4.1 Socio-Demographic Characteristics
Ten local council leaders in charge of six villages from three districts, viz; Sironko, Bulambuli, and Butalejja, in Eastern Uganda participated in this study. Most of the participants were males since top the leadership of village councils in Uganda is exclusive to men. Most participants (50%) fell in the age category of ≥ 60. Though 60% of the participants attended primary education, none of the respondents completed an ordinary level of education to attain the Uganda Certificate of Education (UCE).
4.2 Knowledge and perceptions about the COVID-19 pandemic
Though all the respondents reported having received some information about the existence of the COVID-19 pandemic, there was generally low knowledge and awareness about some crucial aspects of the pandemic. The majority (70%) of the respondents did not know the meaning of COVID-19, while 100% were unaware of some common symptoms such as; headache, sore throat, nausea, vomiting, malaise, muscle pain, diarrhea, loss of taste & smell among others(18). Low knowledge levels about COVID-19 might be partly attributed to the high illiteracy levels among the respondents, since none of them attained the ordinary Uganda Certificate of Education (UCE). Elsewhere, low education levels have been associated with limited ability to comprehend health information, hence predisposing communities to a higher risk of disease transmission (21). Similar to prior research (22–24), our study revealed that radio (9; 90%) was the main source of health information used by the respondents. The scarcity of hydroelectricity power might explain why some information sources such as televisions and the internet were uncommon. Our findings were however in discrepancy with some recent studies conducted in Nigeria and in the United States of America (USA) where other sources of health information besides radio were utilized more(25, 26). In the USA, majority of respondents reported reliance on health professionals as sources of health information, and that age, income and education influenced people’s choice of health information sources (26).
Some clients (10%) falsely believed that the COVID-19 pandemic was a fallacy in Uganda. This misconception may be attributed to the scarcity of genuine COVID-19 information which has created room for the spread of wrong information about the pandemic, especially in rural settings. Most of the participants believed that; hygiene, accessibility to health information, belief that COVID-19 truly exists, contact tracing, and access to sanitizers (100%, 80%, 90%, 100%, and 70%) were very important in influencing the control of COVID-19; while 10% did not know whether high prevalence rates, willingness to adhere to health guidelines and people’s desire to exercise freedom of association & work, could have significant impacts on control of COVID-19. Failure to appreciate the importance of these crucial epidemiological factors poses a threat to the effective prevention of the pandemic.
4.3 Roles of village leaders in the management and control of community transmission of COVID-9.
Participants who confirmed to be formally involved in the fight against COVID-19 in the villages they administer were eighty percent (8; 80%). Similarly, in Thailand, the enormous role of Village Health Volunteers (VHVs), particularly local people or village leaders, in community-based surveillance (CBS) and reporting of highly contagious viral infections has been reported (27). In Thailand, the VHVs were subjected to basic training on how to recognize disease occurrence prior to their engagement in the CBS.
Most participants reported that they respond to alert cases by inviting the concerned government officials and health professionals to manage the cases. This action is appropriate since it rhythms with the Ugandan Ministry of Health’s guidelines (14). Some respondents (10%) reported that they offer first aid to COVID-19suspects, while others reported “taking no action”. The former may accelerate the spread of the pandemic because local council leaders do not have the expertise and mandate to administer any treatment to COVID-19 suspects, while the latter incurs a public health threat since village council leaders are potentially the most immediate government officials available in remote rural settings, and owe to respond appropriately to COVID-19 notification. This is authenticated by the COVID-19 gazette of the government of Uganda (14).
The commonest approaches employed by most respondents to engage in the fight against COVID-19 were; dissemination of COVID-19 information by word of mouth through door-to-door meetings, regulation of public ceremonies such as burials and weddings, and monitoring of visitors that come from distant places. Though these approaches are generally tedious in the event that the personnel lack adequate financing, they have reportedly been employed in other countries(25, 28). For example, a study by Anna Biley et al., 2000 in the United Kingdom reported word of mouth as a commonly used avenue of conveying health information, followed by leaflets, television, and newspapers (28).
Most respondents reported that residents in the villages where this study was conducted had not yet received any aid in form of masks, soap, sanitizers or food, to enhance effective prevention of COVI-19 as reported in some urban parts of Uganda (29), except for some villages in Butalejja district where the residents had received minimal aid in form of soap from a non-government organization called CHLORINE. Generally, the deficiency of materials that are essential in preventing COVID-19 among rural communities was evident.
4.4 Opinions of local leaders about the COVID-19 pandemic
The respondents believed that in the areas where this study was conducted, the degree of community compliance to COVID-19 preventive guidelines was declining drastically at both the household level and in public places. This could be explained by low awareness, inadequate anti-COVID-19 campaigns, and falsified belief of some residents in these rural villages about the non-existence of COVID-19 pandemic in Uganda. The implication is that rural communities in Eastern Uganda are potential candidates for a drastic upsurge of COVID-19 and hence severer damage. Though the respondents were certain about factors that favored their effective participation in the fight against this pandemic, they iterated that their contribution to the fight against COVID-19 was hampered mostly by limited access to COVID-19 information, the inadequacy of communication resources accessible to the rural communities such as radios, high levels of illiteracy among the communities, long-distance to COVID-19 treatment and isolation centers, plus the fact that some of their subjects believed that the village council leaders were not suitable to engage in matters of critical public health importance such as COVID-19.
The respondents opined that the COVID-19 pandemic had incurred negative impacts on both rural and urban communities, with some of the notable cases being; loss of wages and income, loss of human capital, straining of the health sector as well as disruption of social wellbeing and liberty to associate. These opinions are in tandem with several reports which have assessed or projected the adverse socio-economic impacts of COVID-19 on several countries including Uganda, Kenya, United Arab Emirates, and Mexico among others (30, 31).
The respondents also mentioned interventions that may improve preparedness and response to COVID-19 in rural settings, and hence minimize the damage incurred by the pandemic. These included; provision of aid in form of materials necessary for COVID-19 control such as soap and masks, scaling up the water supply and health systems, routine surveys to identify potential asymptomatic COVID-19 cases, and improving health awareness creation.
4.5 Potential risk of community transmission of COVID-19 in rural districts in Eastern Uganda.
The key geographical factors that potentially posed a risk of COVID-19 upsurge to the areas included in this study were: proximity to the porous Kenya-Uganda border(32), hence increased susceptibility to imported COVID-19 cases; tapping water from open sources such as river Mpologoma by a section of the population; and the presence of a mountainous terrain which complicates accessibility hence straining case management. Regarding the porous borders, the potential contribution of people entering Uganda from Kenya, possibly via informal entry points, to the rise of COVID-19 cases in Uganda has been acknowledged previously(8). Also, challenges related to mountainous terrain have been implicated in impeding health service delivery in other countries such as Britain(33). Further, the fact that some of the community members in Butalejja district fetch water from river Mpologoma creates public health concerns with regard to COVID-19 spread. This river receives its water supply from various streams especially from Mountain Elgon; and it flows through several districts in Eastern Uganda, including COVID-19 hotspots such as Mbale district and Tororo district (34, 35). Pollution of river Mpologoma, including sewerage discharge by humans in these hotspots, has been reported (36). This poses a threat to rural communities that use this water downstream since the COVID-19 pathogen (SARS-Cov.2) has been proved to survive in sewerage and in untreated waters in some places (37, 38).
With regard to social factors, breaching of the WHO public health guidelines and the Ugandan government directives set to fight COVID-19 was observed in public places such as markets, streets, sports grounds and all other community gatherings. Commonest indicators included scarcity of mask-wearing & hand-washing resources, and lack of social distancing. This may partly be attributed to the inadequacy of COVID-19 awareness campaigns that would rather be implemented in avenues such as songs, posters, banners, and billboards in the rural communities. In Nigeria, low health awareness was associated with an increased risk of disease spread and decline of the overall public health quality (39).
Economically, we observed the undue presence of commercial perishable agricultural produce such as bananas and tomatoes in rural communities. This could be explained by financial constraints and transportation challenges incurred by COVID-19 restrictions on the traders who deal in conveyance of agricultural merchandise from rural villages to urban markets. The consequence is a potential risk of financial losses incurred to the farmers, and hence impairing their ability to meet the monetary demands of COVID-19 prevention and treatment.
At the homestead level, the availability of locally innovated handwashing gadgets (Fig. 7), was the major and sole indicator of community responsiveness to the COVID-19 pandemic. Though these gadgets were scarcely present, and with no soap availed in some cases, they rather exhibited a positive attitude towards alleviation of this pandemic by the rural communities amidst resource constraints. We also observed that in most cases, the sizes of houses were not commensurate to the large families, in light of the high populations situated in Uganda’s rural settings as compared to urban places (11). The consequence is a potential risk of inhouse accelerated COVID-19 in-house spread in rural communities. Also, we observed the scarcity in homesteads, of food staffs which have been recommended in boosting the body’s ability to fight respiratory viruses such as SARS-Cov.2 (20). This may pose treatment challenges in the case of COVID-19upsurge in these remote rural villages.
4.6 Conclusion and recommendations
Rural communities in Eastern Uganda are vulnerable to the explosive spread of COVID-19, due to challenges related to; low awareness of COVID-19, reluctance in complying with preventive guidelines, finance, technology, terrain, porous borders, scarcity of protective wear and hygiene resources, and Illiteracy. Awareness creation, material aid, execution of preventive rules, and more research on COVID-19 are warranted.