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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

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Makerere University Research shows challenges facing Forcibly Displaced Persons (FDPs) with Chronic Disease in Northern Uganda

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Left to Right: Dr. Esther Nanfuka Kalule, a postdoc fellow on this study; Emma Ikwara, a researcher at CHDC; PhD student Onesmus Kamacooko at CHDC and Dr. Ritah Nakanjako interacting after the colloquium.

By Agnes Namaganda

Preliminary findings from a study by Child Health and Development Centre (CHDC) -Makerere University have revealed several challenges faced by Forcibly Displaced Persons (FDPs) with chronic diseases like diabetes, hypertension and cardiovascular diseases. This study is specifically looking at FDPs in northern Uganda. Accessing food, water, medicine, clothing, toilet facilities, privacy and support is a challenge for healthy FDPs but for those with chronic diseases, these provisions may mean the difference between life and death.

According to Drs, Ritah Nakanjako and Esther Nanfuka Kalule, who are post-doc fellows at Makerere University, FDPs with chronic diseases are unable to access facilities with medicines. Speaking at the February monthly colloquium of CHDC, Dr. Nanfuka said, “Medicines and medical forms are sometimes forgotten by these patients yet some do not know the names of their medicines. For others, these medicines get finished along the way due to the abrupt movements.” These disturbances in the continuity of care affects their health and wellbeing.

Left to Right: Dr. Esther Nanfuka, Dr. Ritah Nakanjako, Dr. Godfrey Siu who is giving the presenters feedback about their presentation and Dr. Aggrey Dhabangi.
Left to Right: Dr. Esther Nanfuka, Dr. Ritah Nakanjako, Dr. Godfrey Siu who is giving the presenters feedback about their presentation and Dr. Aggrey Dhabangi.

As an example, she referred to the constant need to monitor blood pressure or blood sugar for these FDPs. “Even when facilities are available, you may not have the money to refill medicines or you may not remember the name of the medicine.” She added that the stress and trauma of this kind of situation usually exacerbates these conditions.

Speaking about the rationale for doing this research, Dr. Nakanjako said that non-communicable diseases (NCDs) are largely unrecognized and inadequately addressed in humanitarian settings, something which the Red Cross calls ‘a neglected crisis’.  Yet, studies conducted among refugees and asylum seekers across the world report a high burden of NCDs. Uganda hosts over 1.5m refugees, the highest proportion in sub-Saharan Africa with the majority comeing from South Sydan.

“The objective of this study is to examine the experiences of FDPs- which will contribute to knowledge on innovative ways of chronic disease care. This will also contribute to the management of NCDs in humanitarian, low resource settings,” Dr. Nakanjako explained.

Dr. Godfrey Siu (Left) and Dr. David Kyaddondo who is the Principal Investigator of this project interacting with other members of CHDC after the CHDC monthly colloquium which takes place every last Wednesday of the month.
Dr. Godfrey Siu (Left) and Dr. David Kyaddondo who is the Principal Investigator of this project interacting with other members of CHDC after the CHDC monthly colloquium which takes place every last Wednesday of the month.

This 5-year study that started in 2022 will run till 2026 and is funded by the Novo Nordisk Foundation under the Mobility-Global Medicine and Research Fund. It is a collaboration between three institutions; Makerere University, the University of Copenhagen, Denmark and the Sudan Centre for Strategic and Policy Studies in South Sudan. This research is taking place in Nyumanzi Reception Center in Adjumani district; Nyumanzi Refugee Settlement also in Adjumani district; IDP Settlements in South Sudan; and the Bidi Bidi Refugee Settlement in Yumbe District.

Other challenges revealed by the FDPs with chronic diseases include the fear of drinking recommended amounts of water before or during travel to manage urine and to avoid stop-overs for security reasons.

After arrival at Nyumanzi Reception Centre in Uganda, these FDPs with chronic diseases do not receive any special care. It is only those with communicable diseases like TB. Cholera or Covid19 that get special care. Other challenges include; “a limited range of drugs, maintenance of cold chains for insulin, rationed water, lack of drinking water, lack of sanitary facilities and the congestion.

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Water, Sanitation and Hygiene (WASH) Short Course 2024

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Some of the 22 participants that successfully completed the Water, Sanitation and Hygiene (WASH) certificate course joined by course facilitators and administrators show off their certificates in July 2022 at MakSPH. Makerere University School of Public Health, New Mulago Hospital Complex, Kampala Uganda, East Africa.

Did you know that with just a Uganda Advanced Certificate of Education (UACE) or its equivalent, along with at least 1 year of working experience in WASH, you qualify to join our Short Course in Water, Sanitation and Hygiene?

The Department of Disease Control and Environmental Health at Makerere University School of Public Health brings you yet another opportunity to enhance your skills and knowledge in Water, Sanitation, and Hygiene from for the 2024 intake, scheduled to run from 20th May to 12th July 2024.

Designed to equip practicing individuals with the necessary attitudes, skills, and scientific knowledge for effective WASH management, this course is open to officers with limited training in WASH and Environmental Health Practitioners seeking continuous professional development. For more details and application instructions, please refer to the attached course poster or visit the course website at https://sph.mak.ac.ug/academics/water-sanitation-and-hygiene-wash.

Apply before Thursday, 28th March 2024 for a rewarding learning experience!

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Call for Abstracts: Annual Health Professions Education Scientific Conference

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The Vice Chancellor, Prof. Barnabas Nawangwe (Centre Mak tie) with participants at the Health Professions Education Conference held 11th to 12th May 2023 at Hotel Africana, Kampala Uganda.

The Health Professions Education and Training for Strengthening the Health System and Services in Uganda Project (HEPI-SHSSU) at Makerere University College of Health Sciences (MakCHS) is organizing the Annual Health Professions Education Scientific Conference.

Venue: Hotel Africana, Kampala, Uganda

Conference Dates: 10th and 11th April 2024

Theme: Advances in Health Professions Education:  Research, Innovations in Teaching & Learning, Quality Assurance

Sub-Themes

  1. Quality Assurance & Accreditation
  2. Health Professions Education Research
  3. Online Learning  
  4. Innovations in teaching and learning
  5. Graduate Education in Health Sciences
  6. Simulation-Based Learning

Abstracts are welcome in any of the above areas for oral presentations, mini-workshops, thematic poster sessions, and didactic sessions.

We welcome abstracts from all people involved in the education and training of doctors, nurses, allied health professionals, students, health providers, and other stakeholders.

Abstract Submission:

Abstracts should be structured into:

Background, Objectives, Methods, Results, Conclusion

For Education innovations: What was the problem, What was done, Results, and Conclusion (300-word limit).

Include the details of the corresponding author, the author(s), their contacts, and Affiliation.

Send your abstract to: hepishssu@gmail.com

Register today: https://hepi.mak.ac.ug/conference/

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