Characteristics of study participants
Of the 20 study participants, 11 were female, 8 were aged between 29 to 40 years old, 16 were married and all except one had dependents. Fourteen study participants spent their quarantine in a private institution and only three were in quarantine for the stipulated 14 days with the rest spending over 14 days. All except one of our study participants were returning from outside the country, mostly from African (9), Middle Eastern (5) and European countries (4), and most had travelled for work-related reasons (17) or studies (3) (Table 1).
Table 1: Characteristics of study participants
Characteristics
|
Number
|
Sex
|
|
Female
|
11
|
Male
|
9
|
Age
|
|
29 to 40
|
8
|
41 to 50
|
6
|
51 to 65
|
6
|
Marital status
|
|
Single
|
4
|
Married
|
16
|
Occupation
|
|
Health professional
|
7
|
Business & sales
|
3
|
Student
|
3
|
Other professional
|
4
|
Other (fisherman, truck driver, retired)
|
3
|
Have dependents
|
|
Yes
|
19
|
No
|
1
|
Country/ place participant was returning from
|
|
African
|
9
|
European
|
4
|
Middle East
|
5
|
Other (India, within Uganda)
|
2
|
Facility of quarantine
|
|
Public
|
6
|
Private
|
14
|
Days spent in quarantine
|
|
14
|
3
|
15
|
9
|
Above 15
|
8
|
Eighteen of our study participants traveled back to Uganda through organized flights and were thus aware of the requirement to undergo quarantine on their arrival. The other two participants included a truck driver who was transporting goods from a neighbouring country and was stopped along the way, and a fisherman who was found in transit to another island within Uganda.
Experiences in quarantine
Four themes described the experiences of study participants during institutional quarantine, which determined whether participants’ experiences were positive or negative. These themes were: quarantine environment, quarantine management, individual factors and linkage to other services as summarized in Figure 1 and elaborated below supported with participant quotations.
1. Quarantine environment
The quarantine environment had two sub-themes of quarantine facility related factors and compliance with COVID-19 measures.
Facility related factors
Participants were in different quarantine facilities with variations in the facility environment including whether the facility had a compound or not, furnishings, the general hygiene and cleanliness of the facility, and the services and supplies provided including meals among others. Where participants felt that their needs were well catered for, they were positive about their experience.
“My hotel facility was okay. I could buy food and my room had a balcony so I could rest without much interruption. My food was brought to the room and when I was tired of the room, I used the balcony or walked around the hotel. So, for me the ambiance was okay, it was a functional hotel, small but homely and not crowded which is what I wanted. So, my experience was good.” (Female, 36 years, 15 days in private facility)
Other participants complained that the room size was small to allow exercising from inside or the lack of a compound or balcony for them to connect with the outside environment. The lack of internet or pay television or having limited access to television channels also impacted on the quarantined persons’ experiences as some reported being bored while confined in their rooms.
“My colleagues went to Kampala and had a good experience with excellent food and facilities. I regret choosing to stay in this place. At night there was a smell of sewage and I couldn’t open the windows and neither could I go to the veranda when I wanted to exercise. You don’t confine people in dark hotels for such a period of time. Hygiene was poor, they were not cleaning our rooms and they rarely changed our linen understandably. There was a smell of sewage which made me uncomfortable and extremely unhappy for the 14 days I was confined in this one facility.” (Female, 58 years, 15 days in private facility)
The other prominent dissatisfaction reported was with meals where some quarantine facilities offered monotonous meals with no balanced diet or variety or provided unhealthy meals and others provided meals without water. To cope, some participants ordered for food and other necessities through online platforms or relied on their friends and relatives to deliver these for them at the Centre where the restrictions allowed it. Other participants also tried to engage the hotel establishment to change their meals which in some instances yielded results.
Compliance with COVID-19 measures
Another determinant of quarantined persons’ experiences was compliance with the COVID-19 prevention and control measures during the quarantine process by the authorities, the quarantine facility and quarantined individuals. Most participants felt that the COVID-19 prevention measures were not adhered to at the airport including during their transportation to the quarantine facility as many of them were transported in vehicles without any physical distancing which was a sources of annoyance especially that some of them had kept to these measures from where they were and during travel.
“On arriving at Entebbe Airport, they were just asking and telling us which hotels we were going to but then they put everyone in a single bus and those who arrived first had to wait almost for an hour to fill up with no physical distancing. Yes, a full board bus and I am like what? You know I have been maintaining physical distance and wearing my mask where I was for 3 months and now I am on this bus with people from all over the world and we were all being put on the bus with limited windows and aeration for almost two hours. They then start dropping off people going to their hotels as we wait for them to drop us.” (Female, 41 years, 17 days in private facility)
At the quarantine facility, participants who were satisfied with how their facility complied with the available measures were more satisfied as they felt it complemented the purpose of the quarantine exercise and took it more seriously. They were also happier if their fellow participants complied with measures of staying within their rooms, wearing masks and social distancing. On the other hand, where quarantine facilities had gaps in compliance with quarantine measures, participants were more disgruntled and doubted the motives of the quarantine measure which impacted their experience. Reported gaps among facilities were majorly around: cleaning especially in private institutions and hotel staff not following the recommended measures. Moreover, in public facilities, since hygiene facilities were shared, they were well cleaned and participants reported satisfaction with their state. However, there were complaints of other quarantined persons in some public places having access to drugs and alcohol which affected the experience of others.
“Yes, it was good, the only worry we had about the government facilities, we thought they would put us like in a hall you all together you had to fight your own way of survival but we later found out that you were given your own room, the compound was big and you could social distance. It was okay, the facilities were clean; they would clean them in the morning and in the evening.” (Female, 40 years, 17 days in public facility)
There were also suggestions of other quarantined individuals being given preferential treatment compared to others including them seeing their family or being allowed to go for self-quarantine which caused some dissatisfaction among participants.
2. Quarantine management
The quarantine management factors were entity paying the costs, communication while in quarantine and days spent in quarantine.
Entity paying the costs
Quarantine costs including accommodation and meals were either paid by the individual themselves or their employer for those in private facilities or the government for those that opted for public facilities. The participants noted that the hotel costs were exorbitant, and they had been given limited choices of facilities to choose from. Where the quarantine costs were not being borne by the participant themselves, even when they acknowledged that the costs were high, they reported a more positive experience compared to their colleagues who paid the costs by themselves.
“The quarantine costs were expensive but mine was not coming directly from my pocket but rather from my employer. Generally speaking, compared to the rest of other places, this is expensive but the pain and burden of the costs rested with my employer.” (Male, 29 years, 15 days in private facility)
Other participants noted that since all their basic necessities were covered, they never faced financial challenges.
“We never had financial issues because we were given food, we had breakfast, lunch and dinner. We were given tea, soap, mosquito nets, blankets even sanitary pads. We thus did not have financial issues because we had the essentials unless someone wanted to drink wine that’s when you had to dig into your pocket.” (Female, 47 years, 17 days, public facility)
On the other hand, where participants paid the costs themselves, they were dissatisfied and others had to pay for other bills such as electricity on top of the full board accommodation costs. To cope, some of the participants reduced the number of meals they had in a day.
“The hotel was expensive charging us $105 per night and the meals were charged differently and still expensively. We thus resorted to eating breakfast and an early dinner because we were not doing anything and so we didn’t have all the meals. But it was expensive and at the end of my 16 days, the cost was $1860 which is a lot of money that I am trying to claim from my employer but I don’t know about other people.” (Female, 65 years, 16 days in private facility)
Communication
One of the key determinants of participants’ experiences in quarantine was related to the quality of communication they received. Most participants reported communication gaps regarding quarantine preparation, expected quarantine days, COVID-19 testing and receiving results. The other gaps were in: extension of the quarantine period and expected dates of departure, information on COVID-19 preventive measures, and where they would obtain their confiscated passport. These communication gaps negatively impacted the experience of quarantined individuals.
“They take off your samples expecting to get results…because they took our emails at the airport so I thought that maybe they would send results on email but what we got was a verbal communication. They were like “since none of you has been taken out of the hotel by now, it means all of you are okay” (laughs)… This came after asking for the results and that was day 3 yet we had been told that we would get the results in 24 hours. In fact, we did not get the first result, we only got the departure results from the hotel.” (Female, 34 years, 16 days in private facility)
Many participants also reported not receiving any briefing about how to conduct themselves in quarantine and keep safe from COVID-19. Others said that they were simply handed leaflets with information to read which mode did not favour everyone while some obtained information through internet and the media. Participants who had sufficient information to guide their decision making and understand the quarantine process, and those who received regular updates regarding decisions that could affect them reported a more positive experience in quarantine. In fact, some participants reported receiving extra information through their employers who had prepared guidance for them in advance. Some of the participants had also undergone trainings on COVID-19 as health workers which supplemented the Ministry of Health information.
Days spent in quarantine
The Ministry of Health guidelines indicated that a minimum of 14 days in quarantine was expected of persons in institutional quarantine. However, among the study participants, only three spent 14 days in quarantine with the rest having their quarantine duration extended. This extension was attributed to the need to obtain COVID-19 test results for samples taken on the 14th day. Other extensions were based on finding a positive case within the quarantine facility as the guidelines stated a re-start of the quarantine period in such instances. Participants reported anxiety, stress and anger related to their quarantine days being extended and others protested the extensions. Their experiences were further compounded by poor communication received from the authorities and their need to incur more costs especially where they were paying for themselves. Other participants had to start new engagements with their employers to cover the extra costs and others had to use their leave days for the extended periods as the extended period had not been catered for by their employer.
“There was a delay of the results but the formal quarantine days were 14 so when we delayed we had an additional day and yet you have prepared your mind and already communicated to everyone that on the 14th day you are going home but you don’t go and so it brought with it anxiety to the family and myself but I later got over it.” (Male, 29 years, 15 days in private facility)
Some participants had invited their families to pick them but this was not possible due to the extended quarantine duration.
“Of course I was not happy because I expected to leave on Sunday, I even called my son and he drove to Entebbe but when I realized that it was coming to 4pm and the results had not been delivered, I had to tell him to return to Kampala because of the curfew. So, I was not happy as I had already spent several days in quarantine in another country before coming back to Uganda.” (Male, 58 years, 15 days in private facility)
3. Individual factors
Regarding individual factors, the attitude towards quarantine, fears during and post-quarantine and coping measures while in quarantine were important.
Attitude towards quarantine
Having known about the requirement to undergo quarantine as a public health measure prior to their travel, almost all participants reported preparing for it and were positive acknowledging that some had come from areas with high infection and were glad they were protecting the population and their own families. This attitude contributed to their acceptance of the situation and coping with the measure.
“I did not feel bad or anything. Actually, I was glad that at least they are protecting Ugandans from this COVID-19 epidemic. Moreover, I would also want the same for my people to stay safe as we continue to bring back those stranded outside the country and so the quarantine centers were a good idea.” (Female, 31 years, 16 days in quarantine in public facility)
However, other participants had concerns about the procedure saying that they had already been tested from their departure countries and were negative and were not happy being put in the same facility with others who did not know their status.
“I already knew that people coming back had to be quarantined but my concern was that we left our destination after testing for COVID-19 and we were negative and so it is a challenge coming back here and you are told that those results are not being considered and we needed to be quarantined for 14 days in a place with other people who do not know their status but since it was a government decision, we had nothing to do.” (Female, 40 years, 17 days in public facility)
The experience was however different for the participants who had not been prepared for the measure as they were taken into quarantine from attending to their activities such as the truck driver and the fisherman who later reported accepting the measure.
Fears during and post-quarantine
Almost all quarantined persons had fears of either having COVID-19 as some had not been tested beforehand or getting infected while in quarantine as they knew they were in a high-risk environment. Having their initial test results prior to quarantine or early in the quarantine comforted and helped some cope that they did not have the virus. Participants having been told that a positive case in their Centre would lead to an extension of the quarantine period made them fearful while others were worried of the stigma that awaited them in their communities. The fears were compounded in some instances by some not having medical insurance cover or uncertainty of what the infection would mean to them and the continued addition of newer persons to their quarantine facilities.
“My major worry was that they brought new people in our quarantine centre daily whose status and we were never separated. Everyone had their own room but we were mixed, they could not group us like this group which has already spent 7 days here and should occupy this space or the other. We were sharing the same facilities and we worried that if anyone was infected amongst us, we would all have to redo the quarantine, yet you have already done 10 to 13 days and it was a very big challenge. It brought anxiety and people were fearing each other. We tried to do all things such as social distancing and washing hands with soap and water.” (Female, 40 years, 17 days in public facility)
Study participants also strongly worried about being infected by the hotel staff who served them as many of still had contact with the outside environment and did not properly observe the protective measures expected of them.
“You don’t control the people serving you, you don’t know whether they are observing social distancing or washing their hands or wearing a face mask and they are serving all of you. You don’t know whether they are staying in the hotel or coming from out, so it always brought the worry. Food is delivered to you but you don’t know how it was touched by some people…so you don’t control that aspect. You are in quarantine but there is a risk of you being exposed much as you are observing other measures well. Sometimes you find that the one bringing food in the morning is different, lunch is different, and dinner is also brought by a different person. At least they minimized cleaning and changing bed sheets which reduces chances of disease transmission.” (Female, 52 years, 14 days in private facility)
One person reported fear in communicating with their family and friends saying they had been told that their communication regarding quarantine would be tapped by authorities. On the other hand, some participants reported no worries with some saying they were in a very small hotel with a few people and thus the risks were minimal, and others believed they had good immunity and did not have underlying conditions and so could fight off the virus if they got it.
The post quarantine fears ranged from anticipated stigma or violence from the highly alert community. Some participants thus took steps to contact the local authorities about their situation or report to them with their certificates soon after quarantine. The other defence against stigma were the fact that some of them were confident that their communities did not know they had travelled, and they were armed with their test certificate.
“I felt like a bit stigmatized especially in the community but within Kampala, my sister received me very well but the problem now is that I want to head to the village. I called the local area chairperson because in that area when they see someone coming from outside the country, the community rejects you. The Chairperson told me not to have that fear as he was going to make announcements in the community and then when I go, the leaders will be the ones to receive me and take me home as I have my certificate.” (Female, 52 years, 14 days in private facility)
Some participants were fearful of contracting COVID-19 from the community as they were certain of their status having obtained their negative test results. This however also gave others confidence not to worry especially about infecting their family who would not stigmatise them. Due to being very self-conscious, some participants worried about being seen wearing a mask around in public as they could be assumed to be carrying the virus and some resorted to telling those they met not to fear them as they were negative or simply keeping a low profile in their communities. Other participants had fears of how they would start all over again as some had lost their jobs in the countries where they were travelling from or had overspent during quarantine and finances were on top of their worries.
Coping in quarantine
Quarantined persons employed several measures to cope with their situation at different levels. Many of the participants started by preparing themselves psychologically before getting into the quarantine and accepting the situation as a mandatory government policy that they could do nothing about. Within the quarantine, many adopted a routine to keep active and pass time, others kept in touch with their friends and family through frequent phone calls but noted to sometimes be the ones comforting their families, or resorted to work or study which they said lessened the burden of the quarantine days. Other participants relied on their previous experiences as some had experienced quarantine elsewhere or had lived in conflict settings where they had learnt survival skills. Other participants noted viewing quarantine as an opportunity to progress with work or studies, reflect on one’s life, have adequate rest, write about their experiences and make friends and network.
“Aaaah.. You just have to adjust to the situation you are in and loosen up, just allow that you are in quarantine. You have to get up like in a boarding school, go to bathe because they are shared bathrooms and be ready for breakfast. After breakfast you do whatever you want to do with yourself, the social distance was there and you are not allowed to talk to people so much. We just adapted and found ways of living with it.” (Female 31 years, 16 years in public facility)
The other reported coping mechanism were exercising within rooms or in the hotel compound, use of social media and the internet including attending online classes as some hotels had reliable internet, watching television or movies, and sleeping. Additionally, peer support was mentioned to have been key in supporting coping with many socialising among themselves and sharing challenges and experiences while supporting one another. To facilitate this, some quarantined persons created a WhatsApp group that they used to stay in touch within quarantine. Others could sometimes meet and pray together. The Ministry of Health also sent through counsellors but only a few quarantined persons mentioned that this helped them cope.
“During quarantine, we would gather around in the morning about 10 o’clock and share some scriptures and worship while observing social distance and everyone would put on a mask. Also, in the evening we would pray, there is nothing special we did apart from maintaining social distance since everyone knew it was risky place. We also created a WhatsApp group where we could encourage each one to be strong that we could get out of quarantine. The group is still active up to now, and people keep checking on each other asking how are you? how is everyone, are you okay?” (Male, 35 years, 15 days in public facility)
4. Linkage to other services
Linkage of persons to health care while in quarantine and the post-quarantine follow-up also influenced the experience of quarantined persons.
Access to health care
The quarantined persons had other health needs and some requested for medications, monitoring of their health conditions such as diabetes and health checkups. Other times they had medical emergencies and required to be attended to. Where required services were provided, they were more satisfied and the reverse was true where the services were not provided.
“Of course, on the second day of my arrival, they had to check on the heartbeat of the baby to feel whether the baby is doing well. The doctor came back to do a scan to confirm if the baby is still okay and check on those of us who were on medication to see if we needed refills and it was really all good. Personally, I am grateful.” (Female, 31 years, 16 days in public facility)
“I really needed medical care after an asthmatic attack as I had chest pain and I couldn’t even rotate in bed. When I requested for help, the health worker who comes here every morning to take our temperatures planned to take me to see a doctor but they refused him from doing so. The army officer who I think is also a health worker had to bring for me some medication in the room. (Female, 52 years, 14 days in private facility)
Post-quarantine follow-up
Some participants were followed up afterwards by the Ministry of Health team to check on how they were doing or ask how their 14-day quarantine was or provide more quarantine related information. However, participants who received such calls reported a bad experience as some were angry about their quarantine experience and did not want to speak to the Ministry of Health officials. Moreover, these calls were sometimes automated, frequent and uncoordinated and some were a continuation of the calls they had received during quarantine which they felt was an unnecessary bother.
“After quarantine, what is absolutely annoying is if they call you from Ministry of Health to tell you that “hello friends, this is to tell you that you highly suspected to be… because you travelled” that is stigma for me. If I am seated with my friends and I got such calls, they might be like ooh…you know. So, this is what really happens. This is after 2 months you are still getting those annoying and embarrassing calls. Up to today, even when I am seated with my friends, family, even when I am in the supermarket, I pick up the call and they say “hello friends, you know…” I switch it off and for me that is stigma that is terrible (laughs)”. (Female, 58 years, 15 days in private facility)
Moreover, owing to the extended quarantine duration and having obtained their negative COVID-19 test results, many of the participants were reluctant to observe another 14-day self-quarantine period as was required by the Ministry of Health guidelines post institutional quarantine.