Introduction

Since the first Severe Acute Respiratory syndrome coronavirus 2 (SARS)-CoV2 or coronavirus disease 2019 (COVID-19) cases were confirmed in Wuhan, China in November 2019, 240,940,937 cases of COVID-19 and 4,903,911 COVID-19 related deaths have been confirmed [1]. Relatedly in Uganda, 75,537 COVID-19 cases and 781 COVID-19 related deaths have been confirmed [2] with a case fatality rate of 2.5%. The key non-drug interventions recommended by World Health Organization (WHO) namely social distancing, ‘staying-at-home’ covering one’s mouth when coughing, and sanitizing/washing hands [3] were emphasized. Uganda’s COVID-19 task force engaged in an early proactive responses to the COVID-19 pandemic by proposing and encouraging several measures to disrupt COVID-19 transmission in Uganda [4]. Besides enforcement of movement restrictions to curb community transmissions of COVID-19, other public health measures included screening and testing of symptomatic persons, contact tracing, isolation and quarantine, treatment strategies and risk communication and health promotion. On 21^st March 2020, when presidential directives to control community transmission and importation of COVID-19 were enforced, police reports suggested an increase in intimate partner violence (IPV) cases during the COVID-19 lockdown especially among women residing in slum areas [5].

Intimate partner violence which refers to any behavior within an intimate relationship that results in physical, emotional or sexual harm [6] remains a persistent public health problem [7] with 56% of married women experiencing some form of IPV [8]. Either partner can experience violence within an intimate relationship, however, women are disproportionately affected by IPV that is predominantly perpetrated their male intimate partners [9]. Following the first presidential directive in March 2020, cases of household spousal abuse increased during the first week from 46% to 56% [10]. In informal settlements, the burden of IPV is reported to be 7.7% in adolescents who reported IPV victimization [11], 32.2% of youth reported being IPV victims [12] while 44.4% of young girls and women experienced one form of IPV [13].

Subsequent COVID-19 preventive measures such as the lock-downs which are decrees sanctioned by the government to limit people’s movement except for essential reasons [14] became increasingly restrictive [15]. COVID-19 restrictions have also been linked to psychological distress from employment loss which affects livelihoods and quality of life especially in households with high poverty levels trigger IPV with women being disproportionately affected [16]. The COVID-19 lockdown was linked to the high burden of mental health issues [16] and suicidal contemplation among adolescents and young adults in Uganda [17]. Survivors of COVID-19 have also experienced psychosocial challenges such as stigmatization resulting in their isolation and subsequent rejection in some communities [18] including informal settings in urban Uganda.

Adherence to preventive measures remains a central tenet to preventing community transmission of COVID-19 that before the development and global roll-out of COVID-19 vaccines, non-pharmaceutical preventive interventions were strongly recommended by WHO. For example, several studies predicted that after lifting ‘stay at home’ directives, effective implementation of public health responses towards COVID-19 such as consistent and correct face mask use, [19], and effective implementation of social distancing measures [20] could interrupt COVID-19 transmission. However, some unintended effects to at-risk sub-populations such as those under chronic medical care like HIV treatment, urban poor and women were anticipated including gendered effects of IPV on poor healthcare service delivery [21]. Considerable concerns and scepticism grew over what the population-level effects of COVID-19 prevention strategies and policies would have such as increasing violence against women and girls [22]. With prolonged COVID-19 restrictions, adherence to COVID-19 preventive measures could potentially aggravate IPV especially urban poor women living in informal settlements especially with recent reports of community stigmatization towards COVID-19 survivors [23]. Evidence has highlighted how negative socio-cultural, economic effects of specific policies directed to curb COVID-19 preventive transmission has directly impacted households and communities [24]. Some of these include the suspension of public transportation and business operations of that crowd people disproportionately particularly among affected disadvantaged and vulnerable communities such as unemployed, poor women in informal settlements.

Knowledge and awareness of COVID-19 transmission and disease severity is generally high in different Ugandan population [25, 26] despite misconceptions held about the risk of COVID-19 acquisition [27] and recently regarding hesitancy for COVID-19 vaccination [28]. Recent research from Uganda conducted by Lawoko and colleagues showed a high likelihood for COVID-19 risk behaviors among adult refugees with low socio-economic status and those living in rural settlements [29]. Although adherence to COVID-19 prevention measures was reported to be poor during the first phase of the COVID-19 pandemic in Uganda [30] some evidence suggests that women are more adherent to practicing COVID-19 preventive measures when compared to men [25]. A knowledge gap persists on whether and to what extent the adherence to WHO recommended COVID-19 prevention measures influences the occurrence of IPV among women in informal settings in Kampala. The need to establish the extent of adherence to these preventive measures for COVID-19 transmission among vulnerable, urban dwelling women in informal settings of Kampala is warranted in order to inform current national COVID-19 prevention and response efforts. Therefore, our objective was to determine the association between adherence to COVID-19 preventive measures and intimate partner violence among women dwelling in three informal settings of Kampala, Uganda. We hypothesized that IPV exposure would differ among women who remained adherent or were poorly adherent to preventive measures for COVID-19.

Methods

Study measures

Results

Participant characteristics at baseline

We recruited 148 participants at baseline and the response rates were 93.2% and 93.9% at three weeks (midline) and six weeks (endline) respectively (Table 1). Baseline characteristics of participants were; mean (SD) age of 32.9 (9.3) years, 80 (54.1%) had primary-level education, 75 (50.7%) were married/cohabiting, 81 (54.7%) lived in household sizes of 2–4, and 107 (72.3%) were employed/self-employed while 115 (78.2%) reported experiencing difficulty getting food during the COVID-pandemic lockdown period. Regarding intimate partner violence, a total of 86 (58.1%) experienced at least one form of IPV between baseline and endline surveys. A total of 133 (89.9%) women remained adherent to all four COVID-19 prevention strategies between baseline and endline surveys as shown in Table 1.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Baseline characteristics of women living in informal settlements of Kampala, N = 148.

https://doi.org/10.1371/journal.pgph.0000177.t001

Unadjusted and adjusted analysis

In the unadjusted logistic regression model, women who remained adherent to all four COVID-19 preventive measures had three times higher odds of experiencing atleast one form of IPV when compared to women who were poorly adherent to all four COVID-19 preventive guidelines [Odds Ratio 95% Confidence Interval 3.00 (1.04, 8.69)] as shown in Table 2.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 2. Unadjusted and adjusted logistic regression models for the independent association between adherence to COVID-19 preventive measures and intimate partner violence.

https://doi.org/10.1371/journal.pgph.0000177.t002

In the adjusted logistic regression model (Table 2), after controlling for potential confounders, women who remained adherent to all four COVID-19 preventive measures was independently associated with 3.87 times higher odds of experiencing at least one form of IPV when compared to women who were poorly adherent to all four COVID-19 preventive guidelines (OR 3.87, 95%CI 1.09, 13.79).

Discussion

This study examined the association between adherence to COVID-19 preventive measures and intimate partner violence among women living in informal settings of Kampala during the first wave of COVID-19 in Uganda. Our results supported our hypothesis showing that IPV exposure differed significantly between women who remained adherent and women who were poorly adherent to preventive measures for COVID-19. We revealed three key findings. First, nearly half of the women surveyed in informal settlements experienced at least one form of IPV during the first COVID-19 wave in Uganda. Secondly, ten percent of women surveyed in informal settlements experienced were poorly adherent to all four COVID-19 preventive measures between our baseline and endline surveys. Thirdly, our analysis revealed that women in informal settings who remained adherent to COVID-19 preventive guidelines were more likely to experience intimate partner violence when compared to those who were poorly adherent.

Our study adds to the current body of knowledge on the relationship between IPV exposure and adherence to COVID-19 preventive measures among women in informal settings. First, our study described how women in informal settlements who remained adherent to all four preventive measures for COVID-19 over a six-week period during the first wave of COVID-19 were more likely to experience IPV when compared to their counterparts who were poorly adherent. Our findings were in line with previous research conducted in Kampala which showed that lower satisfaction in COVID-19 preventive measures was associated with experiencing violence and discrimination within homes perpetrated by family members [30]. The prior study was conducted among an online sample of women and men which suggests differences with current study. However, the prior study evaluated satisfaction to COVID-19 preventive measures using similar COVID-19 preventive measures as the current study.

Several factors may have contributed to the high burden of IPV associated with adherence to COVID-19 preventive measures among an already vulnerable population of women living in informal settlements of Kampala. Travel restrictions during the first COVID-19 wave prolonged exposure of women with potential perpetrators which could increase the risk of partner abuse. The context of implementation and compliance with COVID-19 preventive restrictions is important due to the economic effects on households such as loss of employment. Failure to obtain alternative income sources while adhering to ‘stay-at-home’ orders increases financial and psychological distress among bread winners. Job loss and hopelessness in the general community were common during the COVID-19 lockdown period in Uganda. Our study cohort were surveyed within a four month period between conformation of the incident COVID-19 case in Uganda on March 21, 2020 [40] and the first presidential directive for a total country lock down. This relatively lengthy and ongoing period of lockdowns and curfews may have been a major source of psychological and economic distress due to loss of household livelihoods hence translating into spousal abuse as a coping mechanism. Such stressful home environments compounded with an increase in household demands especially for supplies or bills raises the risk of abusive behavior as a compensatory mechanism. An imbalance in power dynamics in households during enforcement of COVID-19 restrictions may led to retaliatory abuse by men when the influence, decision making and capacity to provide financial support to their families was challenged. According to the theory of gender and power, IPV may have increased if men were rendered ‘powerless’ in a society that culturally condones male dominance. In addition, ‘stay-at-home’ directives may have aggravated perpetuation of IPV because gender roles that culturally assigned household provision roles to men challenged their masculinity hence men resorting to violence.

Our study also suggested that food insecurity may contribute to the high burden of IPV among women in informal settings. In fact, eighty percent of women in our study could not physically access or afford food reiterating prior research which showed the impact of COVID-19 on increased food insecurity [41]. This was in line with a population-based survey in rural and urban settings in Uganda that revealed an association between male partner perpetration of IPV and food insecurity [42]. It is plausible to suggest that a combination of stressors namely, economic (job loss poverty), and psychological (social isolation) could trigger domestic violence, especially among intimate partners. Several households lost their sources of income especially the men who are usually bread winners in households. This affected the livelihoods and quality of lives of women and their families especially those in disadvantaged communities such as informal settings.

Despite these potential reasons explaining why adherence to COVID-19 preventive measures may increase IPV risk, a need still exists to comprehensively examine the underlying factors for this increased IPV risk. Therefore, we posit that with gradual return to ‘normalcy’ in terms of easing COVID-19 restrictions and increasing economic activity, women impacted most by the financial distress and physical confinement, the duration of exposure to potential perpetrators and risk of IPV may reduce. Current efforts to achieve herd immunity with COVID-19 vaccinations and recently with the development of a COVID-19 pill [43] shows promise of likely easing of COVID-19 restrictions and potential reduction in IPV risk in households in informal settings.

Overall, present findings that reiterate the need for Uganda’s COVID-19 prevention and control measures to be inclusive, contextually tailored and responsive to the needs of marginalized groups. For example, our study was conducted among women dwelling in informal settlements who particularly lack safety nets to enable survival during such crises as the COVID-19 pandemic. Some government efforts aimed at addressing social needs in Uganda’s COVID-19 response included the provision of food relief to the urban poor and temporary suspension to closing some businesses due to non-tax payment. Other ad-hoc interventions to address the challenge of increasing IPV reports following presidential lockdown directives included law enforcement establishing a toll-free hotline with the Uganda Police Force to facilitate reporting of and response to IPV cases during and after the COVID-19 lockdown [44]. This study highlights the need to integrate violence prevention messages into the phased implementation of COVID-19 prevention interventions. This may increase awareness among informal settlement dwellers and a sense of urgency of the public health threat posed by COVID-19 transmission and acquisition. Therefore, government directives for mandatory face mask-wearing and restricting work to ‘essential’ workers-only may have driven the adoption of COVID-19 preventive measures over time. This is supported by the fact that facemask-wearing was acceptable as a preventive measure for COVID-19 particularly by urban dwellers in Kampala [45].

Study implications

Regarding community practice, there is a need for relevant government ministries and stakeholders to engage in continuously implementing COVID-19 preventive measures while exploring underlying social needs and risks to for IPV among informal settlement dwellers that need to be addressed. Consistent community sensitization about the importance of COVID-19 preventive measures is required especially among the urban poor in Uganda. The national COVID-19 preventive task force should integrate IPV survivors who are experiencing prolonged exposure to IPV perpetrators by addressing their safety and psychosocial needs. For future research, although prior studies have conducted predictive models of COVID-19 on mortality, Disease Adjusted Life Years (DALYs), and the economic impact in Uganda, we recommend similar approaches to predict the long-term impact on COVID-19 preventive measures on IPV exposure as behavioral outcome during COVID-19 waves or similar outbreaks in Uganda.

The current policy discourse recommends equity in COVID-19 vaccination among most at-risk persons namely, healthcare workers, and elderly persons. There is a need to promote equity in the allocation of resources (food relief, vaccines, etc.) particularly to women who are marginalized, vulnerable and the urban poor. These populations include women living in informal settings because of their high psychosocial and economic needs and higher risk of exposure to IPV during the COVID-19 restriction period.

Conclusions

A substantial proportion of women dwelling in informal settlements of Kampala experienced at least one form of IPV during the first COVID-19 wave in Uganda. Exposure to IPV was more likely among women who remained adherent to COVID-19 preventive measures when compared to their counterparts who were poorly adherent to COVID-19 preventive measures between baseline and endline. Ongoing implementation of interventions to prevent transmission of COVID-19 should take the social needs and risks for IPV of marginalized and vulnerable women living in informal settings of Kampala into account. Integration of violence prevention and response strategies into the national COVID-19 prevention strategy for Uganda should be urgently initiated.

Supporting information