Adherence to and enforcement of non-pharmaceutical interventions (NPIs) for COVID-19 prevention in Nigeria, Rwanda, and Zambia: A mixed-methods analysis

  1. Hiwote Solomon
  2. Donald M. Thea
  3. Sandro Galea
  4. Lora L. Sabin
  5. Daniel R. Lucey
  6. Davidson H. Hamer

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Abstract

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. Rwanda’s success in implementing COVID-related measures was partly due to strong enforcement and having a population that generally follow the recommendations of their government.

Conclusion

Various forces either facilitated or hindered adherence and compliance to COVID-19 control measures. The lessons learned and recommendations gleaned through interviews with experts involved in the COVID-19 pandemic and quantitative analysis of NPI implementation can be applied to future outbreaks, epidemics, and pandemics. Recommendations include engaging communities, using a risk-based approach to implement containment and closure NPIs, and providing social and economic support to citizens during periods of lockdowns and other measures that interrupt the ability to make a living.

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  1. Version published to 10.1371/journal.pgph.0000389
  2. ScreenIT

    SciScore for 10.1101/2022.03.29.22273120: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    NIH rigor criteria are not applicable to paper type.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    All analyses were performed using SAS statistical software version 9.4 (SAS Institute Inc.
    SAS statistical
    suggested: None
    SAS Institute
    suggested: (Statistical Analysis System, RRID:SCR_008567)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    The study has several limitations. First, given the fluidity of the COVID-19 pandemic and the time it took each of the three countries to get there, external factors such as variants, holiday season, etc., could have affected the degree of implementation. For example, Nigeria reached 10,000 cases in May 2020 while Rwanda reached that point in January 2021. The state of the pandemic and global guidance had changed significantly in between that time. There are also specific limitations in the OxCGRT dataset itself. The dataset does not measure implementation or compliance, nor does it provide subnational measures for almost all countries apart from adding a flag denoting whether the restriction was national or subnational (25). Thus, our nation-focused analysis may miss some variation of policies implemented at the sub-national level. Additionally, our sample size of KIIs is relatively small, therefore there may be other diverse opinions about what worked and what did not during NPI implementation, that were not captured here. During pandemics, apart from effective vaccine strategies, NPIs are one of the most important tools that individuals and communities can utilize to limit disease spread and reduce deaths. In addition, the timing of NPI implementation is crucial. Delayed implementation of NPIs will lead to unchecked proliferation of disease in the community and overwhelm health systems (4,8,39). However, in addition to timing, the success of NPIs depends critically on the ...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a protocol registration statement.

    Results from scite Reference Check: We found no unreliable references.

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  3. Version published to 10.1101/2022.03.29.22273120v1 on medRxiv