Level and determinants of adherence to and satisfaction with use of face masks in the first stage of the outbreak in Uganda, April 2020

Bob Omoda Amodan^1,2,&, Lilian Bulage¹, Elizabeth Katana¹, Alex Riolexus Ario^1,3

 

¹Uganda Public Health Fellowship Program, 4th Floor, Lourdel towers, Plot 1, Lourdel Road Nakasero, P.O Box 7272, Kampala, Uganda, ²Uganda National Institute of Public Health, Ministry of Health, P.O Box 7272, Kampala, Uganda, ³Environmental Health Department, Ministry of Health, P.O Box 7272 Kampala, Uganda

 

 

^&Corresponding author
Bob Omoda Amodan, Uganda Public Health Fellowship Program, 4th Floor, Lourdel towers, Plot 1, Lourdel Road Nakasero, P.O Box 7272, Kampala, Uganda. bomoda@musph.ac.ug

 

 

 

 

On 11 March 2020, WHO declared COVID-19 a pandemic [1]. Countries were urged to institute preventive strategies including personal protective, environmental and social distancing interventions to minimize spread of the disease [2].

 

The Ugandan government progressively implemented several stringent public health measures to prevent and contain local COVID-19 epidemic [3]. On March 18th 2020, the government prohibited mass gathering of people, closed the airport and points of entry, closed schools and all learning institutions and encouraged people to wear masks, keep social distance, not to cough, sneeze or spit in public, and to observe hand hygiene measures [4].

 

Uganda´s index COVID-19 case was confirmed on 21 March 2020, and on 25 March 2020, a partial lockdown was instituted, just following a ban on public transport. A nationwide 14-days lockdown was instituted on 30 March 2020 with a nationwide curfew from 7pm to 6.30am; private transport was banned. The total lockdown was later extended until on 2 June 2020, when the restrictions were eased in phases. At the start of the phased lifting, there were fewer than 300 confirmed COVID-19 cases in Uganda, very low community transmission and no deaths had been recorded due to COVID-19 [5]. Due the economic hardships and collateral impact of the total lockdown, there was strong public pressure on the government to lift some of the lockdown restrictions [6].

 

However, the level of adherence to public use of face masks had not been assessed. Exploring the level of adherence to and satisfaction with use of face mask was key for control of COVID-19. There was need to understand if the public adherence to face mask use was good or bad, and subsequently devise ways to ensure it is maintained or improved as its level of adherence influences the effectiveness of containing the spread of COVID-19. Face mask usage by the public has remained controversial and hotly contested in most countries including Uganda with researchers questioning its potential for protection on both the public and individual levels [7]. Early in the epidemic some experts advised against community wide use of face masks citing their risk for self-contamination and depletion of stocks for the health workers and symptomatic cases who may have needed them most [8]. We assessed the level and factors associated with adherence to and satisfaction with use of face masks as one of the key recommended COVID-19 preventive measures.

 

 

Study design and population

 

We conducted secondary analysis of data abstracted from an online cross-sectional national survey [3] conducted as part of the International Citizen Project (ICP) to assess adherence to preventive measures and their impact on the COVID-19 outbreak. The ICP consortium had a generic questionnaire which we modified to suite our local situation in Uganda. The questionnaire collected information about socio-demographic characteristics; the impact of COVID-19 and associated restrictions on daily life, professional life, and personal well-being; adherence to personal and community preventive measures; and acceptability of these measures. The questionnaire was hosted securely on the study website (https://www.icpcovid.com), and the web-link widely shared during the lockdown period via emails and social media platforms from April 16th to 30th, 2020 [3].

 

Study variables, data abstraction, and data analysis

 

We abstracted data on sex, residence, age, marital status, education, religion, among others, daily personal health, and professional factors were abstracted as independent factors associated with adherence to and satisfaction with mask use.

 

Data extraction and cleaning was done on Microsoft Excel 2019. We analyzed data using STATA 14/SE. From possessions such as radio, motorcycle, bicycle, car, television set, and mobile phone, we derived a composite variable, wealth index quintiles.

 

We described continuous variables using means with standard deviation (SD), and percentages were used to describe categorical variables. Specifically, to determine the level of adherence to and satisfaction with use of face masks as one of the preventive measures against COVID-19, we generated frequency table and calculated the percentages.

 

To find the determinants of adherence to use of face masks as one of the preventive measures against COVID-19, we used modified Poisson regression because prevalence of adherence to mask use was more than 10%. In addition, ordinal logistic regression stepwise modelling was used to predict determinants of satisfaction with use of face masks. Level of significance was considered at p-value of <5%.

 

Availability of data and materials

 

The datasets upon which our findings are based belong to the ICP COVID-19 project. For confidentiality purposes, the datasets are not publicly available. However, the data sets can be availed upon reasonable request from the corresponding author and with permission from the ICP COVID-19 project.

 

Ethical Considerations

 

“The ICP study was approved by the ethics committees of the University of Antwerp, Belgium (20/13/148) and School of Public health, Makerere University, Kampala, Uganda (HDREC number 809)” [3]. All respondents in the ICP consented and entered their data anonymously [3]. During abstraction of data for this study, access to the ICP website was only restricted to one member of the Ugandan study team. This same person did data cleaning and analysis. He also kept all the data confidential.

 

 

This study had 1,726 respondents with mean age of 36 years (SD=11). Less than half (41%) of respondents in the category 29-39 years participated in the survey. Majority of the respondents (59% (1,015/1,726)) were males. Only (3% (47/1,726)) respondents were non-Ugandans. Half (50%) of the respondents had attained tertiary education. Kampala suburb had the highest number (40% (688/1,726)) of respondents. Seventeen percent of the respondents had known underlying conditions.

 

Level of adherence to use of face masks in Uganda, April 2020

 

Of 1,726 respondents, only 566 (33%) adhered to face mask use. Face mask use was similar by sex (52% for males versus 48% for females). Thirty nine percent (219/566) of those who used face masks were in the age group of 29-39 years. Of the 566 who adhered to face mask use, 80 (86%) did not live alone. Adherence to mask use among those who lived as a couple was 30% (14/566). Level of adherence to face mask use decreased with education level i.e., having no education or studied up to primary level (0.53% (3/566)) versus those with tertiary level education ((50% (281/566)) adhered to face mask use. Face mask use was highest (45% (253/566)) among Kampala suburbs. Nineteen percent (107/566) of those with underlying conditions adhered to mask use.

 

Determinants of level of adherence to use of face masks in Uganda, April 2020

 

In multivariable analysis, worry about own health (Adj. PR: 1.1, 95% CI: 1.02-1.1), and having high face mask satisfaction levels (Adj. PR: 1.4, 95% CI: 1.3-1.5) were more likely to adhere to use of face masks as one of the preventive measures against COVID-19.

 

Staying with siblings (Adj. PR: 0.94, 95% CI: 0.91-0.97), and Living in cities/towns other than Kampala (Adj. PR: 0.94, 95% CI: 0.91-0.97) reduced the odds of adherence to mask use Table 1.

 

Level of satisfaction with use of face masks as one of the COVID-19 preventive health measures in Uganda, April 2020

 

Of the 1,726 respondents, 520 (30%) were very satisfied with use of face masks as one of the appropriate COVID-19 preventive measures. Majority (51%) of those who were very satisfied with mask use were males. Fifty-two percent of those who were very satisfied with mask use were living as couples Table 2.

 

Determinants of level of satisfaction with face masks in Uganda, April 2020

 

In multivariable analysis, those in highest wealth index quintile (AOR: 1.7, 95% CI: 1.2-2.4) and females (AOR: 1.2, 95% CI: 1.1-1.5) were very satisfied with mask use. Reporting violence or discrimination at home (AOR: 0.47, 95% CI: 0.23-0.99), and being moderately not worried about loved ones´ health (AOR: 0.75, 95% CI: 0.57-0.99) was less likely to be associated with being very satisfied with face mask use Table 3 and Table 4 respectively.

 

 

This study assessed level and determinants of adherence to and satisfaction with face mask use as an appropriate COVID-19 preventive measures in Uganda. Only a third of the respondents wear face masks in the open. Additionally, 3 in 10 respondents are satisfied with use of face masks as preventive measures. A study [9] reported that spread of COVID-19 could be intercepted if 80% of the population used face masks properly. The general public could have possibly not got strong reasons for using face masks to prevent COVID-19 transmission since there was a lot of inconsistent information around its use [8]. Furthermore, Africans perceived that COVID-19 will be mild, given the hot climatic conditions and largely young population structure [10]. Additionally, Ugandans and Africans at large felt uncomfortable while using masks [11]. Health education programs on the importance of face mask use in containing the COVID-19 pandemic is clearly needed, as well as subsidies and free face masks for those who may not be able to afford them [3].

 

Self-health worry was associated with adherence to face mask use. This resonates with findings that concerns about individual´s health status leads to observance of disease preventive measures [12]. Having a perceived risk has potential in influencing up-take of health promotion and preventive measures. However, risk perception has been affected by widespread misinformation and disinformation in Uganda [13].

 

Those living in cities or towns other than Kampala City Centre were less likely to use face mask. This is because the first cases of COVID-19 were reported in Kampala, and that congestion was perceived to be low in other cities/ towns [3].

 

Satisfaction with use of face masks was directly linked to its observance. This means that there is need to get trust and satisfaction from the public if government interventions are to be embraced [14]. There was a lower satisfaction and adherence to mask use among men. This could be explained by men´s poor health seeking behaviors [15]. COVID-19 risk communication and community engagement targeting males is one of the interventions we cannot ignore in halting transmission of COVID-19 [14, 16].

 

Limitations

 

This ICP study [3] was conducted online, and thus required access to smart phones and internet connectivity for participation. The study could have therefore enrolled only educated people with a certain social standing and thus the findings could have overestimated the level of adherence and satisfaction [3].

 

 

A small proportion of respondents adhered to masks use. Level of satisfaction with use of face masks were similarly low. Sensitization campaigns on mask use, targeting men, large families, and people living outside Kampala City Centre need to be intensified so as to improve level of adherence and satisfaction.

 

 

The authors declare no conflict of interest.

 

Funding and Disclaimer

 

This study was supported and designed by the International citizen project to assess adherence to public health measures and their impact on the COVID-19 outbreak (ICP COVID-19) through Makerere University School of Public, the Uganda Public Health Fellowship Program, and Ministry of Health Uganda. The staff of the funding body provided technical guidance in the design of the study, ethical clearance, and data collection, analysis, and interpretation of data, and in writing the manuscript.

 

The contents of the study are solely the responsibility of the authors and do not necessarily represent the official views of Makerere University School of Public Health, Uganda Public Health Fellowship Program, and the Ministry of Health Uganda.

 

 

University of Antwerp, Belgium conceived and designed the study. BOA and EK collected, analyzed, interpreted the data, and wrote the first draft of the manuscript. LB, EK and ARA reviewed the manuscript to ensure intellectual content and scientific integrity. All authors read and approved the final version of the manuscript for publication.

 

 

Special thanks go to the University of Antwerp, Belgium and the entire team of the ICP-COVID-19 project for conceiving the idea, designing the mother questionnaire, and securing the data. We are also grateful to the School of Public health, Makerere University Kampala, Uganda Public Health Fellowship Program and Ministry of Health for jointly supporting the design and implementation of the study, and taking up the supervisory role and guidance when writing this manuscript.

 

 

Table 1: Determinants of adherence to use of face masks as one the COVID-19 preventive health measures in the Uganda, April 2020

Table 2: Level of satisfaction with use of face masks as one of the COVID-19 preventive measures

Table 3: Determinants of level of satisfaction with face masks as a COVID-19 preventive measure in Uganda, April 2020

Table 4: Violence related determinants for level of satisfaction with face masks as a COVID-19 preventive measure in Uganda, April 2020

 

 

1. World Health Organization. WHO Director-General's opening remarks at the media briefing on COVID-19 - 11 March 2020. Geneva: World Health Organization. 2020. Accessed June 2020.


2. World Health Organization. Responding to community spread of COVID-19: interim guidance, 7 March 2020. World Health Organization. 2020. Accessed Mar 2022.


3. Amodan BO, Bulage L, Katana E, Ario AR, Fodjo JNS, Colebunders R, Wanyenze RK. Level and Determinants of Adherence to COVID-19 Preventive Measures in the First Stage of the Outbreak in Uganda. Int J Environ Res Public Health. 2020; 17(23):8810. https://doi.org/10.3390/ijerph17238810 PubMed | Google Scholar


4. Government of Uganda. President Museveni COVID-19 Guidelines to the Nation on Corona Virus. Uganda Media Centre. 2020. Accessed June 2020.


5. GardaWorld. Uganda: Lockdown measures to be eased from June 2. Garda.com. 2020. Accessed Jul 2020.


6. Lubowa D. Scientists speak out on easing lockdown. Kampala: Daily Monitor, Uganda. 2020. Accessed Dec 2020.


7. Lyu W, Wehby GL. Community Use Of Face Masks And COVID-19: Evidence From A Natural Experiment Of State Mandates In The US. Health affairs (Project Hope). 2020; 39(8):1419-25. https://doi.org/10.1377/hlthaff.2020.00818 PubMed | Google Scholar


8. Schünemann HJ, Akl EA, Chou R, Chu DK, Loeb M, Lotfi T, Mustafa RA, Neumann I, Saxinger L, Sultan S, Mertz D. Use of facemasks during the COVID-19 pandemic. The Lancet Respiratory medicine. 2020; 8(10):954-5. https://doi.org/10.1016/s2213-2600(20)30352-0 PubMed | Google Scholar


9. Ngonghala CN, Iboi E, Eikenberry S, Scotch M, MacIntyre CR, Bonds MH, Gumel AB. Mathematical assessment of the impact of non-pharmaceutical interventions on curtailing the 2019 novel Coronavirus. Mathematical biosciences. 2020; 325:108364. https://doi.org/10.1016/j.mbs.2020.108364 PubMed | Google Scholar


10. Diop BZ, Ngom M, Pougué Biyong C, Pougué Biyong JN. The relatively young and rural population may limit the spread and severity of COVID-19 in Africa: a modelling study. BMJ Global Health. 2020; 5(5):e002699.http://dx.doi.org/10.1136/bmjgh-2020-002699 PubMed | Google Scholar


11. Ahmed MAM, Siewe Fodjo JN, Gele AA, Farah AA, Osman S, Guled IA, Ali AM, Colebunders R. COVID-19 in Somalia: Adherence to Preventive Measures and Evolution of the Disease Burden. Pathogens (Basel, Switzerland). 2020; 9(9):735.https://doi.org/10.3390/pathogens9090735 PubMed | Google Scholar


12. Canadian Mental Health Association. COVID-19 and Anxiety. Vancouver: Heretohelp. 2020. Accessed June 2020.


13. Kasozi KI, MacLeod E, Ssempijja F, Mahero MW, Matama K, Musoke GH, Bardosh K, Ssebuufu R, Wakoko-Studstil F, Echoru I, Ayikobua ET, Mujinya R, Nambuya G, Onohuean H, Zirintunda G, Ekou J, Welburn SC. Misconceptions on COVID-19 Risk Among Ugandan Men: Results From a Rapid Exploratory Survey, April 2020. Frontiers in Public Health. 2020; 8(416).https://doi.org/10.3389/fpubh.2020.00416 PubMed | Google Scholar


14. Duplaga M. Perception of the Effectiveness of Health-related Campaigns among the Adult Population: An Analysis of Determinants. Int J Environ Res Public Health. 2019; 16(5):791.https://doi.org/10.3390/ijerph16050791 PubMed | Google Scholar


15. Usman IM, Ssempijja F, Ssebuufu R, Lemuel AM, Archibong VB, Ayikobua ET, Aruwa JO, Kembabazi S, Kegoye ES, Ayuba JT, Okeniran OS, Echoru I, Adeoye A, Mujinya R, Nankya V, Kasozi KI. Community Drivers Affecting Adherence to WHO Guidelines Against COVID-19 Amongst Rural Ugandan Market Vendors. Frontiers in Public Health. 2020; 8(340).https://doi.org/10.3389/fpubh.2020.00340 PubMed | Google Scholar


16. Skinner CS, Tiro J, Champion VL. The Health Belief Model. Health behavior: Theory, research, and practice, 5th ed. San Francisco, CA, US: Jossey-Bass; 2015. p 75-94. Google Scholar