Healthworker Preparedness for COVID-19 Management and Implementation Experiences: A Mixed Methods Study in Uganda’s Refugee-Hosting Districts

doi:10.21203/rs.3.rs-674967/v1

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Healthworker Preparedness for COVID-19 Management and Implementation Experiences: A Mixed Methods Study in Uganda’s Refugee-Hosting Districts

https://doi.org/10.21203/rs.3.rs-674967/v1

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Background : The negative impact of COVID-19 on population health outcomes raises critical questions on health system preparedness and resilience, especially in resource-limited settings. This study examined healthworker preparedness for COVID-19 management and implementation experiences in Uganda’s refugee-hosting districts.

Methods : A cross sectional, mixed-method descriptive study in 17 health facilities in 7 districts from 4 major regions. Total sample size was 485 including >370 health care workers (HCWs). HCW knowledge, attitude and practices (KAP) was assessed by using a pre-validated questionnaire. The quantitative data was processed and analysed using SPSS 26, and statistical significance assumed at p<0.05 for all statistical tests. Bloom's cutoff of 80% was used to determine threshold for sufficient knowledge level and practices with scores classified as high (80.0%–100.0%), average (60.0%–79.0%) and low (≤59.0%). HCW implementation experiences and key stakeholder opinions were further explored qualitatively using interviews which were audio-recorded, coded and thematically analysed.

Results: On average 71% of HCWs were knowledgeable on the various aspects of COVID-19, although there is a wide variation in knowledge. Awareness of symptoms ranked highest among 95% (p value < 0.0001) of HCWs while awareness of the criteria for intubation for COVID-19 patients ranked lowest with only 35% (p value < 0.0001). Variations were noted on falsehoods about COVID-19 causes, prevention and treatment across Central (p value < 0.0356) and West Nile (p value < 0.0161) regions. Protective practices include adequate ventilation, virtual meetings and HCW training. Deficient practices were around psychosocial and lifestyle support, remote working and contingency plans for HCWs safety. The work environment has immensely changed with increased demands on the amount of work, skills and variation in nature of work. HCWs also reported moderate control over their work environment, high level of support from supervisors (88%) and colleagues (93%).

Conclusions: HCWs preparedness is inadequate in some aspects. Implementation of healthcare interventions is constrained by the complexity of Uganda’s health system design, top-down approach of the national response to COVID-19 and longstanding health system bottlenecks. We recommend continuous information sharing on COVID-19, a design review with capacity strengthening at all health facility levels and investing in community-facing strategies.

Health Policy

Internal Medicine

COVID-19

Health Care Workers (HCWs)

preparedness

resilience

health system

KAP

refugee hosting

humanitarian

Uganda

Refugee Hosting in Uganda

Uganda’s open-door approach to hosting refugees has received international acclaim with its refugee policy described as the most progressive [1] and “the world’s most compassionate refugee policy” [2]. The nation is among the world’s top three refugee-hosting nations and largest in Africa, currently hosting approximately 1.5 million refugees and asylum seekers, mostly from South Sudan. While refugees are spread out in 12 districts, over 67% live in the Western Nile region [3]. Uniquely, Uganda has no refugee camps; instead refugees live in gazetted settlements or wherever they may choose within wider society [4]. This is in line with the government’s policy of service integration where refugees share all services with the host community [5]. Registered refugees have the freedom to freely move, be employed, engage in agriculture or business and access all services, including healthcare. While all refugee settlements in Uganda have lower-level health facilities spread across, these facilities are also used by the host communities that are integrated within or surrounding the settlements [6].Health facilities in refugee settlements also follow the same and referral pathway which requires more complex cases from lower-level facilities to be managed at higher-level facilities [7].

Uganda’s Health Care System

Uganda’s health system comprises of both the private and public sector in terms of infrastructure ownership infrastructure and delivery of health services [8,9]. The health system is decentralized and hierarchical with seven levels starting from the household/village level and culminating at national referral institutions and the Ministry of Health [10]. In order of hierarchy there are the Village Health Teams (VHTs) or community health workers (CHWs) who are the first point of contact with health service users and resident within the village. Next is the Health Centre (HC) IIs, HCIIIs, HCIVs, District Hospitals, Regional Referral Hospitals (RRH) and National Referral Hospitals (NRH). In principle, each level of the health system is equipped to handle progressively complex cases while also referring to the next level upwards [7]. Referrals are therefore an integral part and key operational area for the success of the entire health system. The WHO lists list six key pillars or building blocks of any system critical to its functionality which include service delivery, the health workforce, health information systems, access to essential medicines, financing, and leadership or governance [11]. Having a hierarchical system also means that, across each one of the building blocks, lower-level units in Uganda are less equipped compared to higher- levels units.

Majority of the health facilities are public and therefore government/donor funded where, ideally, services should be provided free of charge. However, health financing remains a key national challenge and the recommended Abuja target 15% of the GDP apportioned to health [12,13,9] has never been achieved, with average health sector allocations ranging from 6%-9% [13,14]. A myriad of other factors including governance, leadership or stewardship shortfalls, changing population profiles with related needs and inefficiencies within the public sector have amplified the growth and prominence of the private health sector and out-of- pocket payments for healthcare [15-18]. In particular, the low funding for Uganda’s healthcare system continues to create an ongoing challenge of insufficient health workforce numbers [18] estimated at 72% staffing levels in public facilities with low HCW- patient ratios [19]. Uganda’s doctor-patient and nurse-patient ratio is approximately 1:25 000 and 1:11 000 respectively which is way below the WHO recommended doctor-patient ratio of 1:1000[19]. This healthworker shortfall has sometimes been mitigated by task shifting which has existed in Uganda since 1918 [20] and which the evidence shows to have improved quality of care in the treatment of HIV/AIDS, tuberculosis, maternal, newborn and child health (MNCH) programs as well as malaria [21-23]. However, task shifting has the potential to significantly undo its intended benefits when there is inadequate training or supervision from skilled health workers, inappropriate compensation for these duties and work overloads as is the case for Uganda [24]. Older and more recent assessments show that Uganda continues to experience serious shortfalls and challenges across all six of the building blocks of in its health system [25,26].

COVID-19

The COVID-19 pandemic has crippled all systems across the globe, some more than others. Even health systems in the most sophisticated and relatively high-performing countries like the United Kingdom, Spain, Italy and United States have been severely affected [27]. Almost all health systems have faced challenges with getting enough personal protective equipment (PPE) and other essential supplies, shortages in health workers, and overflowing hospitals due to the pandemic [28-30]. While all the pillars of the health system have been greatly affected – several studies have reported disruptions in both the physical and psychosocial wellbeing of health workers due to infection with COVID-19, burnout or other COVID-19 related occupational stressors [31-38] and compromised working conditions as some of the greatest challenges faced by the health workforce [39]. Above and beyond these challenges, the evidence has indicated that satisfactory knowledge about COVID-19 was associated with positive attitudes towards treating COVID-19 among health workers in South Africa, Sierra Leone, Ethiopia, Cyprus and Nigeria [40-44].

In Uganda, the response to COVID-19 included a lockdown and other public health preventive measures like banning of public gatherings, movement restrictions including a ban on public transport, curfews and other institutional arrangements grounded in the country’s previous efforts to curb outbreaks like Ebola and Marburg [45,46]. The Ministry of Health also instituted several guidelines for the continuity of essential health services and clinical management of COVID-19 including screening, testing, isolation, and institutional quarantine among others. However, there are several challenges that would significantly undermine Uganda’s health system preparedness to tackle the pandemic including the high HCW-patient ratios in addition to other existing staffing gaps, porous borders which potentially let through infected people especially refugees from neighbouring countries, ineffective quarantine processes and low financing for the health system [19,46,47]. COVID-19 is a highly contagious infectious disease with higher likelihood for infection among healthworkers compared to the general population [48]. The evidence from developed countries with high incidence of covid-19 shows that limitations in human and material capital can complicate its case management [49]. Additionally, the chronic shortages of PPEs have increased patient-to-staff transmissions with a heavy death toll on medical staff [50]. Consequently, these developments have caused fears about the preparedness for COVID-19 management in struggling health systems. Moreover, previous research among HCWs has documented inadequate knowledge and distorted beliefs about causes, risk factors and treatments for different health conditions including cervical cancer [51], hypertension [52], diabetes [53], and mental illness [54]. It is therefore of paramount importance that HCWs have adequate knowledge about all aspects of COVID-19 from clinical manifestation, diagnosis, proposed treatment and prevention strategies[48].

While several studies have reported on health system preparedness including healthworker knowledge, attitudes and practices (KAP) in Africa and elsewhere in the world; to the best of our knowledge only one study [55] has reported on Ugandan HCWs. Even then, this study was conducted within four (4) Makerere University teaching hospitals, all located in the Central region within approximately a 3-15km radius from Mulago National Referral Hospital in Kampala, Uganda’s capital city. Our research builds on and complements the critical knowledge generated by this study to assess healthworker knowledge and describe implementation experiences with data collected in-person from a>three-fold sample size drawn from all levels of Uganda’s health system and different geographical regions. We also show implications of the national health system design on health outcomes for forcibly displaced populations.

The study was cross-sectional descriptive study using mixed-methods including a survey, key informant interviews (KII) and indepth interviews (IDI). The study’s primary population were healthworkers at facilities serving refugee populations in both urban and rural settlements located in the Central, South Western, West Nile and Northern regions of Uganda. Secondary participants included key informants from government ministries and local government offices involved in the refugee response, NGOs and international agencies such as UNHCR. We collected data from seventeen (17) health facilities located within refugee settlements or outside as referral points. Total sample size was 485 with 370 health-workers as survey participants and 115 key informants, including healthworkers.

The survey was conducted using both Computer Assisted Personal Interviews (CAPI) while qualitative methods also used both virtual and in-person interviews.

In terms of analysis, qualitative interviews were audio-recorded, transcribed, coded and analysed thematically, aligning with study objectives. The quantitative data was processed and analyzed using SPSS 26, and statistical significance assumed at p < 0.05 for all statistical tests. A modified Bloom's cutoff of 80% was used to determine threshold for sufficient knowledge level and practices against independent variables on Likert scale (summarized as agree or disagree) on the various attributes measured [56]. Knowledge and practice were compared across regions, health facility levels, facility types, gender and levels of education using Chi-square tests and T-tests.

Socio-Demographic Characteristics

A sample of health care workers (n = 370) were randomly selected from seventeen (17) health facilities serving refugees and host communities in seven (7) districts of Uganda. These health facilities are located in the Central, Western, Northern and North Western (West Nile) regions which also host refugees of different nationalities. Majority of the Health Care Workers (HCWs) worked in regional referral and general hospitals, private facilities and held a diploma or certificate education in a medical field. There were slightly more women than men, and Catholics or Protestants were dominant. Participants varied in cadre, ranging from medical specialist to laboratory technologist; and were mainly placed in outpatient and inpatient settings. There was large variation in number of beds between the different health facilities owing to their variation in facility size; however, on average the facilities studied had 302 beds. The average age in the studied sample was 35 years, as shown in Table 1 below:

Table 1: Socio-Demographic Characteristics

Characteristic

n %

District

Adjumani

Gulu

Kabarole

Kampala

Kyegegwa

Mubende

62 16.8

45 12.2

55 14.9

130 35.1

37 10.0

41 11.1

Region

Central

West Nile

Western

Northern

171 46.2

69 18.7

92 24.9

38 10.3

Health facility level

Region Referral hospital

General hospital

HC IV

HC III

HC II

Clinic

200 54.1

70 18.9

49 13.2

26 7.0

9 2.4

Facility Type

Public

Private Not for Profit

297 80.3

73 19.7

Gender

Male

Female

162 43.8

208 56.2

Education

Primary

Secondary

Certificate/

Diploma

Vocational

Bachelors’ degree

1 0.3

2 0.5

83 22.4

164 44.3

2 0.5

103 27.8

Marital Status

Single

Married

Divorced/separated

Widowed

109 29.5

241 65.1

10 2.7

4 1.1

Religion

Catholic

Protestant

Muslim

Pentecostal

SDA

151 40.8

126 34.1

26 7.0

55 14.9

12 3.2

Cadre

Consultant

Medical officer

Clinical officer

Reg trained nurse

Enrolled nurse

Pharmacist

Radiographer

Laboratory technologist

Other

7 1.9

28 7.6

38 10.3

89 24.1

87 23.5

26 7.0

5 1.4

32 8.6

58 15.7

Department

Emergency

Outpatient

Inpatient

Investigative dept

Other

13 3.5

160 43.2

125 33.8

12 3.2

60 16.2

Age (Mean; Stdev)

34.5 (7.7)

Number of Beds (Mean; Stdev)

306 (446)

Knowledge

One of this study’s objectives was to assess the knowledge, attitudes and practices (KAP) of healthcare workers in the pandemic era. Participants’ overall KAP was analyzed using the sum score of each outcome and categorized Bloom's cut-off point [56].

There was a general high level of knowledge among the surveyed healthworkers on symptoms of COVID-19 (95%), behavioral risk factors for COVID-19 transmission (93%), that COVID-19 mortality is heightened if patient has other health conditions (92%), which patient needs to be tested for COVID (89%), behavioral risk factors for COVID-19 progression (88%), what PPE to use in the fight against COVID (86%), demographic risk groups for COVID-19 transmission (83%), detailed clinical information about COVID-19 (82%) and demographic risk groups for COVID-19 mortality (80%).

We found average knowledge on myths about causes and prevention of COVID- 19 (78%), falsehoods about causes, prevention and treatment of COVID-19 (76%), hospital’s criteria for admission (75%), terminology of the virus causing COVID-19 (74%), myths about causes, prevention and treatment of COVID-19 (74%), readiness to manage COVID as a health worker (69%), case definition of COVID in use in Uganda (67%), type of testing necessary for COVID (66%) and how to properly don and doff the full PPE for COVID care (64%).

There were low levels of knowledge on treatment options for COVID-19 (56%), understanding of the pathophysiology of COVID-19 (55%), how to administer appropriate levels of oxygen for COVID patients (42%), the recommendations around NIPPV and protective gear (38%), criteria for intubation of COVID patients (35%). The information is presented in Fig. 1 below.

There was no significant variation in knowledge levels across the 17 facilities in the surveyed regions. There is however a significantly high proportion (p value = 0.0356) of health workers with knowledge on falsehoods about causes, prevention and treatment of COVID-19 in Central compared to the other regions. There is also evidence higher proportion (p value = 0.0083) of health workers aware of knowledge on treatment options for COVID-19 in Central compared to the other regions. There is a significantly higher proportion (p value = 0.0349) of health workers with knowledge on how to properly don and doff the full PPE for COVID care in South Western region compared to the other regions. The information is shown in Table 2 below:

Table 2: Variations in knowledge about COVID-19 among health workers by region

	Central (n=171)	P value	West Nile (n=69)	P value	South Western (n=35)	P value	Northern (n=95)	P value	Total (n=370)
I know the symptoms of COVID-19	93%	0.1455	97%	0.0084	97%	0.6618	97%	0.4066	95%
I am aware there are behavioral risk factors for COVID-19 transmission	93%	0.3499	97%	0.4742	94%	0.6033	91%	0.5072	93%
I am aware COVID-19 mortality is heightened if patient has other	94%	1.0000	94%	0.2155	86%	0.8262	90%	0.5314	92%
I know which patient needs to be tested for COVID	86%	0.4090	88%	0.5702	91%	0.2311	94%	0.1474	89%
I am aware there are behavioral risk factors for COVID-19 progression	91%	0.3189	87%	0.8102	89%	0.7200	83%	0.1969	88%
I am sure of what PPE to use in the fight against COVID	84%	0.3021	80%	0.8170	97%	0.8635	92%	0.1185	86%
I am aware that there are demographic risk groups for COVID-19 transmission	86%	0.5419	74%	0.2031	80%	0.0690	84%	0.8163	83%
I feel confident that I know detailed clinical information about COVID-19	87%	0.3782	68%	0.0791	85%	0.6583	83%	0.8204	82%
I am aware that there are demographic risk groups for COVID-19 mortality	83%	0.4101	75%	0.3514	77%	0.6776	78%	0.6665	80%
I know there are some myths about causes and prevention of	80%	0.5988	78%	1.0000	80%	0.7874	72%	0.2172	78%
I know there are some falsehoods about causes, prevention and treatment of COVID-19	84%	0.0356*	62%	0.0161*	74%	0.7947	72%	0.4213	76%
I know our hospital’s criteria for admission	68%	0.0900	79%	0.4811	77%	0.7965	84%	0.0639	75%
I understand the terminology of the virus causing COVID-19	78%	0.3175	67%	0.2337	86%	0.1226	67%	0.1730	74%
I know there are some myths about causes, prevention and treatment of COVID-19	78%	0.3175	74%	1.0000	63%	0.1673	70%	0.4329	74%
I fell I am ready to manage COVID as a health care worker	70%	0.8152	58%	0.0763	77%	0.3323	74%	0.3432	69%
I’m comfortable with the case definition of COVID in use in Uganda	70%	0.4882	59%	0.2024	83%	0.0553	58%	0.1009	67%
I understand the type of testing necessary for COVID	68%	0.6475	68%	0.7490	54%	0.1612	67%	0.8543	66%
I know how to properly don and doff the full PPE for COVID care	64%	1.0000	57%	0.2732	82%	0.0349*	65%	0.8562	64%
I am aware of the treatment options for COVID-19	68%	0.0083*	43%	0.0486*	57%	0.9106	43%	0.0236*	56%
I have a good understanding of the pathophysiology of COVID-19	62%	0.1272	39%	0.0154	71%	0.0723	46%	0.1172	55%
I know well how to administer appropriate levels of Oxygen for COVID patients	47%	0.0090*	35%	0.2260	34%	0.2648	44%	0.1179	42%
If I need to intubate a patient, I understand the recommendations around NIPPV and protective gear	41%	0.2770	29%	0.2816	49%	0.3655	41%	0.8602	38%
I know the criteria for intubation of COVIDF patients	39%	0.5072	27%	0.1577	34%	0.2089	35%	0.5902	35%

Contrasting with other facilities, there was a significantly lower proportion of HCWs in general hospitals with awareness on detailed clinical information about COVID-19 (p value = 0.0077), falsehoods about causes, prevention and treatment of COVID-19 (p value = 0.0092), terminology of the virus causing COVID-19 (p value = 0.0406), readiness to manage COVID as a health care worker (p value = 0.0095),treatment options for COVID-19 (p value = 0.0022), understanding of the pathophysiology of COVID-19, (p value = 0.0215). Lower proportion (p value = 0.007) of HCWs in HCIV aware COVID-19 mortality is heightened if patient has other health conditions. Awareness on how to administer appropriate levels of oxygen for COVID patients is significantly higher (p value = 0.041) in Referral hospitals compared to other facility levels. This information is further shown in Table 3 below:

Table 3

Variations in knowledge about COVID-19 among health workers by facility level
	Referral Hospital	P value	General Hospital	P value	HC IV	P value	Total
I know the symptoms of COVID-19	96%	0.5914	97%	0.4684	90%	0.1531	95%
I am aware there are behavioral risk factors for COVID-19 transmission	91%	0.3966	94%	0.7617	98%	0.1801	93%
I am aware COVID-19 mortality is heightened if patient has other	95%	0.1824	91%	0.7798	80%	0.007*	92%
I know which patient needs to be tested for COVID	89%	1.000	91%	0.6201	84%	0.3052	89%
I am aware there are behavioral risk factors for COVID-19 progression	88%	1.000	84%	0.3569	90%	0.6836	88%
I am sure of what PPE to use in the fight against COVID	86%	1.000	80%	0.1979	88%	0.7031	86%
I am aware that there are demographic risk groups for COVID-19 transmission	84%	0.762	77%	0.2315	78%	0.3886	83%
I feel confident that I know detailed clinical information about COVID-19	87%	0.126	68%	0.0077*	78%	0.4986	82%
I am aware that there are demographic risk groups for COVID-19 mortality	81%	0.776	76%	0.4493	80%	1.000	80%
I know there are some myths about causes and prevention of	78%	1.000	73%	0.3616	78%	1.000	78%
I know there are some falsehoods about causes, prevention and treatment of COVID-19	80%	0.280	61%	0.0092*	78%	0.7577	76%
I know our hospital’s criteria for admission	81%	0.107	78%	0.5935	63%	0.0740	75%
I understand the terminology of the virus causing COVID-19	76%	0.603	62%	0.0406*	69%	0.4575	74%
I know there are some myths about causes, prevention and treatment of COVID-19	76%	0.603	70%	0.4885	71%	0.6549	74%
I fell I am ready to manage COVID as a health care worker	76%	0.080	53%	0.0095*	64%	0.4801	69%
I’m comfortable with the case definition of COVID in use in Uganda	68%	0.810	58%	0.1471	65%	0.7805	67%
I understand the type of testing necessary for COVID	68%	0.632	64%	0.7471	58%	0.2707	66%
I know how to properly don and doff the full PPE for COVID care	63%	0.814	53%	0.0824	65%	0.8911	64%
I am aware of the treatment options for COVID-19	62%	0.169	36%	0.0022*	58%	0.7913	56%
I have a good understanding of the pathophysiology of COVID-19	57%	0.649	40%	0.0215*	59%	0.5973	55%
I know well how to administer appropriate levels of Oxygen for COVID patients	51%	0.041*	31%	0.0859	37%	0.5052	42%
If I need to intubate a patient, I understand the recommendations around NIPPV and protective gear	43%	0.248	30%	0.2039	38%	1.0000	38%
I know the criteria for intubation of COVIDF patients	43%	0.062	26%	0.1445	25%	0.1652	35%

Bivariate Analyses On Knowledge And Awareness

Geographical

HCWs ratings of knowledge varied geographically. At district level, HCWs in Gulu and Kyegegwa rated their overall and knowledge and case-management related significantly higher than colleagues in other districts on average. With regard to facility variations, healthworkers at HC III and Regional Referral hospitals rated their overall and case management-related knowledge significantly higher than HCW at other levels on average. In terms of department or position variations, Consultants and Medical Officers demonstrated knowledge in all regards higher than other staff cadre groups on average. There was no significant variation in knowledge by department or gender. However, there was a significantly higher proportion (p value = 0.0239) of male HCWs who understood the terminology of the virus causing COVID-19 compared to female HCWs. Compared across levels of education, HCWs who had attained atleast a Bachelor’s degree were significantly knowledgeable on detailed clinical information about COVID-19 (p value = 0.0066), terminology of the virus causing COVID-19 (p value = 0.0028), treatment options for COVID-19 (p value = 0.0062), understanding of the pathophysiology of COVID-19 (p value = 0.0010) as compared to HCWs with other qualifications. HCWs with certificate level education reported significantly lower knowledge on understanding the terminology of the virus causing COVID-19 (p value = 0.0002), understanding the type of testing necessary for COVID (p value = 0.0038), treatment options for COVID-19 (p value = 0.0051), pathophysiology of COVID-19 (p value = 0.0010), how to administer appropriate levels of oxygen for COVID patients (p value = 0.0438). There was no significant variation in knowledge by age, marital status and religion of healthworkers (Table 4).

Table 4

Variations in HCWs knowledge and awareness by socio-demographic and facility factors
Characteristic	Overall Knowledge (24–96) Mean (St.dev)	Knowledge of relevance to Case Management (15–60) Mean (St.dev)	Knowledge of relevance to Prevention (9–36) Mean (St.dev)
District Adjumani Gulu Kabarole Kampala Kyegegwa Mubende	65.8 (12.5)* 70.1 (12.9) 65.1 (10.9) 68.7 (9.55) 70.3 (12.3) 68.1 (12.3)	38.9 (8.8)* 42.4 (8.9) 38.8 (6.9) 40.8 (6.9) 43.2 (8.0) 40.5 (9.0)	26.9 (5.0) 27.7 (5.1) 26.3 (5.1) 27.9 (3.9) 27.1 (5.0) 27.6 (4.3)
Health facility level Region Referral hospital General hospital HC IV HC III HC II Clinic	68.7 (11.2)* 65.1 (12.0) 67.5 (12.0) 73.0 (10.6) 60.6 (8.3) 66.2 (6.2)	41.2 (7.9)* 38.3 (8.6) 40.3 (8.3) 44.6 (6.1) 36.1 (6.4) 38.4 (3.2)	27.5 (4.5) 26.7 (4.6) 27.2 (4.9) 28.4 (5.4) 24.4 (2.5) 27.8 (3.9)
Gender Male Female	69.4 (11.0)* 66.7 (11.6)	41.5 (7.7)* 39.8 (8.1)	27.9 (4.6)* 26.6 (4.5)
Education Certificate Diploma Bachelors’ degree	63.6 (11.7)* 67.2 (10.7) 71.8 (10.9)	37.8 (8.5)* 40.2 (7.5) 42.8 (7.5)	26.6 (4.2)* 26.9 (4.5) 28.6 (4.7)
Marital Status Single Married Divorced/separated Widowed	68.8 (10.9) 67.4 (11.5) 69.7 (7.9) 74.0 (24.1)	41.0 (7.4) 40.4 (8.1) 40.9 (6.7) 44.3 (17.3)	27.8 (4.5) 27.0 (4.6) 28.8 (2.3) 29.8 (7.3)
Religion Catholic Protestant Muslim Pentecostal SDA	67.9 (11.1) 66.9 (11.6) 70.5 (11.6) 69.7 (11.7) 66.1 (11.3)	40.6 (7.9) 40.0 (7.9) 42.8 (8.4) 41.0 (7.8) 39.8 (8.8)	27.3 (4.5) 26.9 (4.6) 27.7 (4.2) 28.7 (4.8) 26.3 (4.6)
Cadre Consultant Medical officer Clinical officer Reg trained nurse Enrolled nurse Pharmacist Radiographer Laboratory technologist Other	80.0 (7.8)* 75.7 (9.4) 68.2 (9.0) 68.2 (12.4) 64.7 (12.2) 66.6 (8.8) 66.8 (5.0) 70.1 (9.8) 66.5 (10.9)	49.4 (3.7)* 45.6 (6.2) 41.4 (6.3) 41.0 (8.5) 38.1 (9.1) 39.1 (6.3) 40.6 (4.7) 41.9 (6.3) 39.7 (7.2)	30.6 (4.3)* 30.1 (5.2) 26.8 (4.5) 27.2 (5.0) 26.6 (4.0) 27.5 (3.4) 26.2 (1.1) 28.2 (4.4) 26.8 (4.9)
Department Emergency Outpatient Inpatient Investigative dept Other	70.5 (10.3) 67.6 (10.1) 67.6 (13.1) 69.4 (7.9) 68.8 (11.8)	42.8 (7.5) 40.4 (7.1) 40.1 (9.3) 42.1 (5.2) 41.5 (7.7)	27.7 (4.7) 27.2 (4.5) 27.5 (4.8) 27.3 (4.1) 27.3 (4.8)
*Statistically significant at p < 0.05

There was no significant variation in levels of knowledge across public and private health facilities. There was, however, a significantly higher proportion (0.0469) of health workers in private facilities with knowledge on what PPE to use in the fight against COVID-19 compared to health workers in public facilities. Knowledge on how to properly don and doff the full PPE for COVID care was significantly higher (p value = 0.0132) in private facilities compared to public facilities (Table 5).

Table 5

Variations in HCW knowledge by health facility type
	Public (n = 297)	P value	Private Not for Profit (n = 73)	P value	Total (n = 370)
I know the symptoms of COVID-19	95%	1.0000	96%	0.7162	95%
I am aware there are behavioral risk factors for COVID-19 transmission	93%	1.0000	94%	0.7573	93%
I am aware COVID-19 mortality is heightened if patient has other	92%	1.0000	96%	0.2316	92%
I know which patient needs to be tested for COVID	87%	0.4281	96%	0.0669	89%
I am aware there are behavioral risk factors for COVID-19 progression	87%	0.6976	90%	0.6271	88%
I am sure of what PPE to use in the fight against COVID	85%	0.7152	94%	0.0469*	86%
I am aware that there are demographic risk groups for COVID-19 transmission	81%	0.5033	89%	0.2019	83%
I feel confident that I know detailed clinical information about COVID-19	81%	0.7409	86%	0.4099	82%
I am aware that there are demographic risk groups for COVID-19 mortality	78%	0.5280	88%	0.1094	80%
I know there are some myths about causes and prevention of	78%	1.0000	75%	0.5752	78%
I know there are some falsehoods about causes, prevention and treatment of COVID-19	76%	1.0000	75%	0.8554	76%
I know our hospital’s criteria for admission	75%	1.0000	77%	0.7175	75%
I understand the terminology of the virus causing COVID-19	72%	0.5629	81%	0.2064	74%
I know there are some myths about causes, prevention and treatment of COVID-19	73%	0.7712	76%	0.7210	74%
I fell I am ready to manage COVID as a health care worker	67%	0.5820	79%	0.0868	69%
I’m comfortable with the case definition of COVID in use in Uganda	69%	0.6280	57%	0.1012	67%
I understand the type of testing necessary for COVID	65%	0.8115	72%	0.3197	66%
I know how to properly don and doff the full PPE for COVID care	61%	0.4816	79%	0.0132*	64%
I am aware of the treatment options for COVID-19	57%	0.8193	53%	0.6378	56%
I have a good understanding of the pathophysiology of COVID-19	55%	1.0000	54%	0.8755	55%
I know well how to administer appropriate levels of Oxygen for COVID patients	42%	1.0000	41%	0.8744	42%
If I need to intubate a patient, I understand the recommendations around NIPPV and protective gear	40%	0.6418	30%	0.1954	38%
I know the criteria for intubation of COVIDF patients	38%	0.4791	26%	0.1370	35%

Data from the qualitative arm of the study provides some insight and triangulation for quantitative results. First, there was a general understanding on COVID-19 among healthworkers, particularly on its signs and symptoms. In some areas training and strengthening the capacity of healthworkers for case management had been conducted, particularly by health implementing partner agencies in refugee settlements:

We have a team comprising of healthworkers who have been trained on COVID-19 case management… these healthworkers have been subjected to various, about three, simulations for COVID-19 case management. So during simulation exercises we bring in real life scenarios of an actual case of COVID-19 just to build their capacity, and make sure that they are ready to respond incase we get a confirmed case in the settlement here… and then it is mandatory for all the healthworkers to have basic knowledge. So I would say all of them have been trained, but some have been given further guidance with simulation exercises (Implementing Partner, Settlement #1, Region 2)

The moment we heard that its COVID our bosses immediately arranged trainings for us and also equipped us with the essential supplies like more PPEs to go along with that knowledge. Atleast now we know something although we are continuing to learn about this strange disease. Also the Ministry of Health guidelines are helping us all [Healthworker1, Private Health Facility, Region 3]

However, findings in some public facilities showed that COVID-specific training had not yet taken place, although some information had been shared to increase knowledge and awareness:

Up to now we have not seen anyone from the district or Ministry [of Health] coming to train us on COVID. Maybe they will come with time… we received some of these posters on the disease and are using that information and our training to try and protect ourselves and our clients…we are improvising but it’s tough (Healthworker2, Public Health Facility, Region 2)

This was confirmed by data from the national level which also explained its targeted and phased approach to strengthening health facility capacity and preparedness. This was particularly at referral points where most COVID-19 cases were going to end up, as opposed to spreading thin by attempting to simultaneously equip all health facilities:

Part of the reason we locked down was to prepare care capacity and in preparing care capacity, we made sure that every district hospital has a COVID-19 care capacity. In addition to that, there is a specialized COVID-19 team. We have moved around and trained, we made sure that regional referral hospitals have capacity… The model is such that the very severe cases of COVID-19 are supposed to be managed at the regional referrals. The district hospitals are supposed to manage the minor cases; and in this case because we have few cases and all the cases go to the regional referral, we have not covered all the hospitals yet. We have not gotten there yet but will get there. Because COVID-19 one day it’s going to become like malaria and the patients will go to any healthcare centre and be treated…But for now we make sure that the plan is expanded very well and it will come to reach to the point where we are going slowly (KII, Policymaker)

In agreement with some of the quantitative findings on training healthworkers and resulting knowledge, implementing partners and other stakeholders reported constraints with training materials and content, particularly in the early phase of COVID-19. They also noted that short training intervals have limitations on the extent to which they can strengthen healthworker capacity:

All healthworkers in the settlement have been trained even though it is, I don’t know, maybe a one day’s training because the material on COVID is really not so much…and you have seen the trends, it is specifically the asymptomatic or mild cases so if a severe case happened I don’t think our healthworkers here can handle. They will immediately refer (National-Settlement stakeholder 1)

Inspite of this training, there were some knowledge and skill gaps across most facilities and especially the lower-level health facilities:

I won’t lie to you, most of us here know something about this COVID but not everything. It is a new disease and we are also just learning, just like everyone else. Ofcourse we may know abit more than the community but until we have proper training, we will just have to rely on our usual skills, the SOPs and the information as it keeps reachingus (Healthworker3, Public Health Facility, Region 1)

We keep having our knowledge added on to slowly slowly but generally most healthworkers, myself included, do not feel very confident to handle a COVID case right now. So for me I suspect we shall refer [to COVID management centres] if we get one and have not been given extra training by that time (Healthworker 4, Public Health Facility, Region 3)

Practices

Health Worker and Facility Practices regarding COVID-19

We found healthworker and facility practices regarding COVID-19 to be less than optimal in several regards. Between 5–30% strongly disagreed/disagreed that practices to ensure patient safety from transmission (e.g. disinfection, social distancing, ventilation etc) are adhered to or in place. Between 11–55% strongly disagreed/disagreed that practices and precautions to ensure staff safety (e.g. mapping out risk and hazards, staff safety and health contingency plans, non-critical staff working at home or shift working) were being adhered to. Over 30% strongly disagreed/disagreed that practices to improve communication (e.g. having a person assigned for the purpose) were in existence at their facility. Table 6 illustrates this further:

Table 6

COVID-19 practices
HCW/Facility Practices	Strongly Disagree n %	Disagree n %	Agree n %	Strongly Agree n %
Patients, visitors aware of COVID19 prevention practices	236.2	8121.9	19452.4	6918.7
HCWs aware of COVID19 prevention practices	51.4	246.5	18850.8	15040.5
HCWs apply standard precautions for all patients	184.9	8924.1	17346.8	8322.4
Droplets and contact precautions recommended for febrile, coughing patients	225.9	5715.4	18148.9	10227.6
Patients should be placed in adequately ventilated rooms	30.8	205.4	16444.3	17447.0
One-meter distance between beds ensured for all patients	359.5	6517.6	15441.6	11130.0
Hospital has an active COVID19 taskforce	164.3	4712.7	15541.9	14138.1
Hospital has written COVID19 preparedness plans	369.7	9525.7	14639.5	8723.5
People are assigned to communicate status and impact of COVID19 to staff	4010.8	7921.4	16544.6	8523.0
People are assigned to communicate status and impact of COVID19 with authorities	3710.0	8823.8	16043.2	8222.2
People are assigned to communicate with patients about COVID19	297.8	10127.3	17246.5	6718.1
Facility has mapped the COVID19 risks/hazards for all workpoints	267.0	11731.6	16544.6	5915.9
Staff safety is included in contingency plans	4813.0	10027.0	16845.4	5113.8
Non critical staff asked to work from home	10327.8	10127.3	11230.3	5214.1
Shifts introduced to avoid HCW concentrations	8222.2	9325.1	12533.8	6918.7
Facility has a COVID19 M&E mechanism	5113.8	7620.5	17948.4	6317.0
Facility trained management, workers on COVID19 management	256.8	46 12.4	18550.0	11130.0
Staff assisted to minimize direct contact with customers, ensure personal hygiene	164.3	297.8	19051.4	13436.2
Workers in direct contact with clients have PPEs	277.3	4813.0	18249.2	11130.0
Risk of COVID19 in travel has been assessed	4813.0	7018.9	17948.4	6918.7
Facility maintains regular communication with workers	5013.5	7620.5	16644.9	7620.5
HCWs assisted to manage any emerging psychosocial risks	4411.9	8623.2	17948.4	5915.9
Virtual meetings preferred to Face-to-face meetings	5915.9	10227.6	13235.7	7219.5
Hand washing and/or sanitization culture promoted	92.4	195.1	15140.8	18850.8
Surfaces regularly wiped with disinfectants	164.3	6016.2	16143.5	13135.4
Workspace Ventilation is improved	287.6	8623.2	16644.9	8723.5
Good respiratory hygiene promoted and communicated	71.9	338.9	16745.1	16143.5
Social distancing is promoted in congregate settings	277.3	5815.7	15742.4	12734.3
HCWs suspected COVID19 encouraged to self-isolate	225.9	6216.8	14840.0	13536.5
HCWs informed what to do when they suspect to have COVID19	133.5	4111.1	18249.2	13135.4
Facility has planned disinfecting areas	143.8	4311.6	17747.8	13335.9

Using Bloom’s cut-off points, there were high-level practices among HCWs on placing patients in adequately ventilated rooms (94%), respiratory and hand hygiene and prevention of healthcare-associated infections (92%); avoiding face-to-face meetings and giving preference to phone calls, email or virtual meetings (92%); improved ventilation around workspaces (89%)and training of facility management, workers or their representatives on management of COVID at the facility (88%).Workers with suspected symptoms of COVID-19 were encouraged not to come to the workplace and follow available guidance (85%). Additionally, staff were informed on what to do when they suspect to have COVID (84%). The health facilities had an active taskforce to manage COVID (82%); the facility had a monitoring and evaluation mechanism of the COVID prevention strategies and plans (81%). Staff had been assisted to minimize the direct contact with customers and ensure personal hygiene practices such as hand washing and use of hand sanitizers (80%).

There were average-level practices on hand washing at the facility (79%). Droplets and contact precautions were recommended for febrile and coughing patients (78%), social distancing was being promoted in congregate settings where clients gather (77%), good respiratory (e.g. face mask) hygiene was promoted and communicated (77%) and the one- meter distance between beds ensured regardless of whether patients are suspected of having COVID-19 (73%. Patients and visitors were aware of respiratory and hand hygiene and prevention of healthcare-associated infections (72%); while healthworkers were applying standard precautions for all patients (71%). Surfaces (e.g. desks and workstations, doorknobs, telephones keyboards and working objects) were regularly wiped with disinfectant (69%). HCWs who came in direct contact with clients had been provided with personal protective equipment (68%); health facility had written COVID-19 preparedness plans and accessible to all staff (68%) and a person had been assigned responsibility for communications with staff, regarding the status and impact of COVID-19 (66%). The risk of COVID in travel had been assessed with non-essential travel avoided (66%), shifts introduced to avoid large concentrations of workers in the facilities (66%) and a person had been assigned responsibility for communication with health authorities regarding the status and impact of COVID-19 (65%. The facility maintained regular communication with workers and their representatives, including over the internet, or when not possible, over the phone (65%); a person had been assigned responsibility for communications with patients, and their families regarding COVID-19 (61%). The facility had mapped the COVID risks/hazards of all work points and covering all jobs (60%).

There were low-level practices on assistance of workers to manage any emerging psychosocial risks, new forms of work arrangements, and in the promotion or maintenance of healthy lifestyles. Non-critical staff had been asked to work from home or to stay at home (53%) while staff safety and health had been included in the contingency plans, including the modification of staffing (45%). This information is shown in Fig. 2 below:

HCWs in the South Western region reported significantly higher (p value = 0.0157) level practices in avoiding non-essential travel as compared to the other regions. There was also a significant proportion (p value = 0.0312) of HCWs reporting that a person had been assigned responsibility for communications with health authorities regarding the status and impact of COVID-19 in the South West compared to other regions. HCWs in private health facilities reported relatively high-level practices as compared to their counterparts in public facilities (Table 7).

Table 7

Variations in health worker practices by region represented
	Central (n = 171)	P value	West Nile (n = 69)	P value	South Western (n = 35)	P value	Northern (n = 95)	P value	Total (n = 370)
Patients should be placed in adequately ventilated rooms	90%	0.0959	97%	0.3173	97%	0.4664	97%	0.2485	94%
Face-to-face meetings have been avoided, giving preference to phone calls, email or virtual meetings	90%	0.4416	91%	0.7808	97%	0.2857	96%	0.1785	92%
Health care workers are aware of respiratory and hand hygiene and prevention of healthcare-associated infections	88%	0.1361	96%	0.2436	97%	0.2857	95%	0.3192	92%
Ventilation around workspaces have been improved	85%	0.1877	96%	0.0742	94%	0.3583	89%	1.0000	89%
Facility has trained management, workers and their representatives on management of COVID at the facility	82%	0.0609	91%	0.4743	94%	0.2878	94%	0.0928	88%
Workers with suspected symptoms of COVID-19 are encouraged not to come to the workplace and to follow the guidance of the local authorities	87%	0.5379	87%	0.6669	91%	0.3356	78%	0.1009	85%
Staff are informed on what to do when they suspect to have COVID	86%	0.5491	77%	0.1567	89%	0.4360	86%	0.6321	84%
Hospital has an active taskforce to manage COVID	83%	0.777	74%	0.1223	74%	0.2465	91%	0.0337	82%
The facility has a monitoring and evaluation mechanism of the COVID prevention strategies and plans.	74%	0.0643	84%	0.5564	91%	0.1427	87%	0.1729	81%
Staff has been assisted to minimize the direct contact with customers and ensure personal hygiene practices such as hand washing and use of hand sanitizers	81%	0.7858	75%	0.3479	80%	1.0000	80%	1.0000	80%
A culture of hand washing and/or sanitization is promoted at the facility	82%	0.4182	75%	0.4593	80%	0.8896	77%	0.6720	79%
Droplets and contact precautions are recommended for febrile and coughing patients	76%	0.6056	76%	0.7144	79%	0.8914	83%	0.2862	78%
Social distancing is promoted in congregate settings where clients gather	79%	0.6041	72%	0.371	89%	0.1016	73%	0.4148	77%
Good respiratory (e.g. face mask) hygiene is promoted and communicated	78%	0.7964	71%	0.2842	86%	0.2215	76%	0.8370	77%
One- meter distance between beds is ensured regardless of whether patients are suspected of having COVID-19	70%	0.4701	78%	0.3865	77%	0.6094	72%	0.8453	73%
Patients, and visitors are aware of respiratory and hand hygiene and prevention of healthcare-associated infections	69%	0.4748	72%	1.000	86%	0.0742	71%	0.8470	72%
HCW are applying standard precautions for all patients	67%	0.3468	73%	0.7362	77%	0.4528	73%	0.7007	71%
Surfaces (e.g. Desks and workstations, doorknobs, telephones keyboards and working objects) are regularly wiped with disinfectant	74%	0.2358	51%	0.0038*	83%	0.0838	68%	0.8513	69%
Workers who come in direct contact with clients have been provided with personal protective equipment	71%	0.4836	66%	0.7446	71%	0.7151	63%	0.3558	68%
Hospital has written COVID-19 preparedness plans and accessible to all staff	63%	0.2527	69%	0.8701	80%	0.1427	72%	0.4533	68%
A person has been assigned responsibility for communications with staff, regarding the status and impact of COVID-19	58%	0.0726	68%	0.7472	77%	0.1866	74%	0.1375	66%
Risk of COVID in travel has been assessed. Non essential travel has been avoided.	63%	0.4966	66%	1.0000	86%	0.0157*	63%	0.5839	66%
Shifts have been introduced to avoid large concentrations of workers in the facilities	61%	0.2592	63%	0.6307	71%	0.5499	74%	0.1375	66%
A person has been assigned responsibility for communications with health authorities regarding the status and impact of COVID-19	58%	0.1177	70%	0.4221	83%	0.0312*	66%	0.8553	65%
Facility maintains regular communication with workers and workers’ representatives, including over the internet, or when not possible, over the phone	65%	1.0000	63%	0.7499	69%	0.6350	64%	0.8557	65%
A person has been assigned responsibility for communications with patients, and their families regarding COVID-19	58%	0.5081	52%	0.1624	74%	0.1301	68%	0.2094	61%
The facility has mapped the COVID risks/hazards of all workpoints and covering all jobs	63%	0.5064	51%	0.164	66%	0.4882	58%	0.7234	60%
Workers are assisted to manage any emerging psychosocial risks, new forms of work arrangements, and in the promotion and maintenance of healthy lifestyles	62%	0.1892	50%	0.3582	54%	0.8201	49%	0.2221	56%
Non-critical staff have been asked to work from home or to stay at home	49%	0.3871	52%	0.8787	54%	0.9099	58%	0.3836	53%
Staff safety and health has been included in the contingency plans, including the modification of staffing	49%	0.3861	38%	0.2826	57%	0.1739	36%	0.1145	45%

Healthworker ratings of their practices varied geographically. At district level, healthworkers in Gulu and Kyegegwa rated their practices, in all regards, significantly higher than colleagues in other districts on average. In terms of facility variations healthworkers at HCIII rated their overall staffing, communication, risk mapping and monitoring-related practices significantly higher than healthworkers at other levels on average. There were no significant variations in HCWs practices at department or cadre level. Marital status was significantly associated with HCWs ratings although the pattern of variation was inconsistent across the different facets of practice. There were no variations in healthworker practices by gender, religion and education (Table 8).

Table 8

Variations in HCWs Practices by socio-demographic and facility factors
Characteristic	Overall Practice Index (31–124) Mean (St.dev)	Patient Safety index (7–28) Mean (St.dev)	Staff Safety index (12–48) Mean (St.dev)	Communication, Risk Mapping and Monitoring index (11–44) Mean (St.dev)
District Adjumani Gulu Kabarole Kampala Kyegegwa Mubende	82.5 (15.3)* 96.0 (12.3) 82.4 (15.0) 85.6 (13.5) 91.6 (16.8) 87.5 (15.5)	20.6(5.0)* 22.4(4.3) 20.7 (3.4) 20.9 (3.2) 22.2 (3.7) 21.1 (3.5)	31.7 (6.9)* 37.7 (5.5) 31.7 (6.7) 33.8 (6.0) 36.2 (7.4) 34.6 (6.7)	30.2 (5.8)* 35.9 (4.7) 30.1 (6.7) 30.9 (5.7) 33.2 (6.8) 31.7 (6.9)
Health facility level Region Referral hospital General hospital HC IV HC III HC II Clinic	86.8(13.9)* 82.2(14.8) 83.6(17.8) 98.3 (15.3) 86.3(6.9) 95.4(10.1)	21.1 (3.4) 20.8 (4.4) 20.6 (4.4) 23.1 (5.0) 21.0 (2.4) 22.1 (2.6)	33.8 (6.3)* 31.6 (6.5) 33.4 (7.1) 39.4 (6.9) 34.6 (4.0) 38.2 (5.4)	31.9 (6.0)* 29.8 (6.0) 29.6 (7.2) 35.8 (5.4) 30.8 (3.4) 35.1 (4.5)
Gender Male Female	86.0 (14.9) 87.2 (15.2)	20.9 (3.9) 21.3 (3.8)	33.7 (6.8) 34.1 (6.6)	31.4 (6.2) 31.7 (6.4)
Education Certificate Diploma Bachelors’ degree	88.8 (15.5) 85.4 (15.5) 86.7 (15.0)	22.0 (3.9) 20.7 (4.0) 21.0 (3.4)	34.8 (6.9) 33.3 (6.8) 34.1 (6.1)	32.0 (6.9) 31.3 (6.3) 31.6 (6.2)
Marital Status Single Married Divorced/separated Widowed	89.7 (14.9)* 85.1 (14.6) 86.2 (16.4) 93.5 (32.4)	21.9 (3.3)* 20.9 (3.8) 18.6 (7.0) 20.3 (9.1)	35.0 (6.9) 33.3 (6.4) 34.9 (7.5) 38.5 (11.2)	32.8 (6.0)* 30.9 (6.2) 32.7 (6.4) 34.8 (12.6)
Religion Catholic Protestant Muslim Pentecostal SDA	88.8 (15.7) 85.0 (14.2) 86.8 (14.9) 86.1 (14.9) 79.1 (13.7)	21.6 (4.1) 20.8 (3.4) 20.8 (4.0) 21.3 (3.5) 19.1 (5.3)	34.8 (6.8) 33.3 (6.5) 34.0 (6.5) 33.9 (6.8) 30.3 (6.9)	32.5 (6.4) 30.9 (5.9) 32.0 (5.9) 30.8 (6.5) 29.2 (6.3)
Cadre Consultant Medical officer Clinical officer Reg trained nurse Enrolled nurse Pharmacist Radiographer Laboratory technologist Other	96.9 (14.1) 85.0 (14.6) 83.6 (16.0) 86.5 (13.3) 86.4 (17.2) 87.0 (12.5) 78.6 (7.9) 87.4 (12.8) 89.3 (16.0)	22.4 (2.5) 20.4 (4.6) 20.3 (4.6) 20.7 (3.1) 21.5 (4.5) 21.3 (2.8) 20.0 (2.1) 21.4 (3.2) 21.9 (3.8)	37.4 (7.0) 33.3 (6.4) 33.0 (7.1) 34.0 (5.9) 33.7 (7.6) 34.2 (5.5) 30.2 (4.1) 34.6 (5.8) 34.6 (7.4)	37.0 (5.6) 31.3 (6.2) 30.3 (6.9) 31.8 (5.8) 31.1 (6.8) 31.5 (6.2) 28.4 (2.9) 31.4 (5.4) 32.8 (6.2)
Department Emergency Outpatient Inpatient Investigative dept Other	87.2 (14.7) 87.7 (14.3) 84.5 (16.1) 89.1 (15.0) 87.9 (14.7)	19.9 (2.4) 21.4 (4.1) 20.9 (3.7) 21.5 (3.4) 21.3 (3.7)	33.9 (8.4) 34.6 (6.2) 32.7 (6.9) 35.3 (6.0) 34.6 (7.0)	33.4 (6.0) 31.8 (5.8) 30.8 (6.9) 32.3 (6.6) 32.1 (6.0)

*statistically Significant At P < 0.05

Work Environment

HCWs reported increased demands in their work environment amidst the COVID-19 pandemic. 81% indicated that their job requires them to work fast, requires a lot of effort (89%), conflicting demands (62%), excessive work (66%) and lack of adequate time to accomplish work (49%). They also reported increased control in work environment indicated by a high proportion of HCWs reporting the need to learn new things at work (94%), high level of skill (91%), the need to take initiative at work (92%), variation in nature of work (80%) and possibility of making choices at work (70%). Regardless of their changing work environment, HCWs reported that they get adequate support in their work. 74% indicating that their work is enjoyable, pleasant and calm, with support from co-workers (93%) and supervisors (88%) as well as appreciation from supervisor (89%). The information is shown in Fig. 3 below.

There was no significant variation in healthworker perceptions of their work environment across all regions. There was, however, a significantly lower proportion (p value = 0.0387) of healthworkers in West Nile reporting that the job requires them to work fast compared to the other regions. A significantly higher proportion (p value = 0.0257) of healthworkers in South Western region reported that the job requires them to work fast compared to the other regions. There was no significant variation in the perception of work environment among healthworkers across public and private health facilities, gender or education level.

Qualitative findings on healthworker preparedness and frontline practices gave a somewhat different picture in terms of workloads and work environment. While healthworkers at referral health facilities reported increased workloads, those at lower level facilities reported reduced patient numbers to attend to in the pandemic era. Some of the explanatory factors for low workloads include COVID-19 movement restrictions, the health system’s referral pathway, decongesting high-volume facilities through task shifting or innovative community-based mechanisms and community reluctance to utilize health services - including when suspected COVID cases due to fear of related stigma and/or isolation:

The stigma attached to respiratory illnesses would consider anyone suffering from respiratory illness to be suffering from COVID so it makes people to fear seeking medical attention…these days people who are coughing first struggle with their cough from home before coming here (Healthworker, In-Settlement Facility 3, Region 1)

Ever since March when the President said “no movement”, we have much fewer patients… we nolonger do community dialogues, public health talks and sensitizations all because of COVID. To try and adapt we are using community-based surveillance for case detection and management through ICCM programs like malaria so that people who are badly off can be managed at that level which reduces the turnover at the facility (Healthworker 5, Region 2)

Healthworkers, particularly those at in-settlement health facilities, confirmed being prepared to manage COVID-19 cases:

Our involvement begins from the settlement level to the district level because even as a facility we have a rapid response team. Some members of our facility got training to respond to any case (Healthworker, In-Settlement Health Facility 1, Region 3)

We are always prepared for epidemics so our level of preparation is somewhere. We have the facilities like the treatment unit, isolation unit within, training of the team and mobilisation is easier and ofcourse we ensure adherence to the SOPs by all staff (Healthworker, In-Settlement Health Facility 3, Region 1)

This study found one of the biggest challenges to healthworker capacity to mostly be infrastructure and supply-related. Although a number of healthworkers at public facilities reported not receiving any or adequate training or capacity building sessions on COVID-19 care, the reported “winging it” in terms of practice but mostly struggled to deliver healthcare with limited infrastructural adjustments and/or supplies:

I am equipped with information but for utilities like PPEs I am not well equipped (Healthworker 6, Public Health Facility, Region 4)

I don’t think there is a country that has everything, but supplies are a big problem. I personally move with gloves in my bag because we don’t have any in the health centre. Last month we only had two boxes of gloves as the whole health centre… 50 pairs in each, that is 100 pairs of gloves…how are we meant to work with these gloves for 60 days? (Healthworker 7, Public Health Facility, Region 3)

This situation has come with the demand for more human resource and space… also inadequate logistics because stockouts are the order of the day. That includes gloves, handwashing facilities, facemasks and others (Healthworker, Public Health Facility, Region 4)

Equipment is rare as you can be equipped today and it all runs out the following day because most of utilities for COVID-19 are consumables and disposables so we use them on a daily basis. Support in terms of PPEs is supposed to be a continuous exercise but we don’t always have so I don’t feel I am adequately equipped to manage (Healthworker, Public Health Facility, Region 2)

HCW knowledge and awareness of COVID-19 varies across different sociodemographic characteristics. Specifically, knowledge regarding symptoms, criteria for admission, treatment options, protection and safety promotion was rated low by a significant number of HCWs themselves. This could be attributed to the critical stage at which data was collected, as there were only few cases of COVID-19 confirmed in the study setting at the time. The limited knowledge on COVID-19 among healthworkers can be partly be explained by a general lack of empirical data, training and ready guidelines on how to handle a new pandemic. This challenge was not only reported by this study’s participants but also several studies across the world [55, 57, 58] confirmed a paucity of information and progressive lessons in COVID-19 detection, prevention and management. Clinical guidelines and other related directives began to take shape after pandemic onset and research conducted in early phases was bound to find a general gap in knowledge and practice skills. This gap was exacerbated by the initial comparatively low transmission rates and almost no confirmed COVID-19 cases at most health facilities for an extended period of time. In addition, Uganda’s health system design and national response to COVID-19 required prompt referral to higher-level facilities as opposed to managing cases at all levels. Uganda managed to hold off pandemic mortality for some time – its first COVID-19 case was confirmed on 21st March 2020 and first death registered four months later on 23rd July 2020 [59].

Geographical, regional and district variations in HCW knowledge, attitude and practices require further analytical exploration in future research. Several factors could account for these differences. First, Kyegegwa is a direct refugee-hosting district with Kyaka II refugee settlement and has a resident implementing partner (IP) exclusively handling refugee health matters within the settlement, although it also serves the neighbouring host community. Humanitarian health partners across all settlements actively trained and supported COVID-19 management in their respective units [60, 46] partly because they were not constrained or directly under government but supporting the national refugee response. The dynamism and complexity of Uganda’s health system design has been highlighted in previous studies [26]. IP-led system strengthening could also partly explain why some lower-level HCIIIs reported high level knowledge compared to HCIVs or district hospitals because most in-settlement health facilities are at HCIII level, which was not initially prioritized for full scale COVID-19 training and equipping in the government’s phased approach to system strengthening. This would also be a plausible explanation for the underlying KAP variations by health facility ownership (i.e. public vs. private) and community care-seeking behaviour which tends to prefer private over public health facilities, especially for emergencies [15, 61, 62, 63]. Gulu as the regional referral lead, where West Nile [Adjumani district] health facilities also referred COVID-19 cases, would have higher knowledge levels and stronger system capacity. Moreover, Gulu has been at the forefront and has history of managing epidemics such as Ebola [64, 65]so the infrastructure and experience is in place. A number of studies have indeed supported this notion of system preparedness and resilience following an epidemic [66–68]. We recommend that, due to the evolving nature and trajectory of COVID-19, good practices be adopted from the more experienced facilities with flexibility for amendment as new evidence unfolds.

Regional variations on knowledge e.g. on infodemics, which show central region HCWs to have higher knowledge than their counterparts, could be due to better information access on COVID-19. Kampala, also the capital city and central business area, was and remains epicenter of the national COVID response. Initially access to information was mostly available via radio, television and print media mostly accessible in urban settings [69]. We recommend further engagement of all healthworkers and ongoing information sharing - including through their professional and regulatory bodies.

In all aspects of knowledge, HCWs with atleast a bachelors’ degree education exhibited higher knowledge than peers with a diploma or certificate level education. There is nothing surprising there as the evidence shows direct linkages between HCW education level, regulation, supervision, competence to understand or perform deliver services and improved clinical outcomes in healthcare [70, 71]. However, training and competence variations also highlight the need for comprehensive, systematic, tailored and refresher training for all healthworkers with clear outcomes – both for learning and service delivery at the point of care. This is especially needed in resource-limited settings; in light of limited health workforce and fragile health systems which also require task shifting, ongoing supervision and supportive mechanisms [20, 24]. The knowledge, skill, and experience of HCWs remain critical inputs for system capacity and resilience [11] during a pandemic and its aftermath.

Capacity building methods for healthworkers have a bearing on knowledge retention and application [72, 72]. This study’s findings show that the majority of healthworkers do not have first-hand experience in managing COVID-19 cases, although some had undergone simulation training in preparation and nearly all healthworkers could apply basic clinical knowledge to triage, screen, isolate and refer patients. The evidence shows on-site mentorship and support at the point of care, managing actual cases, to be more beneficial and impactful [74, 75, 76]. This is for not only service delivery outcomes but also knowledge retention and translation or application among healthworkers [75, 76].Healthworker and facility practices to effectively manage COVID-19 are constrained by individual factors (e.g. education level, residence or location of work station, hygiene promotion, social distance management etc) and facility-related factors (e.g. poor information/communication, lack of safety plans, risk monitoring and work environmental threats among others).The need for infrastructural preparedness, responsive and resilient health systems cannot be overemphasized [68, 19]. We recommend practical and urgent support for system capacity at all levels, especially in light of surging community transmission, a limited health workforce and congested higher-level facilities. Among others this will require the strengthening of cross-site mentorship, learning, coordination and the referral pathway. Robust processes will entail more on-site learning leveraging technology.

Related to this is the need to empower communities and patients to prevent and self-manage certain conditions, while emphasising health literacy and telemedicine. Strengthening community-based surveillance and ensuring functional health systems for disease prevention and management is critical in the era of COVID-19. There is need to equip community members, leaders, village health teams (VHTs) and lower- level facilities with capacity to respond effectively. In October 2020, and against the backdrop of surging community transmissions, Uganda launched a Community Health Engagement Strategy (CES) with key pillars and a promise to invest the required resources needed for its activation and functionality [77]. Collaboratively engaging local [political, administrative, cultural, religious and technical/health] leaders to take ownership and emphasise adherence to prevention measures will not only contribute significantly to health system resilience but also community agency, meaningful involvement beyond longstanding tokenism and stronger capacity to address the current and future pandemics.

Limitations

The challenges in execution of this study warrant some acknowledgement. First, this was a rapid assessment of the current lived and implementation experiences in refugee settings regarding COVID-19 in specific areas including knowledge, awareness and risk behaviours. As such a cross-sectional study design was most appropriate. With cross sectional findings nonetheless, caution should be practiced in assuming causality. We can only firmly establish associations.

The study was conducted in the earlier phase of Uganda’s first wave of COVID-19. Actual data collection was between September and October 2020 and a lot, including healthworker knowledge or facility capacity, has since changed.

These challenges notwithstanding, the study seems to be in line with our observations and hypotheses, also providing new insights for the effective management of COVID-19 among refugees in Uganda.

CES- Community Health Engagement Strategy; GDP – Gross Domestic Product; HC – Health Centre; HCWs – Health Care Workers; IDI -Indepth Interview; KAP – Knowledge, Attitudes and Practices; KCCA – Kampala Capital City Authority; MakSPH-HDREC – Makerere University School of Public Health Higher Degrees Research Ethics Committee; MNHC – Maternal, Newborn and Child health; MoH -Ministry of Health; NGOs – Non Governmental Organisations; OPM – Office of the Prime Minister; PPE – Personal Protective Equipment; UNCST – Uganda National Council of Science and Technology

Ethics approval and consent to participate

The study protocol was approved by Makerere University School of Public Health Research and Ethics Committee (MakSPH-HDREC, #820). It also obtained clearance from the Uganda National Council of Science and Technology (UNCST), Ministry of Health (MoH), Uganda’s Office of the Prime Minister (OPM) and Kampala Capital City Authority (KCCA). We adhered to all standard ethical principles including informed consent, doing no harm to participants, privacy, anonymity and voluntary participation. In addition, the study team adhered to the COVID-19 SOPs which were operationalized to the different regions, study sites and refugee settlements in consultation with local leadership.

Consent for publication

No individual participant has been identified in this research.

Availability of Data and Materials

All data generated or analysed during this study are included in this published article.

Competing interests

We have no competing interests.

Funding

This research was made possible by a grant (# 50530 REFLECT in COVID-19) funded by Elrha/R2HC (Research for Health in Humanitarian Crises) supported by UKAID, Wellcome and National Institute for Health Research (NIHR). The views expressed in this paper are those of the authors and not Elrha/R2HC.

Authors’ Contributions

GS, SL and CN contributed to study concept and design. EL and BL participated in study conception and provided technical guidance throughout the study. SL, FO, JK and GS contributed to data analysis. All authors contributed to data collection, interpretation of findings and manuscript writing. All authors approved the final version of the manuscript.

Acknowledgements

We acknowledge the following who helped with data collection: Francis Abura, Maria Ssematiko, Steven Twinomujuni, Francis Kinuthia, Joshua Aisu and the entire REFLECT field team.

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Healthworker Preparedness for COVID-19 Management and Implementation Experiences: A Mixed Methods Study in Uganda’s Refugee-Hosting Districts

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Socio-Demographic Characteristics

Knowledge

Bivariate Analyses On Knowledge And Awareness

Practices

Health Worker and Facility Practices regarding COVID-19

Work Environment

Discussion And Conclusions

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