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Interventions to Increase Compliance Levels Around COVID-19 In Refugee Communities

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By Joseph Odoi

Uganda’s open-door policy on refugee-hosting has been internationally acclaimed as “the world’s most compassionate”. And while Uganda is among the world’s top three refugee-hosting nations, possibly the first in Africa, refugee communities continue to be disadvantaged on many fronts with poor socioeconomic and health outcomes.

Refugee settings are already besieged with a socially disrupted existence, and the COVID-19 experience could have catastrophic consequences in their context. Yet the extent to which refugee communities are aware of Covid-19, have complied, and are coping with the related preventive measures, remains largely unknown.

Moved mainly by three issues: 1) Uganda’s open-door policy on refugee hosting; 2) COVID-19; and 3) the knowledge gap on COVID-19 impact in refugee communities,  Makerere University researchers in partnership with different institutions in academia, policy and practice have commenced on a study contributing to increased compliance with the Ministry of Health’s Covid-19 prevention guidelines under the project  entitled “Refugee Lived Experiences, Compliance, and Thinking” (REFLECT) in Covid-19.

According to Dr. Gloria Seruwagi, the Principal Investigator, study findings will contribute to filling gaps in knowledge, policy by designing programmes to increase understanding and compliance levels around COVID-19 and refugee communities:

“Little is known about how refugee communities have complied with the Ministry’s guidelines like social distancing, wearing masks, sanitizing or frequent washing of hands with soap. Yet it is widely known that their living arrangements in crowded spaces with massive WASH (Water, Sanitation and Hygiene) challenges have been a long-standing challenge, even before the Covid-19 pandemic. To address this knowledge gap the Ministry of Health has partnered (as a Co-Investigator) with our study team which also comprises other Co-Investigators from Gulu University, ACORD and Lutheran World Federation which are implementing partners in refugee settlements.” explained Dr. Seruwagi

‘’This mixed methods research has a sample size of ~1,500 participants evenly distributed across three study sites in Central, West Nile and South Western refugee settlements. Similarly, there was fairly even distribution across nationalities with Congolese (30%), Somalis (33%) and South Sudanese (33%). Overall, the majority of participants were aged between 25-34 years (35%), of female gender (68%), of Moslem (30%) or Protestant (36%) religious denomination, uneducated (40%) and earned less than UGX 50,000 weekly (57%). In addition, the overwhelming majority neither smoked (97%) nor drunk alcohol (92%).  Except for age and gender, there were variations in demographic and behavioral characteristics across the three study sites’’ she added.

Preliminary Findings

As part of preliminary findings from the study, Dr Seruwagi noted that there are very high levels of awareness about COVID-19 among the majority of the adult population. However, there are variations in this knowledge across refugee settings, with urban refugees being more knowledgeable on average than their rural counterparts. However, in reverse they [urban refugees] also displayed and reported higher risk behaviour in regards to Covid-19 than their rural-based counterparts who showed relatively more compliance. Despite being more knowledgeable than women with regard to symptoms, causes, risk factors, and treatment of COVID-19, men have poor compliance with Covid-19 preventive measures compared to women.

Children ages 5-12 were found to have very low levels of knowledge, explained by the assumption that adults at home will always pass on information and so, no targeted information is being given to children. “Due to school closure, teachers who are key change agents and transmit information were not in contact with the children. We believe this is a missed opportunity greatly contributing to these low knowledge levels among children”  Dr. Gloria explained while sharing findings at Makerere University (CTF1 Building). In addition to disenfranchisement around access to Covid-related knowledge, school closure further heightened children’s vulnerability with a marked increase in neglect, exposure to different forms of violence and teenage pregnancy.

On attitudes, Dr. Seruwagi noted that previous adverse experiences like war, torture, rape or hunger  have produced a “survivor” mentality with little or no fear  among respondents in refugee communities.  One  refugee said “I have dodged bullets, been tortured and slept hungry for days, what more harm can Covid do to me?”

On adherence to preventive guidelines, Presidential directives and SOPs, handwashing was the most commonly adhered to guideline, again among the adults.  Local leaders had come up with innovative mechanisms for ensuring compliance through supervision; and  most households had washing points at the peak of COVID-19. ‘’Handwashing was even much higher in Muslim communities, mostly because it is in tandem with their religious and sociocultural practices’’ Dr. Seruwagi explained.

On masks, the researchers noted that there was not so much compliance in wearing masks, reportedly after restrictions were eased. There was a lot of “chin-masking” with those who had  just wearing them on chins but without using them to cover up. Some other risky behaviours were observed such as borrowing masks at places where it was mandatory (health facilities, offices) or when they saw authorities and enforcers coming.

On social distancing: the researchers noted that local leaders have tried to enforce this at public meeting spaces; but it’s almost impossible at household level due to large family sizes. Also, sociocultural norms require them to sit together, eat together (including from the same utensils) which makes it almost impractical.

Despite the challenges, the researchers observed that there are also stories of resilience, innovation and improvisation among refugee communities. Local leaders made arrangements to help their people including translating prevention messages into local languages, having strict rules e.g. for social distancing at water collection points and enforcing handwashing facilities at household level. They also internally arranged some relief items. And new businesses (e.g. mask production) were birthed out of COVID-19. Key support systems during Covid-19 were reported to be health facilities, WASH, community leaders including religious leaders and the diaspora.

On the way forward, the research team highlighted the need for innovation and  designing age-appropriate messages and interventions for children, incorporating mainstream COVID-19 messaging in all teacher-learner interactions, building on community resilience and leadership, continuous communication and impact messaging with heavy focus on risk reduction.

In his presentation entitled; REFLECT study implications for policy, Mr. Brian Luswata the Principal Legal Officer from Ministry of Health (MOH) reported that MOH is conducting an integrated Covid-19 response to the entire public regardless of nationality. He indicated that available data shows that over 151 refugees countrywide have contacted Covid-19 and 3 deaths have been registered. He further revealed that MoH conducts regular trainings of health workers in refugee settlements and quarantine facilities have been created to counter any spread of the pandemic. He noted the timeliness and importance of this study, saying it will directly feed into policy and guidelines on the prevention of COVID-19 and other similar pandemics.

Mr. Brian Luswata the Principal Legal Officer from Ministry of Health (MOH) making a presentation at the event.

Representing the Dean, Makerere University School of Public Health, Dr. Elizabeth Ekirapa commended the REFLECT study team led by Dr. Seruwagi noting that the study will shed more light on how to deal with issues like human behaviour during the Covid-19 pandemic.

“When COVID-19 started people were saying nobody is dying and now people have started to die. Human beings keep coming up with explanations in a manner that you wouldn’t expect. So this study will help us learn on how we can deal with ourselves’’ said Dr. Ekirapa who is also Chair of the Department of Health Policy Planning and Management at MakSPH.

She further appreciated the REFLECT study’s multisectoral approach adding that the findings will contribute to changes in the different multisectoral approaches Uganda is using to address COVID-19.

Dr. Elizabeth Ekirapa commended the REFLECT study team led by Dr. Gloria in her remarks

In her remarks, Prof. Josephine Ahikire,  the Principal of the College of Humanities and Social Sciences (CHUSS) said that the role of Makerere University is to create knowledge that will be used for societal development and transformation.

She equally thanked Government of Uganda for continuous support to Makerere University through the Research and Innovation Fund (Mak-RIF) which also has a provision for research on COVID-19. She congratulated the researchers for the timely study which underscores the academia role in social work, humanity and public health. She also thanked the partners for supporting the initiative.

Prof. Josephine Ahikire – the Principal College of Humanities and Social Sciences (CHUSS) giving her remarks at the event

Jesse Kamstra,  the Country Representative for Lutheran World Federation (LWF) commended Uganda’s effort in the fight against Covid-19.

“I feel safer in Uganda than any other country due to the different adaptations they have taken up to make this disease less spread in the country’’  said  Kamstra.

As implementing partners in the study, he mentioned that LWF expects actionable recommendations and evidence-based understanding of social behaviours of refugees during COVID-19. He further noted that the recommendations will be used to adjust future programming together with other implementing partners like Office of the Prime Minister (OPM)’s refugee department.

Jesse Kamstra the Country Representative Lutheran World Federation (LWF) at the event commended Uganda for fighting Covid-19 at the REFLECT STUDY launch

Ms Ellen Bajenja Kajura the Country Director for ACORD, also one of the study partners, expressed her pride at the partnership with Makerere and the other partners. Even from preliminary findings, she talked about some of the immediate actions her organisation will begin taking forward like designing child-friendly messages on Covid-19 in addition to strengthening ACORD’s programming in child protection and gender-based violence.

At the event, Dr. Misaki Wayengera, Chairman of Scientific Advisory Committee (SAC) on the National Taskforce for COVID-19 revealed  that despite challenges brought by Covid-19,  total reopening of various sectors will go on.

‘’We started opening up but some sectors remain closed because we are still studying transmission dynamics, however we shall continue opening up because we will have to live with COVID-19’’ he explained.

Dr. Misaki Wayengera, Chairman of Scientific Advisory Committee (SAC) on the National Taskforce for COVID speaking at the REFLECT STUDY launch

Professor Noeline Nakasujja the Adhoc Chair (psychosocial) on the COVID-19 Taskforce and also Head of Psychiatry Department of Makerere University College of Health Sciences noted the significant increase in Mental Health issues and psychiatry referrals during COVID-19. She decried the limited infrastructure or community capacity to handle these. She called on all stakeholders to work together in their different capacity to address mental health and psychosocial support especially for more vulnerable populations like those in refugee settings.

Prof. Noeline Nakasujja speaking at the event

During the event, refuge representatives shared their experiences during pandemic response.

On what makes Uganda one of the best refugee host community, Ms. Lilly Anek a Refugee representative from Adjumani had this to say: ‘’Uganda is the best refugee host country because they treat us like brothers and sisters. This is why we intermarry as South Sudanese and Ugandans… people treat us so well’’ Similarly, other refuge representatives like Sandie from Kyaka II  at the event were in agreement with her statement as they confirmed receiving handwashing detergents, face masks and training on COVID-19 prevention. Together, they called upon government of Uganda to put in a place an additional taskforce in the refuge communities so that new entrants are quarantined before joining the community.

The event was graced by officials from Office of the Prime Minister (OPM) which manages the national refugee response, UNHCR, representatives from the ministry of health, Makerere University, civil society, the media and other stakeholders. Discussions during this dialogue centered around the growing numbers of challenges during Covid-19, perceptions and nomenclature, infrastructural limits in refugee hosting communities and adaptations to the new normal in this Pandemic era.

Dr Julius Kasozi representing UNHCR assured the study team that UNHCR is more than ready to take forward  and implement any actionable recommendations from the REFLECT study. In his  closing remarks as government representative, Mr. Byaruhanga of OPM said there was a lot to learn  and adapt from the study. He encouraged the study team to engage further with his office to ensure ownership  and uptake of the study findings.

More about the REFLECT Study

The research topic is “Knowledge, adherence and the lived experiences of refugees in COVID-19: A comparative assessment of urban and rural refugee settings in Uganda”. The project has been shorted to the acronym REFLECT (Refugee Lived Experiences, Compliance, and Thinking).

The study is  cross-sectional mixed  and  has a multinational focus covering refugees from South Sudan, Somalia, and Eritrea, Democratic Republic of Congo (DRC), Rwanda, and Burundi.  Similarly, Study sites are Kisenyi in Kampala, Kyaka II Refugee Settlement in Kyegegwa, South-Western Uganda, and eleven (11) refugee settlements in West Nile.

The REFLECT study is funded by the UK government through Elrha/Research for Health in Humanitarian Crises (R2HC) supported by Wellcome Trust, UKAID and National Institutes for Health Research (NIHR). It is conducted by Makerere University with Dr. Gloria Seruwagi as Principal Investigator. The Co-Investigators are from Gulu University, Agency for Cooperation and Research in Development (ACORD), Lutheran World Federation (LWF), the National Association of Social Workers of Uganda (NASWU) and Ministry of Health. The study team includes Dr Gloria Kimuli Seruwagi, Dr. Denis Muhangi, Dr. Betty Okot, Prof. Stephen Lawoko, Eng. Dunstan Ddamulira, Andrew Masaba and Brian Luswata.

Article originally posted on MakSPH

Mark Wamai

Health

Ugandan sickle cell researchers keep pace with aging patients

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Dr. Sarah Kiguli of Makerere University leads the Fogarty-funded program: Enhancing Research capacity for Sickle Cell Disease and related NCDs across the Lifespan in Uganda (ENRICH).

Article courtesy Fogarty International Center

September/October 2024 | Volume 23 Number 5

Until recently in Uganda, most children with sickle cell disease (SCD) never celebrated their fifth birthday—only 30% lived past this milestone. This low survival rate was mainly due to inadequate health care interventions for these children, plus lack of widespread newborn screening, explains Dr. Sarah Kiguli , a professor at Makerere University College of Health Sciences. Things are different today. Over the past decade, the East African nation has instituted a policy of screening newborns while strengthening strategies to manage their health. This means more children with SCD are growing into adolescence and adulthood.

Challenges still exist, says Kiguli. For example, the community and district facilities where many Ugandan children are born cannot provide comprehensive services, including newborn screening. Another issue: the risk of SCD complications related to kidneys, lungs, heart—almost all organs—grows higher as patients grow older, yet scientific research in Uganda hasn’t caught up with the reality of these longer lives. As a result, teens and adults with SCD don’t get “the care they deserve,” says Kiguli.

“It’s very painful for us pediatricians to see our patients encounter challenges and problems when they transition to adult care.”

Renewed research focus

Despite years devoted to children’s health, Kiguli believes it’s time to prioritize studies exploring appropriate SCD management in teens and adults. “We need solutions that address all the patients’ needs, including reproductive health, as they transition out of childhood.” She’s spearheaded a multidisciplinary research training program for researchers focused on the needs of people with SCD at all ages: Enhancing Research capacity for Sickle Cell Disease and related NCDs across the Lifespan in Uganda (ENRICH).

“Among our PhDs, we don’t have anyone from pediatrics—and that’s fine,” says Kiguli. Importantly, the researchers are trained as a group to amplify the benefits of multidisciplinary collaboration. “We’ve been working in silos—pediatricians alone, physicians alone, social scientists alone—that won’t help us address the comprehensive needs of these patients.”

Methodology has also been given sufficient consideration. “We provide both individual and team mentorship from the beginning,” said Kiguli. Monthly meetings help trainees develop personal development goals and career path plans in the hope they will continue in the field. The program also provides research training to health professionals, such as medical doctors, laboratory personnel, and nurses, who are not necessarily doing degree programs, “so those who manage patients routinely might also benefit,” said Kiguli.

South-to-South unity

For the project, Makerere University has partnered with Busitema University, located in eastern Uganda, where “prevalence of the sickle cell trait is as high as 20%,” says Kiguli. (Sickle cell trait refers to when a person has inherited one mutated allele of the sickle cell gene, not two.) This local prevalence contrasts with about 13% prevalence elsewhere in the country. Studying the disease in a high burden locale is highly relevant, because results may influence policy and treatment guidelines.

Kiguli has other reasons for collaborating with Busitema University, which is less than 15 years old. “We want to build capacity at this young institution since our colleagues there have less chance of doing research than we at Makerere do.” Working and supervising trainees together will give Busitema’s faculty much-needed experience, while providing opportunities for faculty at both universities to learn from each other. Kiguli also hopes the new collaboration will advance progress made as result of the universities’ past partnerships. “Capacity must be built in a sustainable way,” says Kiguli.

“It’s important to work collaboratively and not competitively—this is just as important for Makerere University as it is for Busitema University.”

ENRICH trainees talk about their projects

Dr. Jackline Akello
Photo courtesy of Jackline Akello

Dr. Jackline Akello, PhD candidate

Dr. Jackline Akello, PhD candidate

My project is “Sickle cell disease in pregnancy: Experiences in provision and access to care and adverse pregnancy outcomes at Mbale and Kawempe Referral Hospitals.” As an obstetrician and gynecologist, I work as a lecturer at Makerere University and provide clinical care at the two national referral hospitals. I have encountered significant challenges in managing pregnant women with sickle cell disease (SCD) due to a number of healthcare navigation challenges. Additionally, the diverse cultural beliefs associated with SCD in Uganda affect access to care and ultimately outcome and quality of life for the patient.

By October, I will have started the enrolment of 161 pregnant women with confirmed SCD for my project. These participants will be followed throughout their pregnancies to track maternal and fetal complications, including stillbirths and low birth weight. Their experiences with the healthcare system will also be explored. As a Safe Motherhood champion, I have been focusing on hypertensive disorders in pregnancy, including pre-eclampsia, but this October at the Safe Motherhood Conference I will discuss the effects of SCD during pregnancy with the Ministry of Health. One of the endpoints of my study is to improve care for pregnant women who have SCD to enhance their pregnancy experience and outcomes.

Dr. George Paasi
Photo courtesy of George Paasi

Dr. George Paasi, PhD candidate

Dr. George Paasi, PhD candidate

My project is “The Clinical Epidemiology, Spatiotemporal Patterns and Disease Modifiers of Severe Malaria among Children with Sickle Cell Disease in Eastern Uganda.” Uganda ranks fourth among countries with high burden of SCD and is in the top 10 with respect to malaria burden. Eastern Uganda has the highest burden of both diseases. My project addresses this dual burden of SCD and malaria in eastern Uganda—I want to decipher the SCD-malaria syndemic in this region.

I’m a medical doctor, I have a master’s in public health, and I just finished a fellowship in infectious disease, epidemiology, and biostatistics. I’ve worked at Mbale Clinical Research Institute for the last 10 years. Previously, I worked on an NIH-funded trial in Africa called Realizing Effectiveness Across Continents with Hydroxyurea (REACH) as a medical officer, and now I’m embarking on this PhD training. My hope is that the findings from my study will improve the identification of patients with SCD at risk of adverse outcomes when they get malaria. I also want to identify, through spatial temporal analysis, hotspot locations that require priority interventions. I also want to gain skills as an independent researcher in SCD and make a meaningful contribution to this field.

Dr. Anita Arinda
Photo courtesy of Anita Arinda Dr. Anita Arinda, PhD candidate

Dr. Anita Arinda, PhD candidate

My project is “Prevalence, associated factors, course and impact of major depressive disorder in adolescents with SCD in Mulago National Referral Hospital.” We have limited data on mental health of adolescents with SCD, so that’s why my project mainly looks at depression in adolescents (ages 10 to 17).

In our setting, we are fortunate that children with SCD live past their fifth birthday thanks to improved health care, but this presents new challenges. During adolescence, patients enter a crucial stage where they’re trying to develop their identity, yet they’re also beginning to understand the implications of their condition—that having this serious health condition cuts their life short. I want to understand their experiences. How does depression in adolescents with SCD differ from depression in adolescents without SCD? We know that sickle cell disease causes inflammation, so does that contribute to their depression? How does depression affect clinical outcomes, if at all?

If we can understand the underlying mechanisms of depression in teens with SCD, then we might find new ways to manage their care (as opposed to conventional treatment with antidepressants). I’ll do my research at Mulago National Referral Hospital, which has a clinic dedicated to children and teens with sickle cell disease. The clinic provides many services, but unfortunately no specialized mental health services. One day I hope that changes, so that children with SCD and depression can get help early.

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Job Advert: Position of Principal -College of Health Sciences

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Makerere University seeks to fill the position of Principal, College of Health Sciences. The College of Health Sciences is a semi-autonomous academic unit, which consists of Schools, Academic Institutes, Departments and Centers that carry out general and professional training, teaching, outreach and research in various disciplines.

Job description
The Position is a Senior Post in the University created to give leadership to a College of Makerere University.

The Principal is the Chief Administrative, Academic and Financial Officer of the College and is responsible to the Vice Chancellor, University Senate and the University Council for promoting and maintaining academic excellence, efficiency and order of the College.
Eligibility
The person eligible for appointment should possess the following minimum attributes:

  • Hold a PhD or other academic Doctorate in one or more of the disciplines taught at the College;
  • Be at least at the rank of Associate Professor at the time of application;
  • At least four ( 4) years managerial expenence as a Head of an academic Department, Programmes Coordinator or a Research Project Manager in a University, Tertiary Institution or a reputable National Research Institution
  • Teaching experience of at least Six ( 6) years in one of the disciplines offered in the College he/she intends to lead;
  • Applicants who are at the rank of Associate Professor should not be above 61 years at the time of application.
  • Applicants who are at the rank of Professor should not be above 66 years at the time of application
  • Applicants must have demonstrable expenence of networking, research and resource mobilization. Applicants must attach evidence of resource mobilization and research conducted in the last five years.
  • Be a citizen of Uganda.

Tenure
The Principal is appointed to hold office for a term of four years.
Salary: Scale PU3
Mode of application:

i) Interested individuals should submit a letter of application accompanied with Curriculum Vitae, copies of relevant Academic Credentials and naming three referees;

ii) Applicants should make sure that at least two of the three referees have forwarded references concerning their application and suitability by the stated deadline;

iii) The deadline for submission of applications is 7th October 2024 at 5:00p.m.
East African time.

Applications should be submitted to:

The University Secretary
Makerere University
Frank Kalimuzo Building, Study Room 4.1
P.O. Box 7062
Kampala, Uganda
Or search.principals@mak.ac. ug

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IMPACT Program Newsletter Sept. 2024

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A Screenshot of the IMPACT Program Newsletter September 2024. College of Health Sciences (CHS), Makerere University, Kampala Uganda, East Africa.

A very special welcome to the first edition of our newsletter of Makerere University’s Impact research capacity building program. The program is funded by a generous grant from the NIH Fogarty International Center to reduce the impact of rheumatic heart disease across all affected ages. For more than a decade Uganda has been at the fore front of rheumatic heart disease (RHD) research in sub-Saharan Africa. Building on that Foundation Makerere University College of Health Sciences decided it was opportune time to strengthen collaboration with Uganda Heart Institute and US partners: Cincinnati Children’s Hospital Medical Centre (CCHMC) and Children’s National Hospital (CNH) to uplift Uganda’s research capacity to innovate and generate knowledge critical for elimination of rheumatic fever and rheumatic heart disease in the long run.

Whereas doctoral training of doctors and nurses is the main focus of our capacity strengthening initiatives, other levels are not left behind. Training is concurrently ongoing at master’s degree level and in-service for health professionals to better their research careers. The training spots were nationally advertised publicly and recruitment of trainees was competitive. Major research activities are taking place in rural communities in which rheumatic fever is relatively common. The program puts emphasis on community engagement so that the public can understand the importance and centrality of their actions in the control and elimination of rheumatic fever and achieving better quality of life and survival of those having rheumatic heart disease and its complications. The program pays special attention to gender issues in the research we do.

Prof. Emeritus Nelson Sewankambo
PRINCIPAL INVESTIGATOR

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