks. Special messages and efforts should target men, large families, and people living outside Kampala city Centre

References

1. WHO, Technical guidance, in Naming the corona-virus disease (COVID–19) and the virus that causes it. 2020.
2. WHO, Responding to community spread of COVID–19: Interim guidance, 7 March 2020 2020.
3. GoU, President Museveni COVIDC19 Guidelines to the Nation on Corona Virus, S. House, Editor. 2020: Entebbe.
4. GardaWorld. Uganda: Lockdown measures to be eased from June 2 /update 7. 2020 18th July 2020]; Available from: www.garda.com/crisis24/news–alerts/343631/uganda–lockdown–measures–to–be–eased–from–june–2–update–7.
5. Daily Monitor, Scientists speak out on easing lock-down, in Daily Monitor. 2020.
6. Lyu, W. and G.L. Wehby, Community Use Of Face Masks And COVID–19: Evidence From A Natural Experiment Of State Mandates In The US. Health Aff (Millwood), 2020. 39(8): p. 1419–1425.
7. Schünemann, H.J., et al., Use of facemasks during the COVID–19 pandemic. Lancet Respir Med, 2020(10): p. 954–955.
8. Ngonghala, C.N., et al., Mathematical assessment of the impact of non–pharmaceutical interventions on curtailing the 2019 novel Coronavirus. Math Biosci, 2020. 325: p. 108364.
9. BRUCE, R., COVID–19 face masks, in The Independent. 2020.
10. Diop, B.Z., et al., The relatively young and rural population may limit the spread and severity of COVID–19 in Africa: a modelling study. BMJ Global Health, 2020. 5(5): p. e002699.
11. Ahmed, M.A., et al., COVID–19 in Somalia: Adherence to Preventive Measures and Evolution of the Disease Burden. Pathogens, 2020. 9(9): p. 735.
12. Canadian Mental Health Association. COVID–19 and Anxiety. 2020 29th June 2020]; Available from: https://www.heretohelp.bc.ca/infosheet/covid–19–and–anxiety.
13. Kasozi, K.I., et al., Misconceptions on COVID–19 Risk Among Ugandan Men: Results From a Rapid Exploratory Survey, April 2020. Frontiers in Public Health, 2020. 8(416).
14. Duplaga, M., Perception of the Effectiveness of Health–related Campaigns among the Adult Population: An Analysis of Determinants. International journal of environmental research and public health, 2019. 16(5): p. 791.
15. Skinner, C.S., J. Tiro, and V.L. Champion, The Health Belief Model, in Health behavior: Theory, research, and practice, 5th ed. 2015, Jossey–Bass: San Francisco, CA, US. p. 75–94.
16. Usman, I.M., et al., Community Drivers Affecting Adherence to WHO Guidelines Against COVID–19 Amongst Rural Ugandan Market Vendors. Frontiers in Public Health, 2020. 8(340)
17. Van Gelder, N., et al., COVID–19: Reducing the risk of infection might increase the risk of intimate partner violence. E Clinical Medicine, 2020. 21: p. 100348–10034

High level of compliance to handwashing dur-ing the early phase of COVID–19 epidemic in Uganda: A nationwide cross–sectional survey

Authors: Richard Migisha1*, Bob Omoda Amodan1, Lilian Bulage1, Elizabeth B. Katana1, Joseph N. Siewe Fodjo2, Robert Cole-bunders2, Alex Riolexus Ario1, 3, and Rhoda K. Wanyenze4 1Uganda Public Health Fellowship Program, Ministry of Health, Kampala, Uganda2Global Health Institute, University of Antwerp, Doornstraat 331, 2610 Antwerp, Belgium3Ministry of Health, Kampala, Uganda4School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda.

Summary

The World Health Organization recommends frequent hand-washing with soap and water as the cheapest and most essential intervention in preventing the spread of COVID–19. We assessed the level of compliance to handwashing and associated factors among Ugandans in the first two months of the outbreak in the country to inform prevention measures. We abstracted data from the International Citizen Project (ICP), a cross–sectional nationwide online survey conducted between 16thand 30thApril 2020 using a self–administered questionnaire. We collected data on socio–demographic characteristics, the impact of COVID–19 on daily life, adherence to and satisfaction with personal and community preventive measures, and acceptability of these measures, Handwashing compliance was defined as washing hands with soap and water for a minimum of 20 seconds, after touching surfaces, or having been in a public place. We performed multivariable logistic regression to identify factors associated with non–compliance to handwashing
In total 1,726 participants responded with a mean age (SD) of 36 (±11) years (range: 12–76 years); most (59%) were male, and lived in apartments (84%). Nearly all participants (99.7%) had heard about COVID–19. Among the 1,726 participants assessed for handwashing compliance, 1,662 (96%) complied; only 64 (3.7%; 95%CI: 2.9–4.7%) were non–compliant. Respondents who stayed in huts/shacks or who were homeless (aOR=6.1, 95%CI: 2.0–18; P=0.002), and those who had not heard about COVID–19 (aOR=13, 95%CI: 2.4–72, P=0.003) were more likely to be non–compliant. Individuals with a high level of satisfaction with handwashing as an appropriate COVID–19 preventive measure were less likely to be non–compliant (aOR=0.26, 95%CI: 0.15–0.45, P<0.001).The level of compliance to handwashing was very high in the first two months of COVID–19 epidemic in Uganda. Poor housing conditions, low level of awareness about COVID–19, and perceived low level of satisfaction with handwashing as an appropriate COVID–19 preventive measure were associated with non–compliance to handwashing. We recommend continued risk communication and public education especially targeting individuals with poor housing to sustain the high compliance to handwashing. There is need to avail handwashing facilities to individuals with poor housing conditions during the epidemic so as to improve epidemic control

Introduction

Coronavirus disease 2019 (COVID-19), the respiratory disease caused by severe acute respiratory syndrome corona-virus 2 (SARS-CoV-2) remains a major health threat globally, and has overstretched health systems in many countries. In Uganda, the disease outbreak was first reported on March 21, 2020(1).

The disease may be transmitted from person-to-person through respiratory droplets and contact with infected surfaces. Frequent diligent handwashing with soap and water was recommended as key preventive strategy for COVID-19 in the early phase of the pandemic. Soap breaks down the outer layer of the virus. In addition, the slippery and mechanical motion that arises from handwashing with soap causes the virus to rip off from the skin surface(2). Handwashing has been viewed as an important intervention in the fight against the pandemic for a number of rea-sons: firstly, soap and water are cheap and readily available; secondly, handwashing is simple to practice by most individuals independently.

Despite the prescribed benefits of proper and frequent handwashing during the pandemic, compliance from individuals across many countries varied owing to the behavioral nature of the intervention(3). Whereas information dissemination and public education are necessary to change behavior, they may not necessarily be sufficient(3). We assessed the level of compliance to handwashing with soap and water, and associated factors, in the first two months of the COVID-19 epidemic in Uganda

Methods

We abstracted data from the International Citizen Project (ICP), a cross–sectional nationwide online survey that asessed adherence to preventive measures and their impact on the COVID–19 outbreak conducted between 16thand 30thApril 2020 using a self–administered questionnaire. The ICP survey collected data on socio–demographic characteristics; the impact of COVID–19 and associated restrictions on daily life, professional life, and personal well–being; adherence to and satisfaction with personal and community preventive measures; and acceptability of these measures. The questionnaire was circulated via WhatsApp, email, Facebook, and Twitter platforms. Individuals who got the questionnaire were asked to disseminate it further, share it with other persons in their networks. For this study, we abstracted data on socio–demographic characteristics including age, sex, education, location, marital status, housing conditions, and professional  life during the COVID–19 lock down. During the survey, frequency of handwashing was assessed using a close–ended question with the frequencies specified as a number per day. Addi-tionally, participants were asked to respond (‘yes’ or ‘no’) whether they practiced handwashing after touching surfac-es or being in public. Handwashing compliance was de-fined as, washing hands with soap and water for a mini-mum of 20 seconds, after touching surfaces, or having been in a public place (4, 5)
In addition, we abstracted data on participants’ awareness of COVID-19, whether they smoked cigarettes or not, whether they had underlying medical conditions (e.g., dia-betes, hypertension, HIV), and their level of satisfaction with the level of handwashing as an appropriate COVID-19 preventive measure.The level of satisfaction with the hand-washing as an appropriate COVID-19 preventive measure was assessed using a 5-item Likert scale-(1=very dissatisfied to 5=very satisfied). Participants with scores of 1-3 were con-sidered to have low level of satisfaction, while those with scores 4-5 were considered to have high level of satisfaction(6).Data were extracted and cleaned using MS Excel 2019, there-after exported to STATA 13 (Statacorp, College Station. Texas) for analysis. Our outcome of interest was compliance to handwashing with ‘yes’ coded as ‘0’ and ‘no’ coded as ‘1’. We first described participants’ characteristics of the study participants, and compared their distribution among individu-als who complied with handwashing and those who did not comply, using Chi-square or two-tailed Fischer’s exact test. We then performed univariable and multivariable logistic regression to identify factors associated with non-compliance to handwashing.

Results

Characteristics of study participants

Overall, 1,726 participants responded with a mean age (SD) of 36 (±11) years (range: 12–76 years). Most of the participants were male (59%), married/living with partners (58%), and lived in apartments (84%). Nearly all participants had ever heard about COVID–19 (99.7%), and were Ugandans (97%) (Table 1). The distribution of sex (P=0.030), nationality (P=0.011), housing conditions (P<0.001), participants who had ever heard about COVID–19 (P=0.033), smoking and level of satisfaction with handwashing as an appropriate COVID–19 preventive measure (P<0.001) was statistically significant between participants who did not comply and those who complied with handwashing (Table 1).

Compliance to handwashing and frequency during the early phase of COVID–19 epidemic in Uganda

Among the 1,726 participants assessed for compliance to handwashing with soap and water, 1662 (96%) complied; the remaining 64 (3.7%; 95%CI: 2.9–4.7%) were not compliant. Of the total 1,726 participants, most washed their hands 6–10 times/day (41%), followed by 3–5 times/day (34%); Only 31 participants (1.8%) did not wash their hands at all; 30 participants (1.7%) washed their hands more than 30 times/day (Figure 1) 

Figure 1: Percentage prevalence of handwashing by number of times of handwashing per day among 1,726 participants assessed for handwashing compliance in the early phase of COVID-19 outbreak, April 17-13, 2020Factors associated with non–compliance to handwashing during the early phase of COVID–19 epidemic in Uganda

In multivariable analysis, individuals who had significantly higher odds of non–compliance were those who stayed in huts/shacks or who were homeless (aOR=6.1, 95%CI: 2.0–18; P=0.002) and individuals who had not heard of COVID–19 (aOR=13, 95%CO: 2.4–72, P=0.003). Individuals with high level of satisfaction with handwashing as an appropriate COVID19 preventive measure were less likely to be non–compliant to handwashing (aOR=0.26, 95%CI: 0.15–0.45, P<0.001).

Discussion

We assessed the level of compliance to handwashing with soap and water and associated factors in the first two months of the COVID–19 outbreak in Uganda. Nearly all (96%) of the respondents were compliant to handwashing; poor housing conditions (being homeless, or staying in huts/shacks) and not being aware of COVID–19 were associated with non–compliance. Respondents who were highly satisfied with handwashing as an appropriate COVID–19 prevention measure were less likely to be non–compliant.
A recent demographic and health survey in Uganda, prior to the COVID-19 pandemic, reported handwashing compliance of 44% among household members whose house-holds had soap and water available(7). The high level of compliance to handwashing with soap and water observed in this study emphasizes the fact that COVID-19 could have reinforced handwashing behavior(8). This may be attributed to the extensive messaging on different media platforms, emphasizing the importance of handwashing in the pandemic. Consistent with our findings, a study among Polish adolescents also reported a significant improvement in handwashing compliance with soap and water during the COVID-19 pandemic(9). Sustaining the high level of compliance to handwashing in Uganda will require sustained health promotion efforts aimed at improving hygiene, through mass media and social media in the different phases of the epidemic and in the post-COVID-19 era.
Our findings demonstrated that individuals who were homeless or staying in poor housing conditions were more likely to be non-compliant to handwashing with soap and water. Poor housing conditions is an indicator of poor socioeconomic status which is often coupled with water insecurity; under these circumstances of water scarcity, the scarce water is prioritized for other domestic needs such as cooking(10). The water insecurity most common in poor housing conditions in low-income countries may undermine the COVID-19 response efforts in the developing countries, and make water-insecure areas (e.g., slums) epicenters for disease transmission(10). We therefore recommend that designated handwashing points be availed in areas with poor housing conditions so that handwashing with soap and water is more easily accessible to all Ugandans given the wide health benefits of handwashing.
Our study revealed that respondents who had never heard about COVID-19 were more likely to be non-compliant to handwashing with soap and water. Persons unaware of a disease always have low knowledge levels about the dis-ease; the low knowledge ultimately influences the perception of disease severity. According to the Health Belief Model (HBM), persons with perceived severity and susceptibility of being afflicted with life-threatening diseases including COVID-19 are more likely to practice personal preventive measures such as handwashing and facemasks use(11).
Although awareness about COVID-19 was nearly universal among our study population, the fact that respondents who were not aware about the disease were less likely to practice handwashing, calls for the need to continue sensitization and risk communication among Ugandans. Similarly, respondents who were not highly satisfied with handwashing as an appropriate COVID19 preventive measure were less likely to be compliant.

This is consistent with previous findings from research about the influence of of perception of social campaigns by the general public on individual preventive measures(12). It is believed that the attitude towards public health measures practiced in a given society may influence one’s behavior and readiness to accept such interventions(12).

Although our study generated valuable nationwide data on handwashing frequency and adherence to handwashing with soap and water by the Ugandan population, it is important to mention the study limitations. First, the study relied on self–report of handwashing behavior, making it susceptible to social–desirability bias. However, this was minimized by making the questionnaire self–administered. Second, data were collected online via internet; individuals who had no access to internet connection were unable to participate in our study. Therefore, our study sample is not a good representation of the general population in Uganda, and may have overestimated the prevalence of handwashing compliance.

Conclusions and recommendations

The level of compliance to handwashing with soap and water was much higher in the Ugandan population in the first two months of COVID–19 epidemic, compared to ‘normal times’. Poor housing conditions, low level of awareness about COVID–19, and perceived level of satisfaction with handwashing by the public were associated with non–compliance to handwashing. We recommend continued risk communication and public education to sustain the high compliance to handwashing. There is need to avail designated handwashing points to individuals with poor housing conditions during the epidemic so as to improve epidemic control.

Table 1: Characteristics of study participants by hand washing compliance status

Disclaimer

The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the Makerere University School of Public Health, the Ministry of Health Uganda, and Global Health Institute, University of Antwerp

References

1. Migisha R, Kwesiga B, Mirembe BB, Amanya G, Kabwama SN, Kadobera D, et al. Early cases of SARS–CoV–2 infection in Ugan-da: epidemiology and lessons learned from risk–based testing approaches–March–April 2020. Globalization and Health. 2020;16(1):1–9.

2. Roser M, Ritchie H, Ortiz–Ospina E, Hasell J. Coronavirus pandemic (COVID–19). Our world in data. 2020.

3. Lunn PD, Belton CA, Lavin C, McGowan FP, Timmons S, Robertson DA. Using Behavioral Science to help fight the Coronavirus. Journal of Behavioral Public Administration. 2020;3(1).

4. Cucinotta D, Vanelli M. WHO declares COVID–19 a pandemic. Acta Bio Medica: Atenei Parmensis. 2020;91(1):157.

5. Organization WH. Hand hygiene: why, how & when. World Health Organization online resource, retrieved February. 2009;10:2015.

6. Amodan BO, Bulage L, Katana E, Ario AR, Fodjo JNS, Colebunders R, et al. Level and Determinants of Adherence to COVID–19 Preventive Measures in the First Stage of the Outbreak in Uganda. International journal of environmental research and public health. 2020;17(23):8810.

7. Statistics UBo. Uganda demographic and health survey 2016. UBOS and ICF Kampala, Uganda and Rockville, Mar-yland,USA;2018.

8. Alzyood M, Jackson D, Aveyard H, Brooke J. COVID‐19 reinforces the importance of handwashing. Wiley Online Library; 2020.

9. Głąbska D, Skolmowska D, Guzek D. Population–based study of the influence of the COVID–19 pandemic on hand hygiene behaviors—Polish adolescents’ COVID–19 experience (PLACE–19) study. Sustainability. 2020;12(12):4930.

10. Stoler J, Jepson WE, Wutich A. Beyond handwashing: Water insecurity undermines COVID–19 response in developing areas. Journal of Global Health. 2020;10(1).11. Sim SW, Moey KSP, Tan NC. The use of facemasks to prevent respiratory infection: a literature review in the context of the Health Belief Model. Singapore medical journal. 2014;55(3):160.

12. Duplaga M. Perception of the Effectiveness of Health–Related Campaigns among the Adult Population: An Analysis of Determinants. International journal of environmental research and public health. 2019;16(5):791

Effects of COVID–19 on Gender–Based Violence during the Covid–19 lockdown: January 1 to July 30, 2020 in Uganda

Authors: Peter Omms Oumo1, Maureen Katusiime1, Lilian Bulage1, Geoffrey Amanya1, 1Benon Kwesiga1, 1Daniel Kadobera1, Alex Riolexus Ario2,
3Uganda Public Health Fellowship Program1, Kampala, Uganda, Uganda National Institute of Public Health, Kampala, Uganda2, Ministry of Health, Kampala, Uganda3

Summary

After the president instituted a nationwide lockdown on 30 March 2020, in Uganda, emergency public health control measures requiring Ugandans to stay home for 14 days (‘lockdown’) were instituted as part of the public health interventions to stop the spread of COVID–19. Subsequently, police reports indicated a possible increase in gender–based violence (GBV). We evaluated changes in patterns, incidence, and risk factors for GBV before and during the lock-down period to inform GBV preventive interventions and programming. We reviewed routinely–generated GBV records from reported incidences to police stations, district gender and probation offices in 6 Police divisions in Kampala Metropolitan, Lira, and Gulu Districts. We analyzed data from reported GBV cases (January–March) before and during (April–July) the lock-down. We determined incidence using population denominators for the population and region of interest and identified associated factors from reports. Of 390 GBV cases identified, Females 326 (84%) were more affected than males (16%) (p<0.001). Students and pupils were most affected (32) followed by business community (20). Age group 18–34 years most affected (41%) followed by 13–17 years old’s (29%). GBV incidence was higher during the lockdown period compared to before (47.5 vs 24.4/100,000 (p=0.005)). Incidence more than doubled among both females (96 vs 230/100,000; p<0.0001) and males (21 to 43/100,000; p=0.006) and tripled among adolescents aged 13–17 years (26 to 86/100,000; p<0.0001) during lockdown compared to before. Two hundred seventy–six (71%) GBV reports during lockdown were reported as attributed to alcohol consumption compared to 31 (8.0%) before lockdown. We concluded that the incidence of GBV increased across all population groups during lockdown with women, adolescents and students experiencing the greatest burden. GBV associated with alcohol consumption increased substantially. Awareness and prevention efforts should focus on alcohol–associated GBV in any future lockdowns as well as identifying approaches to protect women, adolescents, and school going populations.

Introduction

The World Health Organization (WHO) defines Gender–Based Violence (GBV) as any act that is perpetrated against a person’s will and is based on gender norms and unequal power relation-ships. It encompasses threats of violence and coercion and can be physical, emotional, psychological, or sexual in nature, and can take the form of denial of resources or access to services across ages and genders[1][2]. It is estimated that 35 percent of women worldwide have experienced either physical and/or sexual intimate partner violence, a form of GBV or non–partner sexual violence during their lifetimes[3]. Many countries around the world implemented lockdowns, stay–at–home, and physical distancing measures to contain the spread of Corona-virus disease 2019[4]. Evidence shows that violence can increase during and in the aftermath of disease out breaks outbreaks such as COVID–19[5][7][8]

The President of the Republic of Uganda implemented emergency public health control measures requiring Ugandans to stay home for 14 days after WHO announced lockdowns on 10thJanuary 2020; this was later extended by another 21 days. During this time, many people were undergoing economic hard-ships, as well as the unusual situation of being with their families full–time. Medical and police reports indicated an increase in GBV with children, girls, and women being the most affected [9]. We determined the scope and magnitude of GBV before and during the COVID–19 lockdown period; described the fac-tors associated with increased GBV cases to assist the Ministry of Health with designing interventions to reduce GBV during the pandemic and future similar pandemics.

Methods

Study setting

We conducted the study at police stations in Kampala Metropolitan Region in the divisions of Kampala Metropolitan Police (KMP)–North, Old Kampala, KMP East, and Kiira. Kampala Metropolitan Region is found in the central part of Uganda and consists of the districts of Kampala, Mukono, and Wakiso. Kampala is the capital and largest city of Uganda and was estimated to have a population of 1,650,800 people on 31 July 2019 .We also conducted the study in Gulu and Lira districts. Gulu and Lira are located in Northern Uganda. Lira District is located approximately 337 kilometers by road. Gulu District is bordered by Lamwo District to the north, Pader District and Omoro District to the east, Oyam District to the south, Nwoya District to the southwest, and Amuru District to the west. The investigation was conducted in these districts and divisions based on the high burden of GBV incidents reported as per the Annual Police Crime Report 2019[10].

Study design, data source, and sample size

We conducted a cross–sectional descriptive study using routinely generated Gender–Based violence records from Uganda Police Force, District/divisional Probation offices, health facilities, and the National Gender–Based Violence data bank. We defined a GBV case as a report to the police of an act perpetrated against a person’s will and based on gender norms and unequal power relationships between January 1 and July 30, 2020 in Kampala Metropolitan, Lira, and Gulu Districts. We defined the period of ‘before lock-down’ as January–March 2020, and ‘during lockdown’ as April to July 2020. We considered all GBV cases registered at Police stations and related authorities that met the case definition before and during the lockdown.

Study variables and data collection

We reviewed crime report books and case files from the gender unit in the Criminal Investigations Directorate (CID), the police Child and Family Protection Unit (CFPU), gender and probation offices and collected data on characteristics of GBV cases (socio–demographic variables such as: age, sex, education level, occupation, marital status, number of people in a household, type of housing and in-formation on factors leading to the effects of GBV such as: frequency of abuse, known problems leading to abuse, types of abuse experienced and cause of abuse. We abstracted data to a standardized form.

Data Analysis

Data was captured into an excel sheet and analyzed using STATA version 14. We evaluated the person demographics using frequencies and percentages. We determined district incidence using population denominators for the population of interest. We also determined incidence of various demographic variables per 100,000. We used district populations as denominators and GBV case counts identified from records to calculate the monthly and average month-ly incidence before and during the lockdown.

Results

Socio–demographic characteristics of Gender–Based Violence case–persons, Kampala Metropolitan Gulu and Lira districts, January –July 2020

We identified 390 reported cases during the lockdown. The mean age of GBV case–persons was 24 ± (12), while the median age was 24 years (1–77 years). Females reported more cases 326 (84%) and single people reported the highest number of cases 179 (46%) followed by the married couples 175 (45%) compared to the widowed 5 (1.3%). Age groups 18-34 years 161 (41.2%) reported the most cases fol-lowed by age group 13-17 years 112 (29%). The least reported cases were in the age category of 0-12 years 49 (13%). By occupation, the most reported cases were among; students and pupils 128 (32%), and businessmen 79 (20%) compared to the civil servants 21 (5.4%). couples 175 (45%) compared to the widowed 5 (1.3%). Age groups 18–34 years 161 (41.2%) reported the most cases followed by age group 13–17 years 112 (29%). The least reported cases were in the age category of 0–12 years 49 (13%). By occupation, the most reported cases were among; students and pupils 128 (32%), and businessmen 79 (20%) compared to the civil servants 21 (5.4%).

Incidence of Gender–Based Violence before and during the lock down in Kampala Metropolitan, Gulu and Lira districts, January –July 2020

Although all groups experienced an increase in reports of GBV, the largest increase in reported GBV incidences occurred among students and pupils. Incidence of GBV was higher among the females before and during the lockdown (96 vs 230/100,000) compared to males (21 vs 43/100,000) (p=0.001). The incidence of GBV during COVID–19 lockdown was highest among 18–34year olds (107/100,000) followed by13–17–year olds (86/100,000). GBV Incidence tripled during COVID–19 lockdown compared to before among age group 13–17 years (26 vs 86/100,000; p<0.001), it almost tripled among 0–12–year olds (14 vs 35/100,000; p=0.003) while it doubled among 18–34 years (54 vs 107/100,000; p<0.001) and >35 years (23 vs 45/100,000; p=0.007)

All occupation groups experienced increment in GBV incidence during lockdown compared to before with students and pupils having the highest (30 vs 103/100,000) followed by Peasant farmers (13vs 31/100,000; p=0.006). By marital status, those who were single had the highest incidence during the lockdown (7 vs 138/100,000) although all the groups had significant increment during the lockdown.

Pupils in primary school reported the highest increase in GBV incidence, five times higher during lockdown com-pared to before (38 vs 193/100,000; p<0.001) when compared to their counterparts with other levels of education. Those that lived in houses that were connected to others (164 vs 57/100,000) had reported a high incidence compared to those that lived in apartments (19 vs 7/100,000) (Table 2).

The average monthly incidence increased in all districts except Mukono. Gulu district had the highest average monthly incidence (both before and during lockdown) while the GBV incidence rate in Wakiso increased by 10–fold during the lockdown (Table 3).

Table 1: Socio–demographic characteristics of Gender–Based Violence cases, Kampala Metropolitan, Gulu, and Lira districts, January –July 2020

Table 2: Incidence of Gender–Based Violence before and during the lock down, Kampala Metropolitan, Gulu, and Lira districts, January –July 2020

Table 3: Monthly incidence rates of Gender Based Violence before and during the lockdown, Kampala Metropolitan, Gulu, and Lira districts, January –July 2020

Types of Gender–Based Violence, consequence, place and cause of abuse before and during the lockdown, Kampala Metropolitan, Gulu, and Lira, January–July 2020

Psychological torture/ mistreatment (29%) followed by physical assault (25%) and sexual/ defilement (23%) were the most prevalent forms of abuse identified both before and during COVID–19 lockdown. Being psychologically tortured (48%), fear after abuse (38%)and having wounds/bruises (22%) were the common consequences of abuse faced by GBV victims. Gender–Based Violence occurred mostly at home (51%) followed by in the neighborhood.

Most of the GBV cases were perpetrated by husbands 139 (35.6%) and male intimate partners 91 (23.3%) who were either ex–partners, partners they cohabited with or boyfriends who abused them most recently. Having no reason for being abused (17 vs 29%) followed by anger (11 vs 17.5%) and alcohol abuse (8 vs 12%) were the main reasons highlighted for being abused by the victims

Table 4: Types of Gender–Based Violence, consequence, place and cause of abuse before and during the lockdown, Kampala Metropolitan, Gulu, and Lira, January–July 2020

DISCUSSION

Globally, Gender–Based violence is a very big challenge among the married partners more so in developing countries, Uganda inclusive. It became a very challenging turmoil during the period of Covid–19 lockdown. Global lockdowns have resulted in a horrifying surge in gender–based violence incidences[8]. This study described the patterns, incidence, and factors for GBV occurrence during the lockdown period of the COVID–19 pandemic. Our study found out that Gender–Based Violence increased during the COVID–19 lock-down, up to 10–fold in some districts with women, students and pupils reporting the biggest increase in incidences. Psychological torture, beatings or assault and defilement increased more than other forms of GBV[11].

We also observed that most of the abusers of the women, students and pupils were husbands and intimate partners [2]. A similar study conducted in Eastern Uganda found out that 54% of women suffered from Intimate Partner violence perpetrated by their husbands, ex–partners and intimate partners[12][13]. During this time when many men and women were seated at home, some men still felt that the woman should provide, and when she failed she would be ridiculed as supported by another study in Ghana[14]

We further observed that students and pupils reported the highest increase in incidences of gender–based violence by occupation amongst their counterparts. Several of the incidences reported by this group included teenage girls who had reported incidence of defilement against them. Another study similarly agrees that a total of 77.7 per cent adolescent girls in primary school and 82 per cent in secondary school have been subjected to sexual abuse[15]. Our study notes that during this time, many girls were getting defiled by their Intimate partners or boyfriends[8]

Other forms of violence experienced included beating and assault. We noted that many incidences of physical assault were being re-ported since most of the victims were locked up with their abusers at home. Pre–existing toxic social norms such as the excess consumption of alcohol and gender inequalities have led to an exponential increase in GBV[2]. Many social norms which among others included beating had affected many women and girls in ‘lockdown’ at home with their abusers as this was socially acceptable[5].

Most of the victims were psychologically tortured and were experiencing mistreatment this could have been more prominent with with thee married couples experiencing violence from their spouses leading to a lot of fear both before and during the lockdown. From our findings, many of the perpetrators were known alcohol. Studies have shown that it is common during such stressful times for many perpetrators of GBV to carry out such acts with the influence of alcohol[16].

Anger perpetrated by the stress the people were going through this lockdown period also contributed to the outcomes of GBV. Emotional stress is a form of violence that is usually experienced when people are undergoing challenging situations[16]

We acknowledge that whereas our study obtained data from records of vital statistics from mainly Police records, this was limited by difficulty in obtaining complete information from files since there were no physical respondents to be interviewed. Further more, Furthermore, most of the files were still in courts of law especially those that pertained Sexual Gender Based offences. To ensure that we had representative information, the investigating team had to identify the police officers who initially investigated these cases to provide some of the of missing information leading to the events in question which was quite difficult.

Conclusion

The spread of SARS–COV–2 has created several problems for the people to grapple with. In the absence of a vaccine and effective treatment for this virus, the governments are forced to impose lockdowns to quarantine people at home to reduce the spread of the virus. However, this has resulted in a paradox of problems, which includes issues such as economic instability, mental health problems, andms, problems, and a series of degenerated social habits.

The incidence of GBV increased across all population groups during lockdown with women, adolescents, single people and pupils in primary school experiencing the greatest burden. GBV associated with alcohol consumption increased substantially. Awareness and prevention efforts should focus on alcohol–associated GBV in any future lockdowns as well as identifying approaches to protect women, adolescents, and school going populations

Recommendations

To prevent and address GBV, we must work on dedicated actions and strategies, which contribute to addressing GBV by enhancing the protective factors to prevent GBV. Different stakeholders such as ministry of health, ministry of gender, labour and social development together with Uganda police should put emphasis of strengthening psychosocial support systems both at community and institutional level. Laws and policies against physical abuse especially to the women and children should be enacted and existing ones toughened. Psychosocial capacity building to Local council authorities, child and family protection units and gender offices of police and ministry of gender, the psychosocial department of ministry of health need to be given capacity in handling traumatized victims. A need to increase efforts to raise massive social awareness of the criminal nature of domestic violence and services available to victims.

References

[1]  M. A. Onyango, “Preventing and Responding to Gender–based violence,” pp. 1–47, 2016.

[2] WHO, “Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non–partner sexual violence,” vol. 2008, 2013.

[4] A. Assessment and A. During, “Violence Crisis Services During Lockdown :,” no. August, pp. 1–6, 2020.

[5] W. H. O. General and T. Adhanom, “WHO–2019–nCoV–Violence_actions–2020.1–eng,” no. June, pp. 1–7, 2020

[6] Uganda Bureau of Statistics, “GOVERNMENT OF UGANDA Uganda Demographic and Health Survey 2016,” Udhs 2016, p. 625, 2016, [Online]. Available: www.DHSprogram.com.

[7] E. Katana, L. Bulage, and A. R. Ario, “Violence and Discrimination Among Ugandan Residents During the COVID–19 Lock-down,” pp. 1–19.

[8] L. Johnbosco and N. S. Ggoobi, “COVID–19 AND THE RISING LEVELS OF DOMESTIC VIOLENCE IN UGANDA Policy Brief 005 By September 2020 COVID–19–A DOMESTIC VIOLENCE TRIGGER IN UGANDA,” no. September, 2020.

[9] C. Coordination, C. Management, F. Security, R. Communications, and C. Engagement, “Identifying & Mitigating Gender–based Violence Risks within the COVID–19 Response Last updated :,” 2020.

[10] Uganda Police, “Annual Crime Report 2019,” SAPS Annu. Rep., p. 184, 2020.

[11] UBOS and MoGLSD, “Gender Issues in Uganda: An analysis of gender based violence, asset ownership and employment,” p. 50, 2019, [Online]. Available: https://www.ubos.org/wp–content/uploads/publications/03_2019UBOS_Gender_Issues_Report_2019.pdf.

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