COVID-19 epidemiology and changes in health service utilization in Uganda's refugee settlements during the first year of the pandemic

Strategies to maintain health service provision during the COVID-19 pandemic in refugee settings in Jordan and Uganda

Health system adaptations were rapidly introduced at the start of the COVID-19 pandemic to protect the public and maintain access to health services. Given the specific vulnerabilities of forced displacement settings, understanding which adaptations were used, how they were implemented, their success, and challenges is important for preparedness and response efforts. In this paper, we characterize adaptations in health service delivery implemented by Ministries of Health, the UN Refugee Agency, and partners to maintain health services provision for refugees in Jordan and Uganda. We conducted 21 key informant interviews with managerial and operational staff across 12 organizations who delivered healthcare services for refugees in Uganda and Jordan during the COVID-19 pandemic and applied a framework analysis to the adaptations characterized. The results are presented by WHO health system building blocks. Most adaptations focused on health service delivery specifically procedures for screening and isolation in the community, COVID-19 community support, and facility-level infection prevention measures. Health service delivery adaptations focused not only on ensuring capacity for COVID-19 patients but on adapting mechanisms to support access for those needing regular care. Many adaptations worked in tandem with others as packages to achieve this. Workforce adaptations included task shifting and staffing surges. Modifications related to medical products, vaccines, and technologies focused on procurement, medication management, supporting vaccine strategies, and building testing capacity. Adaptations in leadership and governance, financial and health information systems were identified but mainly described as essential enablers for other adaptations. Key enablers to successful adaptation in this context included the integration of refugees in National Health systems, strong relationships between partners and a supportive environment for adaptation, existing preparedness plans and access to financing. This study highlights the scale, scope and diversity of innovative adaptations implemented to maintain health services for refugees in Jordan and Uganda during the COVID-19 pandemic.

Temporal trends in the incidence and case severity of COVID-19 cases among the Syrian refugees in Azraq camp in Jordan: A retrospective observational study

BACKGROUND

Azraq Syrian refugee camp, located in Jordan, is where the challenges of managing the COVID-19 epidemic meet the vulnerabilities of displaced people. This study aimed to investigate the epidemiological characteristics, incidence, risk factors, and outcomes of COVID-19 among Azraq camp residents.

METHODS

COVID-19 data from Azraq camp were collected by International Medical Corps clinics and analyzed retrospectively from August 1, 2020, to August 31, 2022. Data included demographics, risk factors, testing history, contact tracing, and vaccination profiles. We estimated COVID-19 incidence and analyzed risk factors using Poisson and multilevel logistic regression.

RESULTS

A total of 2,468 confirmed COVID-19 cases were identified, with a prevalence of 5.6 per 100 residents. The camp's monthly incidence rate was more than 50% lower than the national rate, with a 1.7% monthly decrease. Females had a higher incidence than males (6.4% vs. 4.9%, p < 0.001), while the elderly bore the greatest disease burden. Home-based isolation was the main strategy, except during the second wave. Vaccination coverage reached 31.6%, primarily with Pfizer (49.8%). Symptomatic cases made up 44.0% of confirmed cases, with 10.4% requiring hospitalization. Factors independently associated with hospitalization included age, comorbidity, and vaccination status.

CONCLUSION

The study highlights the need for robust surveillance, targeted healthcare interventions, equitable resource allocation, and vaccination campaigns to manage COVID-19 and future epidemics in refugee camps.

The impact of COVID-19 on health service utilization in sub-Saharan Africa-a scoping review

BACKGROUND

Despite comparatively low rates of COVID-19 admissions and recorded deaths in sub-Saharan Africa (SSA), the pandemic still had significant impact on health service utilization (HSU). The aim of this scoping review is to synthesize the available evidence of HSU in SSA during the pandemic, focusing on types of studies, changes in HSU compared with the pre-pandemic period, and changes among specific patient groups.

METHODS

The scoping review was guided by the methodological framework for conducting scoping reviews developed by Arksey and O'Malley. We identified relevant studies through a search of PubMed (MEDLINE), Embase, Scopus, and Web of Science. We then provided a general descriptive overview of the extracted data focusing on the types of studies, patient groups, and change in HSU.

RESULTS

We identified 262 studies reporting on HSU in 39 SSA countries. Studies were mainly quantitative (192; 73.3%), involving multiple centers (163; 62.2%), conducted in hospitals (205; 78.2%), and in urban settings (121; 46.2%). The median number of participants was 836.5 (IQR: 101.5-5897) involving 62.5% females. Most studies (92; 35.1%) focused on communicable diseases and mainly among outpatients (90; 34.2%). Maternal and child health studies formed the largest patient group (58; 22.1%) followed by people living with HIV (32; 12.2%). Change in HSU was reported in 249 (95.0%) studies with 221 (84.4%) studies reporting a decrease in HSU. The median decrease in HSU was 35.6% (IQR: 19.0-55.8) and median increase was 16.2% (IQR: 9.1-31.9). The patient group with the largest percentage decrease was cardiovascular diseases (68.0%; IQR: 16.7-71.1) and the lowest percentage decrease was in patients with infections (27.0%; IQR: 16.6-45.6).

CONCLUSIONS

A large body of literature is available on the effects of the pandemic on HSU in SSA. Most studies report decreases in HSU during the pandemic. However, patterns differ widely across disease categories, patient groups, and during different time periods of the pandemic.

The effect of COVID-19 on the non-COVID health outcomes of crisis-affected peoples: a systematic review

BACKGROUND

The COVID-19 pandemic posed considerable risks to populations affected by humanitarian crises in low- and middle-income countries (LMICs). However, there is limited understanding of how the pandemic may have affected non-COVID health outcomes among crisis-affected populations. Our aim was to examine the evidence on the impact of the COVID-19 pandemic on non-COVID-19 health outcomes for crisis-affected populations in LMICs.

METHODS

A systematic review methodology was applied following PRISMA guidelines. Eligibility criteria were: crisis-affected populations in LMICS; COVID-19; and all health topics, except for sexual and reproductive health which was covered in a linked review. Five bibliographic databases and additional grey literature sources were searched. The search period was from 2019 to 31 July 2022. Eligible papers were extracted and analysed using a narrative synthesis approach based on the study objectives and relevant health access and systems frameworks. A quality appraisal was also conducted.

FINDINGS

4320 articles were screened, and 15 eligible studies were identified and included in this review. Ten studies collected health outcomes data. Eight related to mental health, which generally showed worse mental health outcomes because of the pandemic, and pandemic-related stressors were identified. Two studies assessed physical health outcomes in children, while none addressed physical health outcomes among adults. Nine studies reported on access to healthcare, revealing worse access levels due to the pandemic and noting key barriers to care. Seven studies reported on the impact on health systems, with key challenges including reduced and distorted health care funding, reduced staff capacity, interrupted medicines and supplies, weak information and mixed-messaging, and weak leadership. All fifteen studies on the social determinants of health, particularly highlighting the effect of increasing poverty, the role of gender, and food insecurity on health outcomes. The quality of papers was limited overall.

CONCLUSION

This review found some limited evidence indicating negative mental health effects, increased barriers to accessing care, damage to health systems and magnified impacts on the social determinants of health for crisis-affected people during the COVID-19 pandemic. However, the small number and limited quality of the studies make the overall strength of evidence quite weak.

Impact of Ebola and COVID-19 on maternal, neonatal, and child health care among populations affected by conflicts: a scoping review exploring demand and supply-side barriers and solutions

INTRODUCTION

Armed conflicts have a severe impact on the health of women and children. Global health emergencies such as pandemics and disease outbreaks further exacerbate the challenges faced by vulnerable populations in accessing maternal, neonatal, and child healthcare (MNCH). There is a lack of evidence that summarizes the challenges faced by conflict-affected pregnant women, mothers, and children in accessing MNCH services during global health emergencies, mainly the Ebola and COVID-19 pandemics. This scoping review aimed to analyze studies evaluating and addressing barriers to accessing comprehensive MNCH services during Ebola and COVID-19 emergencies in populations affected by conflict.

METHODS

The search was conducted on PubMed, Scopus, and Web of Science databases using terms related to Ebola and COVID-19, conflicts, and MNCH. Original studies published between 1990 and 2022 were retrieved. Articles addressing the challenges in accessing MNCH-related services during pandemics in conflict-affected settings were included. Thematic analysis was performed to categorize the findings and identify barriers and solutions.

RESULTS

Twenty-nine studies met the inclusion criteria. Challenges were identified in various MNCH domains, including antenatal care, intrapartum care, postnatal care, vaccination, family planning, and the management of childhood illnesses. Ebola-related supply-side challenges mainly concerned accessibility issues, health workforce constraints, and the adoption of stringent protocols. COVID-19 has resulted in barriers related to access to care, challenges pertaining to the health workforce, and new service adoption. On the demand-side, Ebola- and COVID-19-related risks and apprehensions were the leading barriers in accessing MNCH care. Community constraints on utilizing services during Ebola were caused by a lack of trust and awareness. Demand-side challenges of COVID-19 included fear of disease, language barriers, and communication difficulties. Strategies such as partnerships, strengthening of health systems, service innovation, and community-based initiatives have been employed to overcome these barriers.

CONCLUSION

Global health emergencies amplify the barriers to accessing MNCH services faced by conflict-affected populations. Cultural, linguistic, and supply-side factors are key challenges affecting various MNCH domains. Community-sensitive initiatives enhancing primary health care (PHC), mobile clinics, or outreach programs, and the integration of MNCH into PHC delivery should be implemented. Efforts should prioritize the well-being and empowerment of vulnerable populations. Addressing these barriers is crucial for achieving universal health coverage and the Sustainable Development Goals.

Health care utilisation in Cox's Bazar district, Bangladesh, during the first year of the COVID-19 pandemic: A mixed-methods study among host communities

To respond to the COVID-19 pandemic, countries introduced public health and social measures that had indirect societal, economic consequences. Concerns during epidemics include continuity of routine health services. We investigate how healthcare utilisation and healthcare seeking behaviour changed during the first year of the COVID-19 pandemic among host communities in Cox's Bazar, Bangladesh. This mixed-methods study combines quantitative analyses of routine health data and population-based findings about healthcare seeking behaviours. Trends in consultations changed according to facility level (higher-level facilities included Upazila Health Complexes and District Hospitals; lower-level facilities included Community Clinics and Union Health and Family Welfare Centers). At the pandemic's beginning, drops were seen at higher-level health facilities for outpatient department (OPD) consultations, respiratory infections, and antenatal care. Minor reductions or increases were seen at lower-level facilities for the same services. Half of the subdistricts reported a cumulative increase in OPD and respiratory tract infection consultations. Most subdistricts reported a cumulative decrease in antenatal care. Child vaccinations dropped in all subdistricts, half of which did not catch-up, resulting in a cumulative decrease of delivered doses. Fear of contracting COVID-19 and financial constraints were the main reasons for decreased access. Drivers of healthcare seeking behaviours should be better understood to guide preparedness and service delivery modalities at primary and secondary levels.

The implementation of infection prevention and control measures and health care utilisation in ACF-supported health facilities during the COVID-19 pandemic in Kinshasa, Democratic Republic of the Congo, 2020

BACKGROUND

Infection prevention and control (IPC) was a central component of the Democratic Republic of the Congo's COVID-19 response in 2020, aiming to prevent infections and ensure safe health service provision.

OBJECTIVES

We aimed to assess the evolution of IPC capacity in 65 health facilities supported by Action Contre la Faim in three health zones in Kinshasa (Binza Meteo (BM), Binza Ozone (BO), and Gombe), investigate how triage and alert validation were implemented, and estimate how health service utilisation changed in these facilities (April-December 2020).

METHODS

We used three datasets: IPC Scorecard data assessing health facilities' IPC capacity at baseline, monthly and weekly triage data, and monthly routine data on eight health services. We examined factors associated with triage and isolation capacity with a mixed-effects negative binomial model and estimated changes in health service utilisation with a mixed-model with random intercept and long-term trend for each health facility. We reported incidence rate ratios (IRRs) for level change when the pandemic began, for trend change, and for lockdown and post-lockdown periods (Gombe). We estimated cumulative and monthly percent differences with expected consultations.

RESULTS

IPC capacity reached an average score of 90% by the end of the programme. A one-point increase in the IPC score was associated with +6% and +5% increases in triage capacity in BO and Gombe, respectively, and with +21% and +10% increases in isolation capacity in the same zones. When the pandemic began, decreases were seen in outpatient consultations (IRR: 0.67, 95% confidence interval (CI) [0.48-0.95] BM&BO-combined; IRR: 0.29, 95%CI [0.16-0.53] Gombe), consultations for respiratory tract infections (IRR: 0.48, 95%CI [0.28-0.87] BM&BO-combined), malaria (IRR: 0.60, 95%CI [0.43-0.84] BM&BO-combined, IRR: 0.33, 95%CI [0.18-0.58] Gombe), and vaccinations (IRR: 0.27, 95%CI [0.10-0.71] Gombe). Maternal health services decreased in Gombe (ANC1: IRR: 0.42, 95%CI [0.21-0.85]).

CONCLUSIONS

The effectiveness of the triage and alert validation process was affected by the complexity of implementing a broad clinical definition in limited-resource settings with a pre-pandemic epidemiological profile characterised by infectious diseases with symptoms like COVID-19. Readily available testing capacity remains key for future pandemic response to improve the disease understanding and maintain health services.

Estimating the effects of COVID-19 on essential health services utilization in Uganda and Bangladesh using data from routine health information systems

Background

Since March 2020, the coronavirus disease 2019 (COVID-19) pandemic has been a major shock to health systems across the world. We examined national usage patterns for selected basic, essential health services, before and during the COVID-19 pandemic in Uganda and Bangladesh, to determine whether COVID-19 affected reporting of service utilization and the use of health services in each country.

Methods

We used routine health information system data since January 2017 to analyze reporting and service utilization patterns for a variety of health services. Using time series models to replicate pre-COVID-19 trajectories over time we estimated what levels would have been observed if COVID-19 had not occurred during the pandemic months, starting in March 2020. The difference between the observed and predicted levels is the COVID-19 effect on health services.

Results

The time trend models for Uganda and Bangladesh closely replicated the levels and trajectories of service utilization during the 38 months prior to the COVID-19 pandemic. Our results indicate that COVID-19 had severe effects across all services, particularly during the first months of the pandemic, but COVID-19 impacts on health services and subsequent recovery varied by service type. In general, recovery to expected levels was slow and incomplete across the most affected services.

Conclusion

Our analytical approach based on national information system data could be very useful as a form of surveillance for health services disruptions from any cause leading to rapid responses from health service managers and policymakers.

Impact of COVID-19 on health service utilisation in sub-Saharan Africa: protocol for a scoping review

INTRODUCTION

The COVID-19 pandemic has exposed weaknesses in health systems of many countries, including those in sub-Saharan Africa. Despite comparatively low rates of COVID-19 admissions and deaths in sub-Saharan Africa, the pandemic still had a significant impact by disrupting health service utilisation (HSU). The aim of this scoping review is to synthesise the available evidence on HSU in sub-Saharan Africa during the COVID-19 pandemic, especially focusing on (1) changes in HSU compared with the prepandemic period, (2) changes in HSU among particular patient groups studied and (3) identifying factors determining changes in HSU as a result of the COVID-19 pandemic.

METHOD AND ANALYSIS

The scoping review will be guided by the methodological framework for conducting scoping reviews developed by Arskey and O'Malley. We will identify relevant studies on HSU in sub-Saharan Africa during the COVID-19 pandemic using PubMed (MEDLINE), Embase, Scopus and Web of Science databases from 1 December, 2019 to 31 March 2023. We will search grey literature, government and organisational websites for reports and conference proceedings. Included studies will be restricted to those reported in English or French. Two reviewers will independently screen articles at the title and abstract stage for inclusion into full text screening. We will provide a general descriptive overview, tabular summaries and content analysis for the extracted data.

ETHICS AND DISSEMINATION

Ethical approval is not required for the conduct of the scoping review. We will disseminate our findings via open access peer-reviewed journals and scientific presentations. Our scoping review findings will help to determine the feasibility of a subsequent systematic review (and meta-analysis) on HSU during the COVID-19 pandemic.

Understanding the barriers and facilitators of COVID-19 risk mitigation strategy adoption and COVID-19 vaccination in refugee settlements in Uganda: a qualitative study

BACKGROUND

Perspectives on COVID-19 risk and the willingness and ability of persons living in refugee settlements to adopt COVID-19 prevention strategies have not been rigorously evaluated. The realities of living conditions in Ugandan refugee settlements may limit the extent to which refugees can uptake strategies to mitigate COVID-19 risk.

METHODS

In-depth qualitative interviews were conducted between April 2021 and April 2022 to assess COVID-19 knowledge, risk perception, prevention strategy adoption including COVID-19 vaccination, and COVID-19 impact on living conditions in refugee settlements in Uganda. Interview participants included 28 purposively selected refugees who called into "Dial-COVID", a free telephone COVID-19 information collection and dissemination platform that was advertised in refugee settlements by community health workers. Interviews were analyzed using a combination of deductive and inductive content analysis. Emerging themes were mapped onto the Theoretical Domains Framework to identify domains influencing prevention behavior. Results were synthesized to provide intervention and policy recommendations for risk mitigation in refugee settlements for COVID-19 and future infectious disease outbreaks.

RESULTS

The COVID-19 pandemic detrimentally impacted economic and food security as well as social interactions in refugee settlements. Youth were considered especially impacted, and participants reported incidents of child marriage and teenage pregnancy following school closures. Participants displayed general knowledge of COVID-19 and expressed willingness to protect themselves and others from contracting COVID-19. Risk mitigation strategy uptake including COVID-19 vaccination was influenced by COVID-19 knowledge, emotions surrounding COVID-19, the environmental context and resources, personal goals, beliefs about the consequences of (non)adoption, social influences, and behavior reinforcement. Resource constraints, housing conditions, and competing survival needs challenged the adoption of prevention strategies and compliance decreased over time.

CONCLUSIONS

Contextual challenges impact the feasibility of COVID-19 risk mitigation strategy uptake in refugee settlements. Pre-existing hardships in this setting were amplified by the COVID-19 pandemic and related lockdowns. Targeted dispelling of myths, alignment of information across communication mediums, supporting survival needs and leveraging of respected role models are strategies that may hold potential to mitigate risk of infectious diseases in this setting.

REGISTRATION DETAILS

World Pandemic Research Network - 490,652.

Prevalence and Factors Associated With Compliance With COVID-19 Presidential Lockdown Measures: A Cross-Sectional Study

The coronavirus disease 2019 (COVID-19) is one of the most severe global health uncertainties to date. Although significant global effort has been put into implementing COVID-19 pandemic control measures such as lockdowns, travel restrictions, and hygiene precautions, the transmission is expected to resurface once these efforts are discontinued. We aimed to determine the prevalence and factors associated with compliance with presidential 53-day lockdown measures in June-July 2021 in northern Uganda. In this cross-sectional study, 587 adult participants (≥18 years old) from northern Uganda were selected using a systematic sampling method. Data collection involved interviewer-administered questionnaires with an internal validity of Cronbach's α = .72. Socio-demographic characteristics of participants were described, and multivariable modified Poisson regressions were performed to assess prevalence ratios between dependent and selected independent variables, with respective P values at 95% confidence intervals. All analyses were conducted using Stata 17.0. Participants' compliance with the presidential lockdown directives was high at 88%(95% CI: 85%-90%). Compliance with the presidential directives was more likely among participants who agreed to the lockdown measures [adjusted Prevalence Ratio, aPR = 1.28 (95% CI: 1.10-1.49; P = .001)] compared to those who did not, and more likely among those who were afraid of death from COVID-19 [aPR = 1.08 (95% CI: 1.01-1.15; P = .023)] than those who did not. However, compliance was less likely among males [aPR = 0.91 (95% CI: 0.86-0.97; P = .002)] compared to females, those aged 35 to 44 years [aPR = 0.87 (95% CI: 0.79-0.97; P = .013)] compared to those less 25 years; and unmarried [aPR = 0.89 (95% CI: 0.82-0.97; P = .011)] compared to the married. Compliance with the COVID-19 presidential lockdown measures in northern Uganda was high. The factors associated with compliance were the fear of death and agreement with presidential lockdown measures. However, compliance was less likely among males, unmarried persons, and persons aged 35 to 44. The authors recommend more community engagements, participation, sensitization, mobilization, and simultaneous application of multiple public health approaches to improve compliance and control of COVID-19.