Religion Inuences Community Adherence to COVID-19 Guidelines in Uganda

Success of public health government programs depends on effective partnerships between religious institutions, policy makers and medical professionals. Directives from the World Health Organization (WHO) against social gatherings to control COVID-19 transmission have negatively impacted religious-political partnerships. Compliance of rural communities to national lockdowns requires support from community faith leaders. Across the African sub-continent faith plays an important role within communities that display diverse religious practice. Specic guidelines to prevent community transmission and spread of novel coronavirus 2019 (COVID-19) are however, scarce, complicating adherence to best practice as dened by the World Health Organization (WHO). During the Ebola epidemic in Africa, faith groups played a crucial role in spreading information from the WHO to control community disease transmissions. Methods Here we examined A cross sectional was in southwestern Uganda was questionnaire.


Abstract
Background Success of public health government programs depends on effective partnerships between religious institutions, policy makers and medical professionals. Directives from the World Health Organization (WHO) against social gatherings to control COVID-19 transmission have negatively impacted religiouspolitical partnerships. Compliance of rural communities to national lockdowns requires support from community faith leaders. Across the African sub-continent faith plays an important role within communities that display diverse religious practice. Speci c guidelines to prevent community transmission and spread of novel coronavirus 2019 (COVID-19) are however, scarce, complicating adherence to best practice as de ned by the World Health Organization (WHO). During the Ebola epidemic in Africa, faith groups played a crucial role in spreading information from the WHO to control community disease transmissions.

Methods
Here we examined knowledge, attitudes and practices for COVID-19 among market vendors, of faith, in South-Western Uganda. A cross sectional study was undertaken among rural market vendors (n=248) in southwestern Uganda was undertaken using an online questionnaire.

Results
Most moslems (72%) and protestants (70%) were aware that COVID-19 could present symptomatically and the challenges for control of COVID-19 in Uganda. De nitive knowledge of COVID-19 transmission dynamics was most prevalent among individuals of Protestant faith (70%). Most moslems (66%) interviewed found it di cult to comply with public health measures (lockdowns and self-isolation) while most pentecostals (64%) considered wearing as face mask to be impractical. Such discrepancies within a tight knit community and religious groupings in relation to practice shows a need to strengthen and revise policy for the national implementation of COVID-19 guidelines.

Conclusion
Engagement from religious leaders to encourage their followers to abide to COVID-19 guidelines would facilitate Africa's COVID-19 response to become more effective addressing key areas of non-compliance that undermine control e.g. a majority of Pentecostal Christians are hesitant to be associated with alcohol-based hand sanitizers.

Introduction
In many developing countries, religious a liations are deeply rooted in societal livelihoods [1]. In di cult times, communities often turn to God and 'gods' [2]. While novel coronavirus 2019 is spreading Globally, some African leaders have turned to God, ignoring science, as is the case in Tanzania [3]. Religious leaders in Christianity and Islam were key actors, during the Ebola epidemic, to prevent community transmission within their faith communities; their activities widely affected during epidemic/pandemic control [4]. Religious institutions contributed much needed infrastructure in west Africa at a time when the medical institutions were under funded. Faith communities can play a synergistic role in supporting community efforts to control community transmissions of COVID-19 [4].
. In Uganda, a majority of the population is Christian. Success of public health government programs depends on effective partnerships between religious institutions, policy makers and medical professionals [5]. Directives from the World Health Organization (WHO) against social gatherings to control COVID-19 transmission have negatively impacted religious-political partnerships [6]. Compliance of the rural communities to national lockdowns in rural communities is essential and requires support from community faith leaders. Faith leaders provide and underpin crucial psychosocial management [7,8] interrupted by closure of religious institutions. Faith signi cantly in uences the attitudes and coping perceptions of Ugandan medical staff who continue to work under challenging eld conditions with limited infrastructure support as in many developing countries [9]. The challenges created by COVID-19 in rural communities of developing countries have exacerbated an already compromised and underfunded infrastructure. Individuals handling patients with infectious diseases have become victims of signi cant stigma within their community [10], exposing yet another challenge associated with COVID-19 management in rural communities of Africa. Communities are reluctant to use alcohol-based hand wash to comply with the conditions of their faith [11]. In Burundi and Tanzania individual continue to perceive COVID-19 as a disease from God and many Ugandans consider COVID-19 a disease of "whites" [3]. Clear directives and information from religious leaders in developing countries remains scarce. The voices of faith leaders can allay fears within their communities during times of public distress [12]. This study aimed to assess knowledge and attitudes amongst market vendors of faith background on COVID-19 guidelines in Uganda.

Study design
A cross sectional study was undertaken in April 2020 involving fruit sellers and food store owners (dry and wet raw food sellers) of southwestern Uganda. The questionnaire was administered and responses collected electronically as previously described [13].

Statistical analysis
Data in MS Excel was analyzed using WinPePI. Independent variables were religious denominations; all responses on knowledge were regarded as dependent variables. A con dence interval of 95% was considered and statistical signi cance regarded when P ≤ 0.05.

Discussion
Diversities in opinion among major religious groups in Uganda were notable. Knowledge as regards COVID-19 epidemiology was strongest in those of Christian faith but the basis for divergence in opinion between the faith groups were not investigated. Faith leaders are revered in Uganda and more broadly in Africa [5] highlighting the critical role faith leaders and groups in disseminating national guidelines in rural communities to control COVID-19.
The majority of community members from all religious backgrounds acknowledge that the elderly are at heightened risk of COVID-19. Information on COVID-19 is mainly acquired through radio in Ugandan rural communities [13]. However, increasing misinformation on COVID-19 in Uganda [3] shows that religious institutions would help bridge the knowledge gap, especially as most African countries prepare to come out of their respective COVID-19 national lockdowns. COVID-19 has been associated with increased religious activity, with many people in Africa seeking divine intervention [2,10].
In Uganda, the lack of readiness to self-isolate and reluctance to wear a mask in some faith groups is problematic. Faith plays a crucial role in psychosocial lifestyles [7,8,14], governmental strategies to encourage communities to abide to the WHO guidelines to avoiding crowds and wear face masks would be strengthened through messaging partnerships developed with community leaders. Faith leaders routinely interact with locals and are in a strong position to evolve compliance to COVID-19 guidelines in their communities. Religious leaders in Kenya have come to appreciate COVID-19 guidelines and have encouraged their communities to abide and support government efforts to control COVID-19 in their neighborhoods [9].
Hand washing remains problematic, a willingness to wash hands with soap and water was not common across all faith groups; there is an opportunity for government to work in collaboration with stakeholders to encourage compliance to prevent community COVID-19 transmission [14,15]. Muslims and other faith groups cannot associate with alcohol [11], messaging to use alcohol-based sanitization is not likely to be effective in these communities and is regarded as offensive. Interventions in partnership with faith leaders should be explored for the long term management of COVID-19 and in general for infectious disease management [16] and people tend to give more attention to their religious leader's times of panic.
That most respondents purporting to Christian faith are aware of asymptomatic carriers of COVID-19 only strengthens the need for vigilance and preventative measures at community level -the importance of continuous engagement to change community attitudes for positive change. In Tanzania, religious a liations have been shown to improve HIV and AIDS control projects [17], demonstrating the relevance of this study.

Conclusion
The faith sector is critical to establishing long term preventative measures for health security in the community for COVID-19. Government should engage with religious leaders for further community education to support public health policy in the community and promote policy adherence for COVID-19 guidelines.

Declarations
Ethical approval Expatiated ethical approval from Kampala International Ethical Review Board was acquired and registered as Nr.UG-REC-023/201914. Written, informed consent was obtained from the study participants for the publication of any potentially identi able images or data included in this article.

Consent for publication
Not applicable.
Availability of data and materials Data set available in g share: https:// gshare.com/s/96e3d8b0a24ca83c5617