key: cord-0853933-9pyh99os
authors: Solomon, H.; Thea, D. M.; Galea, S.; Sabin, L. L.; Lucey, D. R.; Hamer, D. H.
title: Adherence to and enforcement of non-pharmaceutical interventions (NPIs) for COVID-19 prevention in Nigeria, Rwanda, and Zambia: A mixed-methods analysis
date: 2022-03-30
journal: nan
DOI: 10.1101/2022.03.29.22273120
sha: f4a13cb45b7cca80aa50286911a93e2bc2b43bdb
doc_id: 853933
cord_uid: 9pyh99os

Introduction: In the early parts of the COVID-19 pandemic, non-pharmaceutical interventions (NPIs) were implemented worldwide, including in sub-Saharan Africa, to prevent and control SARS-CoV-2 transmission. This mixed-methods study examines adherence to and enforcement of NPIs implemented to curb COVID-19 in Nigeria, Rwanda, and Zambia, leading up to the 10,000 th case of laboratory-confirmed COVID-19 in each country. Additionally, we aim to evaluate the relationship between levels and changes of NPIs over time and changes in COVID-19 cases and deaths. Methods: This mixed-methods analysis utilized semi-structured interviews and a quantitative dataset constructed using multiple open data sources, including the Oxford COVID-19 Government Response Tracker. To understand potential barriers and facilitators in implementing and enforcing NPIs qualitative data were collected from those involved in the COVID-19 response and analyzed using NVivo. Quantitative results were analyzed using descriptive statistics, plots, ANOVA, and post hoc Tukey. Results: Individual indicator scores varied with the COVID-19 response in all three countries. Nigeria had sustained levels of strict measures for containment and closure NPIs, while in Rwanda there was substantial variation in NPI score as it transitioned through the different case windows for the same measures. Zambia implemented moderate stringency throughout the pandemic using gathering restrictions and business/school closure measures but maintained low levels of strictness for other containment and closure measures. Rwanda had far more consistent and stringent measures compared to Nigeria and Zambia. Rwandas success in implementing COVID-related measures was partly due to strong enforcement and having a population that generally obeys its government. Conclusion: Various forces either facilitated or hindered adherence and compliance to COVID-19 control measures. This research highlights important lessons, including the need to engage communities early and create buy-in, as well as the need for preparation to ensure that response efforts are proactive rather than reactive when faced with an emergency.

140 number, between 0 to 100, that reflects the level of a government's response along certain 141 dimensions to measure the indicators upon which a government has acted, and to what degree. Record closings of schools and universities X X C2

Record closings of workplaces X X C3

Record canceling public events X X C4

Record limits on gatherings X X C5

Record closing of public transport X X C6

Record orders to "shelter-in-place" and otherwise confine to the home X X C7

Record restrictions on internal movement between cities/regions X X C8

Record restrictions on international travel (this records policy for foreign travelers, not citizens) X X

Record presence of public info campaigns X X H2

Record government policy on who has access to testing Note: this records policies about testing for current infection (PCR tests) not testing for immunity (antibody test) X H3

Record government policy on contact tracing after a positive diagnosis Note: Policies include only those that would identify all people potentially exposed to COVID-19

x H6

Record policies on the use of facial coverings outside the home x H7

Record policies for protecting elderly people (as defined locally) in Long Term Care Facilities and/or the community and home setting This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted March 30, 2022. ; This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted March 30, 2022. ; 206 compared to W 3 (p>0.05), which again indicates similar implementation of the measures calculated 207 in the containment and health index during W 1 , W 2 , and W 3 . This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. "…the enforcement piece I could say that there were radio talks about any of the measures 298 that were put in place by the government and local entities were in charge of making sure 299 these measures are respected by the general population." -Participant 2, Rwanda 300 301 Whereas enforcement was a success in Rwanda, enforcement was a major challenge in Nigeria 302 and Zambia. KII participants noted that the length and protracted nature of the response have had 303 major consequences in terms of compliance and adherence to several public health and social 304 measures that were being implemented at various points throughout the pandemic, not only by the 305 community but some KIIs mentioned government figures themselves were not adhering to 306 precisely the measures they were responsible for enforcing.

"…there were not really [consequences for lack of adherence] …well they put it there…but 308 complying with the law and enforcing is one thing…on a few cases here and there they did. 309

But it didn't last. In about a week or two everybody had forgot, and they went back…even 310 the guy who is supposed to be enforcing it is not wearing a mask *laughs*" This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 360 Economic instability was felt across the African continent; however, Zambia became the first 361 African country to default on its Eurobond national debt during the pandemic (29). The pandemic 362 caused the Zambian economy to enter its deepest recession in history with the economy shrinking 363 by 4.2% in 2020 (30-32). An assessment of the Zambian economy a year into the pandemic 364 claimed that the "recession goes beyond the containment measures (which were moderate) and 365 reflects vulnerabilities to external shocks and unfavorable internal macroeconomic decisions, with 366 potential long-term implications" (33).

Additionally, as key informants noted, enforcement of NPIs was met with resistance and 368 noncompliance in countries where governmental authority was weak or contested, or 369 misinformation was high (34-37). Similarly, physical or social distancing measures were also 370 difficult to enforce and implement. Aside from the high population density in many communities 371 in Africa, social interaction is a key aspect of life. In urban areas in Africa, public transportation 372 systems are often overcrowded, dense shanty towns and informal settlements are part of the 373 physical infrastructure, and many people do not have the luxury to self-isolate even if they are 374 positive, as many homes face overcrowding. For example, Makoko in Lagos, Nigeria has 300,000 375 people whose homes are built on stilts in a lagoon (35). In rural areas, many households share for use under a CC0 license.

This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted March 30, 2022. ; https://doi.org/10.1101/2022.03.29.22273120 doi: medRxiv preprint

COVID-19 was affected by access to basic necessities (sanitation, water

In addition to several long-term effects of implementing NPIs, timing plays a crucial role

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