Survey participation
The response rate was 55% (n = 225) across the sample, with 197 participants who completed the survey online and 28 participants who elected to respond via phone call. This response rate was higher than expected compared to other electronic surveys, which have reported response rates of approximately 25% (for example [10, 11].) Respondents participated from 84% (n = 113) of districts in Uganda (Fig. 1.)
Respondent characteristics
The distributions of respondent characteristics are shown in Table 1. Most of the respondents have more than five years of professional experience (91%) and are involved with programme implementation (65%). In terms of education, most of the respondents had achieved at least a Diploma (88%) and only eight individuals (4%) reported that they had not completed a minimum of a Certificate qualification.
Table 1
Survey respondent characteristics
Characteristic | n | % |
Professional experience (yrs) |
< 1 | 2 | 1 |
1–5 | 18 | 9 |
6–10 | 58 | 29 |
11–20 | 72 | 36 |
> 20 | 52 | 26 |
Education |
Primary | 2 | 1 |
Secondary | 6 | 3 |
Certificate | 17 | 8 |
Diploma | 65 | 32 |
Bachelor’s degree | 72 | 36 |
Master’s degree | 38 | 19 |
Doctorate | 1 | 0.5 |
Region |
Central | 34 | 17 |
Eastern | 67 | 33 |
Northern | 61 | 30 |
Western | 39 | 19 |
Job activities* |
Policy development | 11 | 5 |
Programme implementation/support | 131 | 65 |
Clinical | 86 | 43 |
Laboratory | 14 | 7 |
*Respondents could select more than one activity |
Perspectives on the state of COVID-19 in Uganda
To provide context to the responses, the survey captured the respondents’ perspectives on the state of COVID-19 in Uganda. The majority of participants reported that Uganda’s response had been either “Good” or “Fair” compared to other countries (49% and 31%, respectively.) Further, in terms of the national COVID-19 guidelines at the time of the survey, 79% of respondents “Agreed” or “Strongly Agreed” that they were clear and sufficient for the general population.
To understand how the burden of COVID-19 compares to the impact of other diseases on the everyday lives of Ugandans, survey participants were asked to rate COVID-19 alongside fifteen diseases with the highest Disability Adjusted Life Years (DALYs) in Uganda, as reported by the Global Burden of Disease estimates for the year 2019 [12]. Figure 2 shows the percentage of respondents who rated the burden of each disease from “No impact” to “Highest impact” on the everyday lives of Ugandans, with the diseases listed in descending order from highest DALYs to lowest DALYs. COVID-19 is listed last because DALY estimates are not available yet. Most participants (over 60%) described malaria as having the “highest impact” on Ugandans. Over 50% of respondents described neonatal conditions as having “no impact” or a “minor impact” on the lives of Ugandans, while only 3% described neonatal diseases as the “highest impact”, despite this being the highest cause of DALYs in Uganda.
Reports of disruptions to health services were widely reported at the beginning of the COVID-19 pandemic [13, 14]. The participants were asked to select which of the services had been disrupted at the beginning of the pandemic and then also select which services were still disrupted at the time of the survey (approximately 9–12 months after the pandemic began.) All respondents reported that at least one type of health service had been disrupted at the beginning of the pandemic, while over 14% of respondents reported that there were no longer disruptions to any health services at the time of the survey. Figure 3 shows the percentage of participants who responded that routine services, emergency services, and/or public health outreach and campaigns had been disrupted at the two time points. At the time of the survey, the majority of respondents still thought public health outreach/campaigns were still disrupted, while most respondents felt that there were no longer disruptions to routine and emergency services. When asked to name specific programmes or services that were most urgently needed to restart, the most frequently mentioned were HIV outreach services, antenatal services, and immunization campaigns.
Personal protective equipment (PPE) is a key aspect of limiting the transmission of COVID-19. The survey participants were asked about whether they had adequate PPE in order to be protected during their work activities. In total, 85% of respondents did not have adequate PPE to protect themselves during work activities. The percentage did not vary significantly by job level. However, there were variations geographically, with districts in the Central and Northern regions reporting more adequate PPE compared to those districts in the Western and Eastern regions (Table 2.)
Table 2
Percent of respondents reporting that they do not have adequate PPE to protect themselves during work activities
Geographic region | n | % |
All regions | 191 | 85 |
Central | 173 | 77 |
Eastern | 202 | 90 |
Northern | 175 | 78 |
Western | 214 | 95 |
When asked to report which specific PPE they were lacking, the respondents reported the following: 55% lacking surgical masks, 69% lacking respirator masks, 44% lacking gloves, 68% lacking face shields/visors, 63% lacking eye goggles, and 73% lacking gowns, aprons, or coveralls.
Sources of information for health workers
Respondents were asked to select the information sources they use or access at least once per month (Table 3.) The results indicate a decidedly social process of information gathering, with three of the five most utilised sources being modes of interacting with others. The second most frequently selected source of information was hard copies of Uganda Ministry of Health materials, which was reiterated throughout the survey. This is especially key for those individuals, particularly those working at the sub-district level, who may not have reliable access to the internet to find and use the most up-to-date materials on websites. Interestingly, peer-reviewed articles and reports from outside Uganda were reportedly used least frequently by respondents.
Table 3
Percent reporting use of specific sources of information for their job
Sources of information | n | % |
Social Media | 160 | 79 |
MoH hard copy materials | 148 | 73 |
Work meetings/colleagues | 147 | 73 |
MoH electronic materials | 129 | 64 |
Community meetings | 128 | 63 |
WHO electronic materials | 109 | 54 |
Mass media | 104 | 51 |
Textbooks | 102 | 51 |
WHO hard copy materials | 101 | 50 |
Published papers and reports from Uganda | 86 | 43 |
Religious leaders | 86 | 43 |
Published peer-reviewed articles and reports from outside Uganda | 68 | 34 |
In terms of sources consulted specifically for COVID-19 information, the respondents were asked which current channels utilised by the Ministry of Health they used to access information. The most frequently reported source of information was mass media/news media websites, followed by the Uganda Ministry of Health website/media (Table 4.)
Table 4
Percent reporting use of channels for COVID-19 information for their job
Channel | n | % |
Mass/news media | 180 | 89 |
MoH website/media | 156 | 77 |
Social media | 140 | 69 |
Personal messaging apps | 127 | 63 |
WHO website/media | 120 | 59 |
Peer-reviewed journals | 56 | 28 |
About three-quarters (74%) of respondents reported that they had adequate information about COVID-19 to stay safe and perform their jobs. When asked to specifically identify how the COVID-19 information they receive could be improved, the responses fell into four categories: improvements in the actual content and format information, increased training and learning opportunities, improvements in the dissemination strategies, and empowering health workers. To allow for prioritisation of improvements, the distribution of respondents who reported suggestions under each of these categories is shown in Table 5, along with examples of the most mentioned suggestions under each category.
Table 5
Respondents’ suggested improvements in the COVID-19 information they receive
Responses | Examples | n | % |
Improve the content and format of COVID-19 information | Translated versions of materials, add visual content to materials, share current research findings | 60 | 46 |
Training and learning opportunities for health workers | Online workshops, mentorships, training follow-ups, training refresher courses | 46 | 35 |
Improve the dissemination of COVID-19 information | Hard copies of guidance/information, utilisation of multiple forms of communication (especially SMS and email), more frequent updates | 42 | 31 |
Health worker empowerment | Co-development of guidelines and programmes, empowering lower levels of health service deliver, motivating heal workers | 22 | 17 |
To understand the potential impacts of having adequate information, the respondents were asked about the extent to which they were responsible for disseminating COVID-19 information to others. The vast majority of respondents reported that they were responsible for disseminating accurate and timely information about COVID-19 to various groups (Table 6.) This highlights the importance of ensuring that the information sent to health workers in the first place is adequate and timely, as it a part of a larger chain of information dissemination that has significant impacts on combatting COVID-19 in Uganda.
Table 6
Percent of respondents who report being responsible for disseminating COVID-19 information to various groups
Group | n | % |
Community members | 186 | 91 |
Other health workers | 168 | 88 |
Patients | 148 | 77 |
Policymakers | 111 | 58 |
Other government officials | 4 | 2 |
Sources of information in the communities
In order to efficiently and effectively target health information to the communities, the survey asked respondents for their insights as to how communities receive information about health in general and COVID-19 specifically. Figure 4 shows where individuals in the communities receive information about health generally. The most frequently selected source of information was the radio across districts in all regions.
In terms of COVID-19 specifically, as shown in Table 7, mass media and public health campaigns and outreach activities were mentioned as the most effective ways to disseminate COVID-19 information in open-ended answers by the majority of survey participants (Table 7). The latter is especially important, given that the majority of respondents also reported that public health campaigns and outreach activities were still disrupted (Fig. 3). Additionally, approximately one-third of respondents mentioned the display of COVID-19 information in public places and during social and community activities. This would require the production of materials in hard copies, which is something that district- and sub-district level respondents highlighted as a particular need throughout the survey.
Table 7
Most effective ways to disseminate COVID-19 information to the communities, as mentioned by % of respondents
Response types | Examples | n | % of respondents |
Mass media | Newspapers, TV, radio | 115 | 60 |
Public health campaigns and outreach activities | Community-based campaigns, public address system, community sensitisation, home-to-home visits, town criers, focus groups | 111 | 58 |
During community and social activities | Churches, community meetings, funerals, schools | 73 | 38 |
Materials displayed in public places | Materials, leaflets, posters, brochures | 58 | 30 |
In communications from leaders | Community leaders, District leadership, police, political leaders, religious leadership | 50 | 26 |
Community-based health workers | CHWs, VHTs | 50 | 26 |
Routine health services | Health centres, health education, head education | 40 | 21 |
Through translated materials | Materials in local languages | 8 | 4 |
Social media | Facebook, Twitter | 6 | 3 |
Telephone dissemination | Telephone calls or SMS | 2 | 1 |
Transportation | Boda Boda drivers, public transportation | 2 | 1 |
Ninety-six percent of respondents reported that additional COVID-19 informational materials were needed in the communities. Respondents selected the top three places most in need of additional materials (Fig. 5), with radio selected most often across the regions.
The next most frequently selected places to display information were religious centres in districts in the Western region, markets across districts in the Northern region, and in community centres in the Central and Eastern districts.
In terms of content of this additional information, the most frequently mentioned need was specific and detailed information on proper homecare of COVID-19 cases. Respondents also highlighted the need for current local statistics, risk behaviours relevant to the area, and guides to proper use of PPE and disinfectants. Over half of the survey participants reported that information in hard copy/paper format and translated materials were needed to disseminate COVID-19 information into the communities, which was identified throughout the survey.
In terms of target groups, young people were most often mentioned, followed by the elderly and school groups. Local political leaders and traders were also frequently mentioned as important target groups for additional information. These groups are all different in terms of their communication methods and COVID-19 risk behaviours, and therefore efforts should be made to tailor the COVID-19 informational materials for each group.
Rumours and myths
Uganda’s COVID-19 response is delivered to villages which feature a plurality of public authority, empowering religious leaders to deliver public health messaging. Our results indicated the prevalence of religious explanations for COVID-19, and the involvement of Christian and Islamic leaders, as well as traditional/ clan elders in the response. Approximately one-third (n = 87) of respondents reported hearing of religious explanations, which included beliefs derived from Christianity, Islam, or customary religious practices, in relation to COVID-19. The prevalence of religious explanations was higher across districts in the Eastern (47%) and Northern (43%) regions compared to the Central and Western regions. Across all respondents, 33% of religious explanations related to COVID-19 being caused by divine will – manifesting as a punishment from a Christian or Muslim God, or signalling the “end of the world”. For example:
The disease was already proclaimed by God and it truth has come
Christians say that the Bible says that this world has come to an end, and for this to happen many signs will manifest such as diseases without cure, and now there is COVID
COVID-19 is a God related punishment for the sins of mankind.
Twenty-nine percent attributed COVID-19 prevention, or cure, to Christian or Muslim practices, including prayer, or the cessation of public worship practices. For example:
Communal burials, marriage introductions and trans-night church prayers spread COVID-19
God heals all diseases so stopping church services worsens the disease
The respondents were also asked to describe any COVID-19 health- or care-seeking behaviours based in religious beliefs (Fig. 6).
These results thus point to emerging local conversations and attempts to define the role of religious and traditional practitioners in the COVID-19 response. Interestingly, when asked specifically about religious explanations for COVID-19, the respondents identified multiple connections to Christianity and Islam, along with traditional forces. Yet, when asked generally about rumours and myths, a much broader rumourscape was reported, which included other forms of healing, substances and global fears of bio-terrorism and capitalism exploration.
International experts have drawn attention to analysing the form and production of misinformation relating to COVID-19 [15]. Rumours and myths, spread both online and offline, could present a problem for the effective implementation of public health measures. COVID-19 is the first pandemic where media and social media have been used at such a massive scale to disseminate government guidance and safety information to populations. Yet, at the same time, these channels are being used to amplify misinformation related to the virus. The WHO has termed this abundance of false and misleading information as an “infodemic”, and has suggested that combatting misinformation is integral to the COVID-19 response [15]. The following section outlines the contours of the infodemic in Uganda, as reported by survey respondents.
The respondents reported widespread rumours about myths, origin, protection and cures for COVID-19. Addressing the channels through which rumours spread is an essential step in combatting the “infodemic” which accompanies COVID-19. In order to understand the production of rumours and myths and target response efforts, respondents were also asked to identify the sources of misinformation.
Table 8 shows the frequency and distribution of sources reported by the survey participants. Community talk and social media were identified as the most prevalent sources of rumours. Secondary to this, political and religious leaders were identified as figures which incited rumours about COVID-19. Responses indicate that sources of rumours are both offline and online. Whilst social media was identified as a key medium through which misinformation was spread, respondents also identified sources as being in communities, or leadership.
Table 8
Frequency and distribution of responses on the sources of rumours, as reported by > 5% of respondents
Type of source | n | % |
Community talk/gossip | 88 | 46 |
Social Media | 77 | 40 |
Politicians or Political Leaders | 33 | 17 |
Religious Leaders | 17 | 9 |
Peers | 12 | 6 |
These results suggest that plans to combat misinformation must take a dual focus: working with communities and leaders influential in said communities, as well as analysis patterns of use and access to social media. Further research should identify how online sources are interpreted and spread through community networks.