Perceptions of COVID-19 risks and protective actions: a qualitative study in six Sudanese communities (preprint)

Background Risk communication is an essential strategy in outbreak response. Understanding perceptions of health risks and protective behaviours is critical for informing effective risk communication during outbreaks. This study aimed to explore Coronavirus disease (COVID-19) knowledge, risk perception and precautionary behaviours during the early weeks of the COVID-19 epidemic in Sudan.Methods In-depth telephone interviews were conducted with 59 adults from six of urban, rural and forcibly displaced communities in Sudan. Participants were from households with members at higher risk of severe COVID-19 outcomes. We analysed data using participatory group analysis followed by a thematic inductive and deductive analysis of interview transcripts. We used the Health Belief Model to analyse, present and discuss the findings.Results Most participants perceived a high susceptibility to COVID-19, especially among older people, due to novelty and transmission characteristics of the disease. However, a few were mainly concerned about the livelihood implications of the government’s response. Our respondents had good knowledge about COVID-19 although there were a few misconceptions. Most participants viewed COVID-19 as a highly infectious, dangerous and fatal disease. Most participants understood the benefits of protective measures and reported complying with hand hygiene. A few reported complying with social and physical distancing, including stay-at-home orders. Compliance was generally poorer among older adults. Many participants reported substantial financial and social barriers to compliance and resistance to compliance in their communities fuelled by COVID-19 denialism, rumours, misinformation, and poorly enforced government restrictions.Conclusion High levels of knowledge and a high perceived susceptibility and severity of disease were not enough to motivate high levels of compliance with the protective measures in the study communities. Financial and social obligations to protective measures, coupled with COVID-19 denialism and rumours, were significant barriers to compliance. Early risk communication interventions should promote contextually appropriate, high-impact, low-cost interventions and tackle emerging rumours and misinformation.

Population mortality before and during the COVID-19 epidemic in two Sudanese settings: a key informant study (preprint)

Background Population mortality is an important metric that sums information from different public health risk factors into a single indicator of health. However, the impact of COVID-19 on population mortality in low-income and crisis-affected countries like Sudan remains difficult to measure. Using a community-led approach, we estimated excess mortality during the COVID-19 epidemic in two Sudanese communities. Methods Three sets of key informants in two study locations, identified by community-based research teams, were administered a standardised questionnaire to list all known decedents from January 2017 to February 2021. Based on key variables, we linked the records before analysing the data using a capture-recapture statistical technique that models the overlap among lists to estimate the true number of deaths. Results We estimated that deaths per day were 5.5 times higher between March 2020 and February 2021 compared to the pre-pandemic period in East Gezira, while in El Obeid City, the rate was 1.6 times higher. Conclusion This study suggests that using a community-led capture-recapture methodology to measure excess mortality is a feasible approach in Sudan and similar settings. Deploying similar community-led estimation methodologies should be considered wherever crises and weak health infrastructure prevent an accurate and timely real-time understanding of epidemics' mortality impact in real-time.

Alternative epidemic indicators for COVID-19: a model-based assessment of COVID-19 mortality ascertainment in three settings with incomplete death registration systems (preprint)

Not all COVID-19 deaths are officially reported and, particularly in low-income and humanitarian settings the magnitude of such reporting gaps remain sparsely characterised. Alternative data sources, including burial site worker reports, satellite imagery of cemeteries and social-media-conducted surveys of infection, may offer solutions. By merging these data with independently conducted, representative serological studies within a mathematical modelling framework, we aim to better understand the range of under-reporting using the example of three major cities: Addis Ababa (Ethiopia), Aden (Yemen) and Khartoum (Sudan) during 2020. We estimate 69% - 100%, 0.8% - 8.0% and 3.0% - 6.0% of COVID-19 deaths were reported in these three settings, respectively. In future epidemics, and in settings where vital registrations systems are absent or limited, using multiple alternative data sources could provide critically-needed, improved estimates of epidemic impact. However, ultimately, functioning vital registration systems are needed to ensure that, in contrast to COVID-19, the impact of future pandemics or other drivers of mortality are reported and understood worldwide.

Changes in social mixing and attitudes and practices to precautionary measures in a maturing COVID-19 epidemic in six communities in Sudan: A Qualitative Study (preprint)

IntroductionWith low COVID-19 vaccination coverage, non-pharmaceutical interventions remain critical to mitigating the COVID-19 epidemic in Sudan. We explore changes in social contact patterns, risk perception, attitudes, and practices towards protective measures during an evolving COVID-19 outbreak in six illustrative communities in Sudan.Methods This qualitative study took place in six communities in five Sudanese states using focus group discussions with community members and non-participant structured observations in public spaces. A total of 117 participants joined 24 group discussions. We used a two-stage thematic analysis. ResultsThe perceived importance of precautionary measures was higher than reported and observed adherence. Adherence was consistently low throughout the epidemic and was mainly driven by enforced movement restrictions. As restrictions were lifted, social contacts outside the household resumed pre-COVID-19 levels, and risk perception and individual and institutional adherence to protective measures diminished. We identified an environment that is socially and economically unsupportive of preventive practices, compounded by widespread rumours, misinformation and mistrust in the government-led response. However, we identified new social habits that can contribute to reducing COVID-19 transmission.ConclusionThe unfavourable social and economic environment, coupled with the low visibility of the epidemic and epidemic response, has likely modulated the influence of higher risk perception on adopting precautionary behaviours by individuals. Governments and non-governmental actors should increase the visibility of the epidemic and epidemic response, enforce and incentivise infection control measures in public areas, promote emerging preventive social habits, and actively track and address rumours and misinformation related to COVID-19 and COVID-19 vaccines. 

Acceptability and feasibility of strategies to shield the vulnerable during the COVID-19 outbreak: a qualitative study in six Sudanese communities (preprint)

Background Shielding of high-risk groups from coronavirus disease (COVID-19), either within their households or safe communal structures, has been suggested as a realistic alternative to severe movement restrictions in response to the COVID-19 epidemic in low-income countries. To our knowledge, this concept has not been tested or evaluated in resource-poor settings. This study aimed to explore the acceptability and feasibility of strategies to shield persons at higher risk of severe COVID-19 outcomes, during the COVID-19 epidemic in six communities in Sudan. Methods We purposively sampled participants from six communities, illustrative of urban, rural and forcibly-displaced settings. In-depth telephone interviews were held with 59 members of households with one or more members at higher risk of severe COVID-19 outcomes. Follow-up interviews were held with 30 community members after movement restrictions were eased across the country. All interviews were audio-recorded, transcribed verbatim, and analysed using a two-stage deductive and inductive thematic analysis. Results Most participants were aware that some people are at higher risk of severe COVID-19 outcomes but were unaware of the concept of shielding. Most participants found shielding acceptable and consistent with cultural inclinations to respect elders and protect the vulnerable. However, extra-household shielding arrangements were mostly seen as socially unacceptable. Participants reported feasibility concerns related to the social isolation of shielded persons and loss of income for shielding families. The acceptability and feasibility of shielding strategies were reduced after movement restrictions were eased, as participants reported lower perception of risk in their communities and increased pressure to comply with social commitments outside the house. Conclusion Shielding is generally acceptable in the study communities. Acceptability is influenced by feasibility, and by contextual changes in the epidemic and associated policy response. The promotion of shielding should capitalise on the cultural and moral sense of duty towards elders and vulnerable groups. Communities and households should be provided with practical guidance to implement feasible shielding options. Households must be socially, psychologically and financially supported to adopt and sustain shielding effectively.