Perceptions and adherence to preventive measures for Coronavirus Disease 2019 among rural communities in Uganda

1) Project background, context and needs addressed The Coronavirus Disease 2019 (COVID-19) pandemic has spread to over 205 countries and territories globally with over 2 million confirmed cases and 140,000 deaths. Africa has the least burden of confirmed cases but is expected to rise exponentially. Uganda has so far registered 74 confirmed cases, and 9% are locally transmitted. COVID-19 is spread from person to person through respiratory droplets and contact with contaminated objects. In the absence of effective treatment or vaccines, governments worldwide have opted for non-pharmaceutical interventions. Low-income countries such as Uganda may not be able to manage exponential increases in COVID-19 cases because of weak health systems. Consequently, the Government of Uganda has implemented stringent preventive measures for the disease which are largely behaviour-based. These measures include frequent hand washing with soap, physical distancing, self-quarantine for those with symptoms, avoidance of non-essential travel, avoiding contact with the eyes, nose and mouth, and staying home . Information on these measures has been communicated to the general public through mass media platforms such as televisions, radios, newspapers and social media. Messages have taken on various forms such as songs, presidential directives and ministerial speeches. Rural communities of Uganda are home to over 75% of the population who are largely poor with limited access to health services. These communities have lower literacy rates, limited access to electricity and smart phones, and majority cannot afford internet services. In addition, the communities are usually hard-to-reach, have poor telecommunication network, and as such may have limited access to information on COVID-19 prevention. Another challenge faced by rural settings is limited access to safe water and soap which may reduce their adherence to personal hygiene measures. High numbers of people living per household in rural communities may reduce adherence to physical distancing. Studies currently being conducted in Uganda on the adherence to COVID19 measures are majorly web-based and use self-administered questionnaires. Consequently, these studies exclude residents of rural communities by enrolling only participants with access to a computer or smartphone, internet and with high literacy levels. This study therefore aims to understand the perceptions and adherence to COVID-19 preventive measures in the midst of the challenges associated with living in rural Uganda. 2) Aims or research questions being addressed Broad objective To assess community perceptions and adherence to COVID-19 preventive measures in rural Wakiso district, Uganda in order to provide essential information needed by public health officials and other stakeholders to make an informed decision on the most effective strategy for reduced transmission. Specific objectives 1. To establish community perceptions towards COVID-19 preventive measures. . 2. To assess community adherence to COVID-19 preventive measures as issued by the Government of Uganda. 3. To explore community barriers and facilitators of adherence to COVID-19 preventive measures. 3) Study design Methods Study design The study will be a community-based cross-sectional study that will involve both quantitative and qualitative methods. A semi-structured questionnaire will be used to collect data on specific objectives 1 and 2. An observational checklist will be used to collect data on specific objective 2. A Focus Group Discussion (FGD) guide and Key Informant Interview (KII) guide will be used to obtain data on specific objective 3. Study Area The study will be carried out in Wakiso district located in central Uganda. It is the most populated district in the country with a population of 1,997,418 as per the 2014 census, and has 8 constituencies. Consequently, the district was chosen as an appropriate site because of its largely rural population. A recent report for the district shows 38% of households had no access to electricity, illiteracy rate at 9.5% among persons aged 18 years and above, and the most common occupation being subsistence farming (65%). The average household size is 4.7 with 47% households resided in dwellings with only one room for sleeping. In the district, 30.2% of household members are aged at least 10 years and 31% of households have no member with a mobile phone. Radio remains a dominant (65.3%) source of information to the households, 24.6% of persons aged at least 10 years use internet, 62.8% of households have access to drinking water while 12.0% of households own a computer. Study duration 12 months Sample size calculation and sampling Using the formulae for cross sectional studies, assuming a sampling error of 5%, and a statistically conservative prevalence of 50% adherence to COVID-19 preventive measures (COVID -19 is a new disease therefore there are no previous studies carried out on this subject in Uganda), a final sample size of 385 participants was obtained. 4 parliamentary constituencies will be randomly selected from the 8. 2 rural sub-counties will be randomly selected from each of the 4 constituencies. From each sub-county, 2 villages will be randomly selected. From each village, households shall be selected by systematic random sampling. Within a household, the household head or an adult above 18 years in the absence of the household head will be involved in the study. Data collection At each household, data will be collected using a semi-structured questionnaire and observational checklist by trained research assistants with proficiency in Luganda, the local language mostly used in Wakiso district. Respondents will be asked questions on: knowledge on COVID-19; perceptions on COVID-19 preventive measures such as individual susceptibility, effectiveness of preventive measures, belief in government; level of adherence to COVID-19 preventive measures such as social distancing, staying at home, hygiene measures, self-quarantine when with symptoms, avoidance of unessential travel; assess the determinants of adherence such as age, sex, socio economic status, gender, size and household composition, level of education, communication channels, culture, and accessibility to water and soap; coping mechanisms such as water storage, bulk buying, alternative sources of disinfectants. An observational checklist will be used to observe type, functionality and usage of handwashing facilities as well as presence of soap. Data collection tools will be pretested in a rural village within Wakiso district that will not be part of the study sites. During pretesting, validity and reliability of individual questions in the questionnaire will be assessed. For the qualitative component, 6 FGDs will be conducted among community health workers (front line health workers based in the community) in 4 constituencies. 12 KIIs will be conducted among local leaders, health practitioners, religious and cultural local leaders, and district health authorities. Respondents will be asked questions on barriers and facilitators adherence to COVID-19 preventive measures such as political will, availability, affordability and accessibility to enabling environmental factors, and coping mechanisms. Data collection will be supported with FGD and KII guides, which will be developed in English, and translated to the local language. Data management and analysis Quantitative data will be examined and cleaned on a daily basis during data collection and will be entered in EpiCollect5. Data will be exported to Stata 15 software for analysis. Qualitative data will be audio recorded, transcribed, translated (where necessary) and analysed using thematic analysis with the help of Atlas ti. Ethical considerations Ethical approval for the study will be obtained from the Makerere University School of Public Health Higher Degrees, Research and Ethics Committee, and registration at the Uganda National Council for Science and Technology. Participation in the study will be voluntary. Consent and confidentiality The reason for the study will be explained to participants in simple clear terms and in a language they understand best after which a written consent will be obtained prior to the start of data collection. Participant names will not be recorded, and data will be stored and backed up on drives that are passcode-protected which only the principal investigator will have access. 4) Approach used to maximise the impact of research outputs, to improve health and the research community • Stakeholder involvement from the early stages of the research to create ownership. Stakeholders will include from Ministry of Health, Wakiso District Health Office, and village / local council chairpersons, health workers from surrounding health facilities, and influential persons such as religious and cultural leaders. • Dissemination of findings to all stakeholders (listed above). • Dissemination of findings to the study areas through a community dissemination workshop and community radios. • Publication of findings in an open access peer-reviewed journal, blogs, newspaper articles and presentations in conferences and seminars. • Open access to data sets for future secondary analysis. 5) Expected outcomes • To provide essential information that will be used to design interventions related to recommended preventive measures for COVID-19 among rural communities in Uganda. • Results will be used for future planning in case of other related epidemics and pandemics. • Information will be used to advocate for the most effective strategy for reducing transmission of COVID-19 and related viruses in rural areas in Uganda. 6) Your role in the project • I will be the principal investigator therefore involved in overall project oversight with supervision from Dr. David Musoke (my immediate supervisor at Makerere University). • Specifically, I will be involved in conceptualization of the study, data collection, data entry and analysis, manuscript writing and dissemination.