Health
Interventions to Increase Compliance Levels Around COVID-19 In Refugee Communities
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.
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.
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.
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.
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.
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.
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
KAMPALA, July 9, 2025 — Makerere University has been hailed as a continental and global leader in health policy and systems research. This recognition came during the Partnerships for Stronger Knowledge Systems in Africa (KNOSA) Learning Forum, held July 8–10, 2025, hosted by Makerere University School of Public Health (MakSPH) with support from the WHO Alliance for Health Policy and Systems Research.
Delegates from Uganda, Kenya, Ethiopia, and Somalia applauded Makerere’s role in advancing evidence-informed policymaking and strengthening national knowledge systems. The forum highlighted the institution’s trusted leadership, practical research, and commitment to driving real change.
Dr. Kumanan Rasanathan, Executive Director of the WHO Alliance, praised Makerere’s long-standing role in bridging research and policy:
“You are a shining beacon on the continent and for the world,” he said. “In this moment of crisis, where every health investment must be efficient and equitable, Makerere’s leadership matters more than ever.”
He emphasized the Alliance’s 25-year partnership with Makerere: “We know Makerere University very well. My predecessors have worked with the Alliance since its inception in the 1990s. Makerere has been especially instrumental in advancing the field of health policy and systems.”
Dr. Rasanathan called for a move away from siloed approaches toward more adaptive, coherent systems. He reaffirmed WHO’s commitment to supporting regional initiatives like KNOSA that are driving this shift across Africa.
In the face of current funding cuts, Dr. Christine Musanhu of the WHO Uganda Country Office echoed these sentiments with a stern call to action: “In times of uncertainty, we need national systems that not only generate evidence but also understand and communicate it in ways that drive real change.”
She warned of tightening budgets, citing an 11% cut (roughly $67 million) in global funding for Uganda’s public health programs. “We are being asked to do more with less,” she said, urging countries to reprogram resources towards high-impact, evidence-based interventions.
Adding that, “Evidence must go beyond routine data—it is a measure of transformation.”
This year’s KNOSA forum focused on sharing country-level progress, refining evaluation approaches, enhancing communication products, including scientific publications, and engaging more deliberately with Uganda’s wider policy and research ecosystem.
Makerere University Vice Chancellor Prof. Barnabas Nawangwe, while sharing the institutional vision, called for African universities to lead from the front in addressing health and development challenges: “We can do all the research in the world, but unless it moves beyond our laptops and lecture rooms into real decision-making spaces, it won’t change lives.”
He noted that Makerere contributes over 80% of Uganda’s academic output and praised MakSPH and the College of Health Sciences (MakCHS) for innovations that have shaped responses to HIV, Ebola, and COVID-19. “Our work, backed by partnerships with government and global collaborators, is proof that African universities must lead from the front.”
Professor Nawangwe urged deeper collaboration within KNOSA: “Our continent is interconnected. We cannot afford to work in silos. We are stronger together.”
Dr. Aku Kwamie, the unit head at the WHO-Alliance, noted that there is a need for partners to shift their thinking regarding policy. She particularly shared three critical transitions to institutionalize evidence use: embedding knowledge within institutions, not just individuals; linking research directly to decision-making; and advancing from isolated academic work to system-level thinking. These shifts, she noted, are essential for embedding evidence into routine governance.
Professor Freddie Ssengooba, a Health Policy and Knowledge Systems expert at MakSPH, reaffirmed Makerere University’s regional leadership in the field and stressed the urgency for African countries to take full ownership of their health systems considering the shifting funding landscape:
“Health policy and knowledge systems research may not be as prominent as epidemiology or disease control,” he said, “but it’s central to how we harvest and connect knowledge with policy and resources. When the vaccine is here and the evidence is clear, that’s when they come to us, asking, “How do we achieve over 80% coverage?”
He praised KNOSA for helping elevate the field’s relevance: “There’s real appreciation for the work we do—not just with Uganda’s Ministry of Health, but across the region.”
Recalling the early collaboration with WHO, he said, “Back in 1997–98, a few of us, myself included, responded to an initial call and began what has now become a long-standing relationship with the WHO Alliance.”
“The Alliance is building capacity across Africa to ensure that research doesn’t stop at findings but goes on to shape decision-making and society,” he disclosed.
Professor Rhoda Wanyenze, the Dean of MakSPH, is currently ambitiously driving her colleagues, staff, and partners to embrace the culture of evidence use. She reiterated the School’s commitment to leading in evidence translation: “I’ve often told the Vice Chancellor—we at the School of Public Health are not in an ivory tower. We are deeply connected to real-world problems.”
To her, the need for a clear framework to improve engagement with decision-makers and address uneven success in research translation has never been greater than now: “Yes, we publish in high-impact journals. But the question is, what change happened because of your evidence?”
“I would love to see the School lead in developing a framework that showcases what we’ve done well and identifies where we can grow.”
She also acknowledged Prof. Ssengooba’s influence in broadening the lens on knowledge management: “You’ve challenged us to think beyond institutions, to consider networks and systems. That’s a gap we must fill.”
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