12: Psychosocial Implications and Programming Responses Against COVID-19 in Africa

In January 2020, the World Health Organization declared the outbreak of the novel coronavirus disease, COVID-19, a Public Health Emergency of International Concern. In Africa, COVID-19 cases continue to rise rapidly across the entire continent. Implications of the COVID-19 public health response have exposed families, including children and youth, to multiple vulnerabilities. In Phase 1, lockdown, the economic and health impact of the infection, control and prevention (ICP) public health responses has been severe, and in the longer term may even be ‘catastrophic’ (The Lancet Global Health, 2020: 612). This chapter describes the psychosocial implications of COVID-19 for African communities, drawing on case studies from Uganda and South Africa.

The Ugandan government in particular showed leadership by responding quickly and decisively to the impending threat of COVID-19, drawing on preparedness responses developed in relation to other viral outbreaks such as during the Ebola crisis. In Uganda, lockdown restrictions were introduced on 18 March 2020 just before the first case of COVID-19 in the country was detected. Public and private transportation was banned, public gatherings were suspended, shopping malls were shut down and a 7 pm curfew was instigated. Anguyo and Storer (2020) noted that among the 80 per cent of ‘hand to mouth’ workers employed in the ‘gig’ economy and informal sector, COVID-19 responses significantly disrupted people’s ability to earn money. South Africa also implemented tough public health measures. Citizens could only undertake essential trips to buy groceries or seek medical assistance, and in some cases lockdown was enforced by the use of rubber bullets (The Guardian, 2020).

In January 2020, the World Health Organization declared the outbreak of the novel coronavirus disease, COVID-19, a Public Health Emergency of International Concern. In Africa, COVID-19 cases continue to rise rapidly across the entire continent. Implications of the COVID-19 public health response have exposed families, including children and youth, to multiple vulnerabilities. In Phase 1, lockdown, the economic and health impact of the infection, control and prevention (ICP) public health responses has been severe, and in the longer term may even be ‘catastrophic’ (The Lancet Global Health, 2020: 612). This chapter describes the psychosocial implications of COVID-19 for African communities, drawing on case studies from Uganda and South Africa.

The Ugandan government in particular showed leadership by responding quickly and decisively to the impending threat of COVID-19, drawing on preparedness responses developed in relation to other viral outbreaks such as during the Ebola crisis. In Uganda, lockdown restrictions were introduced on 18 March 2020 just before the first case of COVID-19 in the country was detected. Public and private transportation was banned, public gatherings were suspended, shopping malls were shut down and a 7 pm curfew was instigated. Anguyo and Storer (2020) noted that among the 80 per cent of ‘hand to mouth’ workers employed in the ‘gig’ economy and informal sector, COVID-19 responses significantly disrupted people’s ability to earn money. South Africa also implemented tough public health measures. Citizens could only undertake essential trips to buy groceries or seek medical assistance, and in some cases lockdown was enforced by the use of rubber bullets (The Guardian, 2020). The social aspects of infection, control and prevention severely stressed collective coping responses through impact on trust and reciprocal support. An increase in social isolation and loneliness has also been a marked feature of the impact of COVID-19 lockdown restrictions. A recent South African survey carried out between 13 April and 14 May during lockdown by the University of Johannesburg and the Human Sciences Research Council (HSRC) found that 60 per cent of South Africans surveyed suffered from stress. The second most cited emotion was fear or feeling scared (45 per cent). Feeling depressed or irritable accounted for 29 per cent of responses, 18 per cent of respondents were angry and 12 per cent happy. Importantly, compared to those aged 25 year and older, 18–​24 year-olds were more likely to report loneliness, boredom, anger and irritability (Bohler-Muller, 2020).

Survey responses also captured the economic impact of the crisis on South Africans. Between 85 and 89 per cent of respondents reported they were very concerned about the economic impact of the lockdown on their circumstances, while 60 per cent strongly agreed with the statement that they had difficulty paying their expenses (University of Johannesburg & HSRC, 2020). Economic factors also affect ICP compliance. In African contexts, in the Ebola crisis, the ability to act upon correct knowledge often conflicted with having access to resources to do so (Abramowitz et al, 2017). In the South African survey, the percentage of respondents who ran out of soap or hand sanitizer in the time period of the survey increased from 31 per cent to 40 per cent (University of Johannesburg & HSRC, 2020).

One of the most important findings from this survey, however, was that hunger emerged as a key mediating factor with respect to psychosocial wellbeing. Over the time period of the survey, the proportion of respondents who reported having gone to bed hungry increased from 33 per cent to 43 per cent (University of Johannesburg & HSRC, 2020). Those individuals that reported that they or their families had gone hungry experienced more stress and depression. In early June 2020, calls to South African ‘Childline’ increased by 25 per cent over the previous two weeks, reaching over 11,000 calls (UNICEF, 2020a). Children reported being worried about high levels of physical and emotional abuse, with new complaints relating to parents’ substance abuse at home. Children were anxious about hunger, returning to school and a loss of livelihoods –​ all of which were compounded by safety concerns (Huijbregts, 2020; UNICEF, 2020a). According to Save the Children (2020: 24): ‘One of the biggest risks for children in Sub-Sahara Africa remains the risk of COVID-19 becoming a hunger and livelihood crisis ahead of a public health crisis’.

These factors are likely to place severe stress on African communities in response to the crisis, straining collective resilience. An African definition of community resilience put forward by Ebersöhn (2019) draws on the metaphor of ‘flocking’ –​ that is, a community identifies those that are vulnerable and manages the distribution of its social resources. Flocking mobilizes social capital (for example, psychosocial support), cultural resources (in good times when we celebrate, as well as bad when we mourn together), collective resources (for example, food, labour, a car to collect groceries for each other or to take someone to the hospital), and economic resources (for example, small loans to begin and sustain businesses). Wherever possible, flocking assists individuals and families to get up again, to recover from adversity and not to be dependent on others. However, the survey cited previously suggests that community resilience was challenged by lockdown. While 70 per cent of South Africans surveyed supported lockdown, in response to a question whether, in the immediate future, COVID-19 will be more likely to make South Africans feel more united and supportive of each other or alternatively more suspicious and less trusting, less than half, 48 per cent, believed South Africans would be more united, 28 per cent responded ‘more suspicious’, while 16 per cent did not know and 8 per cent said neither. Furthermore, over half of respondents (53 per cent) believed the worst was yet to come.

In summary, lockdown public health responses required to mitigate the impact of coronavirus have severely stressed collective and locally relevant resources and coping responses. Supporting community resilience is an overlooked strategy in efforts to mitigate public health emergencies (McKay and De Carbonnel, 2016), yet the learning from the earlier Ebola crisis in East and West Africa indicated the importance of engagement with communities ‘Efforts in the direction of awareness and community involvement could prove to be a better strategy to control the [Ebola] epidemic and root the response in social participation’ (Pellecchia et al, 2015: 2) using existing community support networks and local government social services structures. A key priority therefore in developing an effective public health response to COVID-19 is to understand the impact of ICP measures on community resources and how resilience can be built back through local support systems.

The case studies presented in the analysis below are based on two organizations with whom the first author works with. TPO Uganda engages with communities to improve mental health and socioeconomic wellbeing. The Regional Psychosocial Support Initiative (REPSSI,) based in South Africa, is a regional organization encompassing 14 countries whose mission is to mainstream psychosocial support into programming in East and Southern Africa. Both organizations are involved in leadership roles in developing psychosocial support for COVID-19-affected communities.

Psychosocial impact of COVID-19 on communities and programming responses

Families affected by HIV/​AIDS and impact on vaccine-preventable diseases

In a TPO Uganda project targeting children and families affected by HIV and AIDS in South-Western Uganda, persons living with HIV and AIDS have not been able to access routine services due to COVID-19. The most affected are patients that need assisted support to meet clinic appointments. The 7 am to 7 pm curfew has restricted the number of activities field staff can implement. Since travel by public means is constrained, caregivers cannot find their way to health centres. The most affected are caregivers of children that are undergoing treatment. People have become scared of visiting health centres due to fear of infection1. Parental fears about potential exposure to COVID-19 is also negatively impacting Diphtheria, Pertussis and Tetanus (DPT3) vaccination rates. In South Africa, for example, April 2020 vaccination rates for DPT3 were 20 to 30 per cent below that of months preceding the implementation of ICP public health measures (UNICEF, 2020a). Similarly, there has been a sharp decrease in measles coverage, sparking fears of an outbreak in the North West and Western Cape (UNICEF, 2020b).

Impact on sexual violence survivors

The public health system for mental health services is quite under-resourced in Uganda. In a TPO project supporting survivors of violence in northern Uganda they require, at a minimum, a three-point service delivery structure; a functional health structure to provide screening and post-event prophylaxis; a social worker to provide psychosocial support and trauma counselling; and legal aid support in addition to law enforcement. In a normal environment, TPO facilitates the coordination of a harmonized response. However, with COVID-19, this service structure has been disrupted and rendered ineffective. Survivors of violence are taking longer to access the minimal service package as providers are unavailable, while need is increasing.

Impact on mental health and wellbeing of refugee youth

TPO Uganda undertook a study to assess the impacts of the COVID-19 pandemic on the mental health and wellbeing of young people in Kiryandongo refugee settlement.2 Focus group discussions were carried out with the youth in July 2020. A total of 25 youth (15 males and 10 females) ranging from 13 to 28 years participated. They were taken through a series of questions about young people’s experience of how the pandemic has affected their mental health and their opinions on how best the government, NGOs and community could help them cope.
  • Alcoholism: From the discussions, it was noted that the youth have resorted to taking alcohol because of the disease, as it has no cure, and they believe they have to enjoy their last days on earth.

  • Early marriage: Closure of schools has left many young people idle and with no hope for the future. They are stressed and think reading books when they are not going to do exams is waste of time. In addition, they have been hearing rumours that they are likely to repeat their classes and they would rather drop out of school. Most girls now think the only option is to get married. One of the girls had this to say: “Before coronavirus while at school we were given some necessities like sanitary towels, now schools are closed I don’t know what next. I even talk to myself a lot because of the many thoughts corona has brought and the only option I have is to get married and get such necessities”.

  • Early pregnancy: Many young girls are getting pregnant and some have had abortions, putting their lives in danger. One of the girls said:

‘We are stressed by poverty and when some men promise to buy us some basic needs we may end up sleeping with them. In addition, you see churches were closed which were keeping us busy since we would spend time there singing and fellow-shipping. This has forced some young people to join bad company and end up having sex.’

  • Fear and phobia of police: Young people have developed a fear of the police as a result of the COVID-19 preventative measures guidelines which they enforce. Most young people panic and run away when they see them.

  • Separation between parents and children: Some parents and children were separated in different counties and districts due to lockdown and border-crossing closures causing a lot of stress.

  • Poverty in homes has increased, which has led to misunderstandings among families and this in turn affects young people. The youth reported that they have become desperate due to lack of basic necessities. Some youth such as bodaboda (motor bike taxi) riders have resorted to stealing due to loss of employment.

Despite the adverse impacts of coronavirus on the mental health of young people, the focus group participants reported that the crisis has also had some positive impact. As they are not in school, children and youth are helping parents in gardens and this has increased crop production. Some youth reported that the crisis has brought them closer to their parents as they are getting to spend more time with them. They have been able to work with parents as ‘apprentices’ such as in the construction of houses and some young people feel they can use these skills in the future. The recommendations made by young people to address the challenges they experience included provision of initial start-up capital for small businesses to revive those lost since capital has been used to meet basic needs; to provide sanitary towels to girls even when they are not at school or training them on how to make them; to enforce laws that govern selling of alcohol, especially to persons below the age of 18; to enforce laws against early child marriages; provide them with radios to get clear communication and also help them learn during this period as schooling had moved to radios and online; devise all possible means how they can do their exams and avoid repeating their classes; give permits and transport assistance for people stranded in other districts to reunite with their families. The young people argued that the fact that the pandemic is new and has affected every sphere and aspect of life means it needs a collective effort from all community members. They themselves would welcome a chance to participate in or volunteer to support any project that would aim to support their mental health needs.

Psychosocial responses

Rapid ethnographic research is central to appreciating local understandings related to COVID-19. In the Ebola crisis, there was a failure to take sociocultural beliefs, narratives and practices seriously, which impeded infection prevention, compliance and control (Abramowitz et al, 2017; Manguvo & Mafuvadze, 2015; Wilkinson & Fairhead, 2017). Adherence responses to ICP public measures health across a range of disease outbreaks in Africa shows varied practices as a result of different understandings of quarantine protocols, social pressures and cultural factors (Webster et al, 2020).

In both Uganda and South Africa, TPO Uganda and REPSSI are seeking to maximize the use of radio and social media to enhance behaviour change and reduce stigma. Radio has a greater reach than social media as many households do not have internet access (UNESCO, 2020). Pre-recorded psycho-education messages, parenting and positive coping messages are being used to reach out to communities with ICP COVID-19 information to address misconceptions and cultural risk practices (greeting by shaking of hands, hugging, coughing and spitting in public). This utilizes research from reliable sources (WHO, Ministry of Health) on common means of transmission, prevention measures, signs and symptoms, behaviours and practices that encourage the spread of the coronavirus disease, benefits of timely diagnosis, caring tips for a person who has recovered from COVID-19 and emergency contact numbers. Radio messages are designed differently for women, youth and men (preferences regarding programming style, languages, theme music for programme signature tune, times of day) and use humour, drama and personal experiences to emphasize key points and messages. Given the demands of physical distancing in the context of increasing psychosocial stressors, TPO Uganda has responded with the development of telecounselling. This innovation grew exponentially from April to July 2020.

Conclusion

COVID-19 and public health mitigation efforts have had a devastating effect on the livelihoods and psychosocial wellbeing of Ugandans and South Africans. Although deaths are concentrated among older people, youth aged 18 to 25 years –​ who make up over 60 per cent of the population of Uganda –​ have been significantly affected in ways that have been so far poorly understood. The analysis here indicates that school closures due to lockdown and containment strategies impact girls and boys differently. A key priority is mainstreaming psychosocial concerns in multi-sectorial responses so rapid ethnographic assessment can inform these in culturally appropriate, cost-effective ways.

Notes

1

Anti-retroviral Therapy Coordinator, Kabale Regional Referral Hospital, Uganda, June 18 2020.

2

TPO Uganda Report, Impact of COVID-19 on Mental Health and Well Being of Youth, Kiryandongo District, 5 July 2020. Survey and report compiled by Kakai Bridget, Norah Nabwire, Twongyeirwe Amon and Rachael Atuheire, TPO, Uganda.

References

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