The Impact of COVID-19 Restrictions on the Health and Well-being of Women Living in Informal Settlements in Uganda.

The Impact of COVID-19 Restrictions on the Health and Well-being of Women Living in Informal Settlements in Uganda. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Impact of COVID-19 Restrictions on the Health and Well-being of Women Living in Informal Settlements in Uganda. Moses Tetui, Na-Mee Lee, Laseen Alhafi, Lesley A. Johnston, Susan Babirye, and 10 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4555351/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: The COVID-19 pandemic significantly impacted Uganda, with the first case reported in March 2020, resulting in extensive public health restrictions, including a lockdown, curfew, and closure of schools and workplaces. Urban residents, particularly those living in poverty in informal settlements, faced heightened challenges due to inadequate access to basic services, financial hardships, and increased caregiving responsibilities, especially for women. Women faced heightened risks of gender-based violence and engaged in transactional sex as coping mechanisms. This study explored the strategies used by women in Kampala and Mbale cities to meet basic needs during the pandemic and their implications for HIV infection vulnerability. Methods: Researchers conducted in-depth discussions with 282 women from various age groups in Kampala and Mbale's largest informal settlements, gathering insights into their pandemic experiences. These discussions, held in local languages, explored women's social, family, and financial challenges, as well as their perceptions of HIV risks. Transcripts were translated by local language experts before analysis. The team analyzed the transcripts using NVivo version 14 software, identifying patterns and themes that revealed survival strategies employed by women. Results: The study identified three interconnected themes that capture the complex strategies and challenges faced by women in informal settlements in Kampala and Mbale during the COVID-19 pandemic. Women struggled to cope with financial hardships and increased caregiving responsibilities, often resorting to desperate measures like transactional sex to survive, despite their resilience. The pandemic exacerbated vulnerabilities, heightening risks of HIV transmission and mental health issues, particularly among women living in poverty. While support networks provided some relief, they often fell short of meeting the diverse needs of women in these communities. Conclusions: The study shows that women in Uganda's informal settlements demonstrated resilience by taking on new roles and engaging in trading, but their reliance on transactional sex revealed stark power imbalances, increasing their vulnerability to gender-based violence, unintended pregnancies, and HIV infection. This highlights the urgent need for targeted interventions that address the complex challenges women face in crisis situations, which could enhance their resilience and alleviate their multiple struggles, with valuable lessons for similar contexts in low- and middle-income countries. Survival strategies COVID-19 HIV vulnerability Informal settlements Women Kampala City Mbale City Uganda Introduction The first case of COVID-19 in Uganda was reported on March 21, 2020( 1 ), and as of December 6, 2023, Uganda had reported 171,876 cases and 3,632 deaths( 2 ). Daily life was disrupted for many Ugandans, when public health restrictions, including a total lockdown during the early stages of the pandemic, were implemented on April 1, 2020, with imposition of a curfew, closure of schools and workplaces (except for those offering essential services), cessation of public transport, and restrictions on the use of private vehicles( 3 , 4 ). Although some easing of restrictions occurred a few months later, many were reimposed when the Delta variant emerged in 2021. Schools in Uganda remained closed for nearly two years( 5 ). Although the effects of the lockdown measures were far-reaching, residents of urban areas living in poverty were especially affected by these disruptions to daily life. Urban residents living in poverty often reside in informal settlements characterized by unplanned and unregulated housing, high levels of overcrowding, and limited public infrastructure including roads, schools, and sewerage systems( 6 – 8 ). Income levels are much lower in such settlements compared to the rest of the city, with most informal settlement residents living hand-to-mouth and in poor sanitary conditions( 9 ). As a result, residents grapple with complex health and social issues, mainly due to inadequate access to basic resources such as clean water, adequate sanitation, and healthcare. During the pandemic, lockdown related restrictions on mobility greatly affected the Ugandan economy, disrupting the market and production supply chains( 10 , 11 ). These disruptions disproportionately affected the Ugandan population, with the most profound effects being on the informal sector, which employs many urban residents living in poverty, most of whom are women and youth( 12 , 13 ). Individuals reliant on the informal sector include casual laborers, hawkers, tailors, hairdressers, market stall operators, food vendors, urban refugees, and internal migrants, among others. It is estimated that about 23% of urban residents living in poverty lost virtually all of their daily income( 14 ), exacerbating financial hardships as they had little or no savings( 15 ). This loss was felt more greatly by women, who mainly relied on informal money-earning opportunities, earned only one-half of the nominal monthly income as compared to men, and had far fewer savings than men( 14 , 16 ). Further, the COVID-19 pandemic introduced an additional burden of unpaid work for women in the form of home schooling, additional childcare upon school closures, taking care of the sick, and ensuring extra precautions for hygiene and sanitation within the home( 17 , 18 ). This increased workload affected gender power relations in the home and in the community, as women experienced emotional and physical exhaustion as they attempted to keep up with new care demands( 18 ). These changes, exacerbated by isolation, also increased the risk of gender-based violence and family abandonment( 19 – 21 ). Given these challenges, many women were left particularly vulnerable and had to make difficult decisions about how to support themselves and their families, turning to various strategies including unprotected transactional sex( 22 , 23 ). Experiences of gender-based violence and participation in transactional sex activities are associated with higher risk of acquiring HIV and poor sexual and reproductive health outcomes( 24 ). These risks are suggested to have increased during the pandemic when health services became more difficult to access( 22 ). In Uganda, as in many other places, it has been noted that most COVID-19 interventions were top-down and did not consider local contexts, especially the burden that these measures placed on those living in informal urban settlements( 15 ). who are the most vulnerable group with a low capacity to adapt financially when faced with stringent public health measures( 25 ). Additionally, a similar study among urban refugees living in Uganda revealed increased income insecurity, sexual and gender-based violence, and anxiety during the initial lockdown( 15 , 24 ). Although it remains difficult to predict the full extent of the long-term socio-economic impacts of the COVID-19 measures on the health and well-being of communities in Uganda, it is important that policy actors consider the effects on the most vulnerable groups, including residents of urban informal settlements living in poverty( 26 ). Particular attention should be paid to the experiences of vulnerable women living in informal settlements( 17 , 19 ). This study, a component of the WomenRISE initiative developed and funded by the Canadian International Development Research Centre 1 , explored the strategies that women living in large informal settlements in Kampala and Mbale used to meet basic needs at the individual and household levels amidst COVID-19 related restrictions, and the impact that these may have had on the determinants of health and well-being, including greater risks for HIV infection and transmission. This phase of the study was designed to develop an understanding of the lived experiences of women in these local contexts to co-develop inclusive strategies to address the most significant challenges and to prepare for future pandemics. Methods Focus group discussions (FGDs) were conducted with women of different age groups in the four largest informal settlements in Kampala and Mbale. Twelve FGDs were conducted in each city (n = 24 groups total), comprised of 144 women in Kampala and 138 women in Mbale. The focus groups were made up of women either unemployed or participating in the informal work and were divided by three broad age ranges in each city: 17–24 years, 25–49 years, and ≥ 50 years. Discussion questions focused on women’s social, familial, and financial experiences during the pandemic, as well as their experiences and perceptions of and HIV-related risks and vulnerabilities. The FGDs were conducted in the predominant local languages (Luganda and Lugisu in Kampala and Mbale respectively) by research assistants from the Makerere University School of Public Health. Transcripts were translated into English and analyzed using QSR NVivo software, version 14. The FGD data were analyzed both deductively and inductively( 27 ). Codes related to pandemic consequences, coping strategies, and HIV were developed based on the research questions and further refined through an iterative coding process involving several researchers (MT, ML, CJ, LA, LJ). The coded transcripts were then analyzed inductively to develop themes that capture the stories and experiences of the women with whom we spoke. Findings Three inter-related themes illustrate the ways by which women living in informal settlements attempted to meet individual and household needs during restrictions associated with the COVID-19 pandemic, each representing a significant determinant of health and well-being. The first theme pertains to individual financial and behavioural strategies that women employed in response to the dire poverty and hunger they experienced. The second captures experiences of women turning to transactional sex or relationships to make money for food and survival. The third highlights strategies for survival as experienced through social networks and communities. Financial and behavioural strategies This theme is comprised of financial and behavioural strategies employed by women to confront the challenges posed by COVID-19 lockdowns. Two sub-themes emerged: finding new work lockdowns and “hustling” for survival. Residents of informal settlements had been facing poverty and financial insecurity well before the COVID-19 pandemic. However, when the pandemic measures led to the loss of jobs and increased hunger, women experienced greater livelihood insecurity. Some of the strategies discussed included cutting expenses and learning to save money, rationing food, and changing eating habits or embracing alternative foods in the absence of daily staples. Because women are often the decision-makers regarding food and cooking in the home, these strategies had an impact on the entire family. For example, women reported purchasing only basic items when funds allowed, choosing cheaper foods than the family would normally consume, and preparing fewer and smaller meals in a day for themselves and their children. Women were also burdened with the task of finding means to care for their children and other sick family members. When medicines and health services became largely inaccessible and unaffordable due to financial difficulty and restricted transport, women turned to using home-made remedies to treat COVID-19 and other illnesses. Finding new work The pressures of caregiving and feeding the family were heightened during the pandemic due to tensions between women and their male partners. Due to closure of workplaces and schools and travel restrictions, men in the informal settlements lost jobs running businesses, practicing trades, driving taxis or motorcycles, or working in schools. In households where men were the primary breadwinners, this effect was damaging to intrafamilial relationships, and tensions were high –leading to sometimes violent quarreling. Many women reported having been abandoned by their husbands or partners who chose to escape mounting social and family pressures to provide financially. As a result, women were left alone with their children, unable to work owing to the lockdowns and curfews, and struggling to feed themselves and their children. “Families disintegrated and men ran away from their responsibilities. We women remained as the tree to hold the branches (children) that we produced.” (FGD 07) My husband came back but he sits at home and looks on. He is not working so I can't ask him for anything, so I consider myself as a single mother, I take care of my own children.” (FGD 10). Given such circumstances, women had to redouble efforts to earn income and at the same time care for family members. Driven by the dire need to care for and feed their families, women turned to trading activities, such as vending food and produce and collecting and selling used plastic bottles to recycling companies, or domestic and janitorial jobs such as sweeping roads and government buildings floors and washing clothes or dishes for other homes and businesses. Some women started to work for the very first time during the lockdown, while others diversified their work and embraced previously shunned work and lower-paying jobs such as vending food or domestic janitorial jobs. COVID found me washing clothes for money, but my husband did not like me washing clothes. He would say that this is for beggars. I would do it stealthily; I go and wash clothes when he is not around, and I would return home before he does. He would ask me whether I had been loitering around the village and I would tell him no, yet I had been washing clothes for people (FGD 09). Hustling for survival In searching for work, many women turned to proscribed means to make money or find food, circumventing stringent lockdown measures and engaging in illegal activities. For example, they operated and worked in bars, women’s salons, and restaurants despite strict and sometimes violent police surveillance of such establishments. In some circumstances, women reported having to bribe police and to hide prohibited activities. Additionally, when restrictions barred transport between cities, women had to negotiate with ambulance drivers or motorcycle riders to secretly carry them or their goods, such as food or supplies for their marketing activities. " I had a bar, and some of my customers gave me some advice, saying “you have children now, if you close the business how will you survive?” So, they took me to the police officer in charge and we talked, so we would give him 40,000 per week so that our businesses could remain operating, so that they do not arrest us, but that was [during the first wave of the pandemic]. [During the second lockdown], it became very difficult, the policemen would disturb us so much. When they arrest you, you must pay money to get out and you also must pay for the customers they find in your bar.” (FGD 07) “…our parents in the village, they could not send food because of transport problems. I used an ambulance just to get food, we risked it. If [the police] could check, we could get arrested. That is how we survived” (FGD 03) “I had a house with both a rear and front door and I used to tell my customers to come in from behind and tell them not to shout. During that time, not even cats used to shout” (FGD 13) Women who were unable to find paid work resorted to extreme measures to survive, such as picking food from garbage bins, consuming unsafe water, cooking grass for sustenance, foregoing meals, begging, and selling personal property. Some of these measures were emotionally draining, increasing vulnerability to mental health problems and propensity to engage in risky behaviours, such as alcohol abuse, unprotected sex, and transactional sex. Transactional sex Women described participating in transactional sexual activity to meet basic needs. This activity was done temporarily and out of desperation. In the prolonged absence of income, with few other options for survival, and amidst growing mental distress, many women – especially younger women – turned to transactional relationships with men to support themselves and their families. In such circumstances, women described feeling a sense of helplessness, being unable to provide for themselves otherwise, or their distress at watching their daughters turn to such measures. “There were some women who were not working; the spouse also has nothing to offer; the children are crying, so as she is moving, she finds another man, say John, who asks her how life is; she explains that the situation is bad; he gives her 5000 shillings (USD1.4); and then the next time he calls her, still the situation is bad; he tells her to meet him somewhere, and she ends up going with him” (FGD 22) “You could not look on as your child is dying of hunger, so we resorted to “detoothing” (conning men out of money). We were chased from everywhere that we went to. You find your girl child with a man so old they are suited to be dating you, the mother, and you feel a lot of pity in your heart. Sometimes with a man you have even dated before and now they are wooing your child. You both know you are sick (HIV), and he goes to your child, and you feel very bad at heart. It was a really a hard time indeed” (FGD 03) Participating in such sexual activities for survival posed a high risk for HIV and unwanted pregnancies. Women who turned to transactional sex did so out of immediate and urgent need to make money to feed their families and had little bargaining power in transactional relationships. As men had the power to refuse one woman to seek another, women felt as though they could not advocate for safer sex practices, such as inquiring about HIV status and using condoms. Unintended pregnancies were reported to be commonplace, leaving women in a cycle of poverty and financial difficulty when men did not take responsibility for the pregnancies or provide support for the child. “Because of COVID, I did a job that I did not expect to do, and yet it was the riskiest. Those who would come with a lot of money did not want to use protection, and even if you want to use protection, the money will attract you because he will tell you, ‘I have 50,000 shillings (USD13.5) but I don’t want protection,’ so you accept.” (FGD 08) “Me, I will never forget the moment I lost my job, and I did not have food so in order to survive I got a man who impregnated me and then he ran away. Up to now, I don’t know where he is” (FGD 08) Conversely, some women sought, or were pressured to enter, more traditional or long-term relationships to better their financial circumstances. For example, some women married during the pandemic as an explicit financial strategy, while others were involved in extra-marital affairs or polygamous arrangements. However, such relationships were not always helpful, as women in these situations also experienced partner abandonment and other financial challenges within their relationships. “I decided to get married to a man who cooks chapati because then there is food” (FGD 23) Survival strategies through social networks and communities Two general kinds of social or community-level support were discussed: social networks and organized support. Social networks included personal relations such as friends, immediate and extended family, neighbors, and community members. Organized support came through formal organizations such as women’s savings groups, political leaders, employers, NGOs, churches, and government, which provided space for not only networking but also material and mental support. Social networks Women recounted turning to family members, friends, neighbours, and church groups to socialize and counsel one another. Being in the company of others was crucial for some women who found strength and stress relief through conversation, games, and communal worship. As a result of relying on such social supports and sharing the experience of difficulty during the pandemic, some women experienced a strengthening of friendship and family relationships. These social networks were also a source of practical support. Sharing of food rations or helping with childcare were common, as was finding opportunities for work through social connections. While friends, neighbours, and church communities were often mentioned as helpful, immediate, and extended family members were the most identified source of social support. Residents of both Kampala and Mbale described receiving money and food from family members during times of desperation and hunger. “I had a neighbor whose situation was not as bad as mine because she used to help me. She was there for me, took care of my child” (FGD 03) “In the village, [my family] would try and find means to send me cassava and bananas (Bogoya), so when the bananas would ripen, I would sell them, and the little money I would get was what I would use to buy posho (cornmeal)” (FGD 08) Other women sent their children to rural areas to stay with immediate or extended family to lessen the burden on themselves. As above, this was done by circumventing lockdown measures, allowing connection between family members and communities in cities and the countryside despite travel restrictions and curfews. “When Covid came, I couldn’t afford rent, so I first sent the children to the village, and I remained with my husband. I could go to town and hustle whatever little I would get, and we would buy some food and send some money to the children in the village” (FGD 24) Psychosocial support was especially important during these periods of severe mental distress. Some women spoke of finding reprieve from feelings of hopelessness or thoughts of suicide through friends’ counsel, or of providing the same support to others in similar situations. However, for those who experienced such mental health crises and hopelessness, finding company in friends or family was not a panacea. “My marriage had come to an end; my family was broken, and I was by myself with two children. I was stranded and hopeless and said to myself, “let me just die.” My mother found me (trying to take my life) and she talked me out of it saying that this was not the end. My mother was very prayerful so she would take me to church, but later, even the churches were closed, and we were ordered to pray from our own houses. My mother kept encouraging me. Covid greatly affected me, and I have never recovered to date” (FGD 24) Alcohol was consumed as a home remedy for illnesses and protection against COVID-19. They told us that when you take alcohol, you don’t get COVID, so I started taking alcohol because we were near a hospital and we would see people dying of COVID, so I resorted to taking waragi (alcohol) so that I don’t die. It also helped me manage stress because even just inhaling it you would fall asleep and wake up when the stress has decreased. My head would spin, and I forget that there is even COVID” (FGD 20) Some women turned to alcohol and drug use under the stress of lockdowns. While for some, substance use was a new activity, for others, the lockdown restrictions increased existing use The intertwining challenges of substance use, mental health issues, and heightened vulnerability to HIV created by a lack of basic needs comprised a complex social landscape, especially for younger women. “I was a drunkard, and my friends were also drunkards, we would leave home to go, and we drink, got more friends to join us, because we had no food, we would get too drunk, and the men would take us to their rooms” (FGD 13) Organized support Some families in Kampala and Mbale received assistance from formal organizations such as government, churches, and non-governmental organizations, mostly in the form of food relief distributions. Churches donated and distributed cornmeal ( posho ) and beans to supplement the Ugandan government’s relief efforts. In some cases, churches also provided financial assistance for some community members requiring aid. Other non-religious, non-governmental organizations were also present in some communities providing food, monetary aid, mental health support, or health services, though this type of assistance was not commonly available to our focus group participants. “There was a church near us that would give us posho (cornmeal) and some money. The landlord would also buy proteins for us. My spouse also needed treatment because he was discharged before full recovery. The church people really helped with that” (FGD 10) Similarly, political leaders and some employers supported women during the lockdown periods to overcome some of the challenges they were faced with including providing basics such as food. Political leaders also mediated between landlords and tenants to provide longer grace periods for payment of rent in arrears. In some cases, support came from employers providing short term assistance to their employees. “One morning the landlord removed the roof of the house as we had been unable to pay the rent. I cried that day and ran to my sister, I explained everything to her, and she promised to help talk to the chairperson which she did and the two went and talked to my landlord, he cooled, and the house was roofed again by God’s grace” (FGD 01) “After some time, a MP (Member of Parliament) came and gave us maize flour and I took it home” (FGD 03) However, this organized support was not sufficient and, in some cases, lacking in terms of quality of food or basics provided to households. For example, some women reported that the beans and posho (corn meal) they received from the government were of poor quality and made their situation only worse. This was illustrated in situations where the poor-quality beans needed more scarce and costly cooking fuel to prepare a basic meal. “The food that government gave us, it was maize brand (low grade cornmeal), and the beans were rotten, and they don’t get ready (cooked). We almost died of hunger and yet we had children” (FGD 01) Women also organized themselves into informal savings groups. The groups acted as an avenue for socializing and relieving stress as well as a means of financial saving by which women pooled resources to meet immediate basic needs. These savings groups were both formal and informal. While some organized themselves into formalized Savings and Credit Cooperative Organizations (require legal registration and are often considered more secure by its members given the formal recognition and clear pathways for resolving conflicts that may arise) savings groups, others pooled resources with friends and neighbours to meet basic needs. Discussion This study portrays the challenges faced by women in urban informal settlements in Uganda during COVID-19 lockdown and illustrates the consequent risks to health and well-being. Although many of the challenges resulted in serious livelihood insecurity and related challenges to health, it is also clear from our participants that they were often able to call on personal and social resources to manage difficult situations. As such, the results of the study reflect broader discourses on women's strength in navigating economic hardships and societal expectations, particularly as traditional gender roles collide with the realities of a global crisis increasing the burden of their care work( 28 , 29 ). Despite significant adversity, women engaged in trading activities, entered the workforce, and embraced new roles to support themselves and their families, albeit in the informal sector in which job precarity, unequal pay, and poor working conditions often reinforce the cycle of poverty among women and expose them to serious health risks and gender-based violence ( 30 , 31 ). The portrayal of women’s lived experiences of Covid-era public health interventions in this study adds depth to discussions on gender inequality, emphasizing the importance of understanding how gender shapes women's experiences during times of crisis. The experiences of the women in our study reveal the emotional and physical toll of extreme survival measures, identifying their vulnerabilities to mental health crises and behaviors that place their health at greater risk. These findings are consistent with studies from other low- and middle-income countries, particularly in informal settlements, that report the disproportionate impacts of the pandemic among women in relation to food insecurity, household violence, and access to sexual and reproductive health services( 28 , 29 , 32 ). In our context, we found that many women experienced abandonment by men (partners), which increased the burden of work and compounded the toll of economic hardships on women’s mental and physical well-being. Some women, grappling with severe financial difficulties and food insecurity, turned to short-term sexual survival strategies( 22 , 33 ). Long before the pandemic, several studies have highlighted the complex and intersectional relationship between socioeconomic status and sexual health outcomes, including HIV and unwanted pregnancies, within informal settlements in Uganda and other sub-Saharan African countries( 22 , 33 – 35 ). Engagement in transactional sex and longer-term relationships for economic support illuminates the compromises impoverished women must make, even as it places them at heightened risk of HIV infection. Our findings are in line with other studies that have found that the heightened stress of poverty during the pandemic, combined with a decline access to essential health services and medicines, likely increased the risk of HIV infection or otherwise worsened the health of those already affected( 36 ). This combination of factors has significant consequences for a population with a large burden of HIV and higher rates among women( 37 ). Similarly, the current study underscores the vulnerability of women in these transactional relationships, shedding light on unequal power dynamics and compromised ability to negotiate safer sex practices( 22 , 34 , 38 ). This finding is consistent with literature on gender-based violence that indicates that exploitation within intimate relationships further undermines women’s ability to remain healthy in adverse conditions( 39 – 41 ). COVID-19 restrictions placed households at significant financial and psychological risk, compromising quality of life in low-income households. These conditions can trigger gender-based violence by exacerbating underlying tensions. Studies have shown that the rate of intimate partner violence increased during the COVID-19 pandemic, both in Uganda and other contexts, due to a myriad of factors such as stress from job loss, social isolation, increased time with partners during the lockdown, and broader social and economic instability( 20 , 21 ). Furthermore, the erosion of social norms and stay-at-home orders may have challenged ideals of masculinity and power within homes and relationships, leading men to resort to violence( 21 ). Our results support these findings, whereby women’s decision-making power and authority were further compromised by their precarious living situation. Women’s homelives are made more precarious by the threat of family abandonment. The loss of the primary breadwinner can have a devastating effect on households. Freitas et al. reported similar scenarios during the 2015 Zika outbreak in Brazil( 42 ). Mothers whose children were infected by the Zika virus experienced social and gender inequality and poverty, marital infidelity, violence, and abandonment. In our study, restrictions associated with the COVID-19 pandemic threw women into similar positions. Women had to make difficult decisions about how to care for their families, such as transactional sex as discussed previously. The unintended pregnancies and the ensuing challenges faced by women align with broader discussions in the literature concerning reproductive autonomy and the societal implications of limited access to family planning resources, especially in informal settlements( 38 , 43 ). In this way, transactional sex serves as a lens through which to examine the complex interplay of gender, poverty, and power dynamics, contributing to the ongoing dialogue on the challenges faced by marginalized women during times of crisis. The study emphasises the multifaceted challenges faced by women in informal settlements in Uganda during the COVID-19 pandemic. Economic precarity was a central theme, resonating with existing literature on urban poverty in informal settlements( 44 ). Women engaged in precarious work in informal sectors encounter exacerbated hardships, reflecting broader discussions on the vulnerability of women in informal economies not just in Uganda but in most low-and-middle-income countries( 9 ). Such vulnerabilities are only made worse in pandemic situations in which women are required to bear the burden of increased child and general household care( 45 ), thereby exposing them to worsening mental health conditions and susceptibility to unsafe means of survival( 22 , 29 , 33 , 46 ). Ogando, Rogan and Moussie describe how, in some low- and middle-income countries, women’s share of the care work can be as much as 75 to 90% higher than men’s and that the COVID-19 crisis has intensified this inequality( 18 ). Women’s vulnerability during the pandemic has increased their vulnerability to the worsening of the gender burden( 17 ). Power relations were altered as women lost their income earning opportunities. Even as our research finds that some women were able to establish new forms of securing an income, their unpaid reproductive and community responsibilities increased. From the shock of school closures and increased childcare responsibilities, to heightened hygiene and sanitation precautions, to growing commitments to the community, these care work expectations compromise women’s physical and mental health, while also entrenching gender imbalance within the household. As a result, women are placed at greater risk of gender-based violence and family abandonment. Conversely, in the face of such hardships, the significance of social connections and psychosocial support networks emerges as a crucial aspect of women's strategies of survival. This finding aligns with literature emphasizing the importance of community ties for mental well-being in the context of informal settlements( 47 , 48 ). Researchers have previously explored the interconnectedness of social relationships and mental health among Ugandan women, especially during times of crisis( 49 ). Social networks and capital play a crucial part in sustaining women especially in situations of adversity and underdeveloped mental health services( 50 ). Additionally, the role of institutions in providing relief mirrors research on the complexities of assistance programs in informal settlements( 51 ). While institutional support was present, our study underscored the limitations and challenges of such aid efforts, highlighting the importance of tailoring aid to the needs of the population( 52 , 53 ). Broader structural change is needed to provide social welfare support for these communities beyond the pandemic context( 18 ). At the same time, smaller scale adjustments that recognized and adjusted to the burden of school closures, the lockdown measures, and the free reign given to the police to enforce these measures may have also supported marginalized groups. Plans to address future challenges akin to the COVID-19 pandemic must recognize the precarity of those living hand-to-mouth. Interventions must be inclusive, tailored, and responsive to the needs of marginalized communities. Women, who lose decision-making power and whose voices and priorities are ignored during times of adversity, need to be included in the formulation of these plans and interventions to ensure that they do not suffer a repeat situation of their experiences during COVID-19 in which their physical and mental health was compromised( 54 ). Conclusions The study identified challenges faced by women in Uganda's informal settlements amid the COVID-19 pandemic. It underscores the intricate interplay of economic struggles, strength, and vulnerability, contributing to the literature on gender roles and crises. Despite economic hardships, women displayed resourcefulness in trading activities and adapting to new roles. However, the reality of transactional sex as a survival strategy was also identified. This strategy exposes unequal power dynamics and contributes to unintended pregnancies, gender-based violence, and vulnerability to HIV infection. Additionally, transactional sex emphasizes urban poverty and the exacerbated hardships faced by women engaged in precarious work within informal sectors. The significance of social connections and psychosocial support networks emerges as crucial for women’s survival, highlighting the importance of community ties for mental well-being. While acknowledging institutional support, the study underscores its limitations. Overall, the research deepens our understanding of the multifaceted experiences of women in Uganda’s informal settlements during the pandemic, encompassing economic challenges, resilience, and the dynamics of community and institutional aid. The study’s findings point to several ways to address the challenges faced by women in Uganda’s informal settlements during crises. Initiatives focusing on economic empowerment, such as skills training and entrepreneurship programs, can alleviate the economic vulnerability of women engaged in precarious work. Strengthening access to reproductive health services and implementing community-based health programs are crucial to addressing unintended pregnancies and heightened vulnerability to HIV infection resulting from transactional sex. Securing access to education for lower-income girls can create a protective shield against teenage pregnancies and increase chances for a better livelihood. Psychosocial support services tailored to the unique needs of women in informal settlements, along with community building and social networks, can provide essential emotional and mutual support. Advocating for policy changes, refining institutional aid strategies, and promoting further research on women's experiences during crises are integral components for a comprehensive approach to improving the well-being of these women. Important to note is the need to ensure that these changes are grounded in local realities by approaching them through a collaborative co-design approach that centers and reflects community needs and aspirations. By implementing these recommendations, stakeholders can foster resilience and mitigate the multifaceted challenges faced by women not only in Uganda's informal settlements but in similar settings in other low and middle-income countries. Declarations Ethics approval and consent to participate Ethical approval for this study was obtained at three institutions. Makerere University School of Public Health (SPH-2022-323), University of Waterloo (44725) and Uganda National council of science and Technology (HS2458ES). All participants provided written informed consent prior to participating. Consent for publication Not applicable. Availability of data and materials The qualitative transcripts used during the current study are available from the corresponding author on reasonable request. Competing interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The study was funded by IDRC (Grant No. 110028-002) awarded to Makerere University, Uganda and the University of Waterloo, Canada. Authors' contributions MT led the conceptualization and drafting of the manuscript. MT, ML and LAA led the data analysis process, all the other authors iteratively reviewed the coding process and contributed to the overall framing of the findings. SB provided oversight to the data collection process while Kawooya led the data collection. CRJ and SB provided the overall technical guidance to the conceptualization and framing of the manuscript. All authors reviewed drafts of the manuscript, were involved in the iterative data analysis process, provided substantial input, and agreed to the contents of the submitted manuscripts. They approved the submitted version of the manuscript. And have agreed both to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. Acknowledgement s We would like to all our study participants and project partners including Makerere University, University of Waterloo, Afri-Slum Uganda, and Uganda AIDS commission, Kampala City Council Authority and Mbale City Council. References Uganda MoH. Uganda confirms 1st case of COVID-19. Saturday 21 March 2020 Kampala Ministry of Health 2020 [cited 2023 12-13-2-23]. https://www.health.go.ug/covid/2020/03/23/uganda-confirms-1st-case-of-covid-19-saturday-21-march-2020/ . WHO. WHO coronavirus (COVID-19) dashboard Geneva World Health Organization 2023 [cited 2023 13-12-2023]. https://covid19.who.int . Uganda MoH. Corna virus disease- 2019 (COVID-19); Preparedness and Response Plan. Kampala Ministry of Health; 2020. Najmul H, Abdinasir Yusuf O, Audrey G, George OA, Danny A, Rashid A, et al. Lockdown measures in response to COVID-19 in nine sub-Saharan African countries. BMJ Global Health. 2020;5(10):e003319. Health EiG. How did Uganda respond to the COVID-19 pandemic? 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West NS, Ddaaki W, Nakyanjo N, Isabirye D, Nakubulwa R, Nalugoda F, et al. A Double Stress: The Mental Health Impacts of the COVID-19 Pandemic Among People Living with HIV in Rakai, Uganda. AIDS Behav. 2022;26(1):261–5. Vithalani J, Herreros-Villanueva M. HIV Epidemiology in Uganda: survey based on age, gender, number of sexual partners and frequency of testing. Afr Health Sci. 2018;18(3):523–30. Seidu A-A, Aboagye RG, Okyere J, Agbemavi W, Akpeke M, Budu E, et al. Women's autonomy in household decision-making and safer sex negotiation in sub-Saharan Africa: An analysis of data from 27 Demographic and Health Surveys. SSM - Popul Health. 2021;14:100773. Campbell JC, Baty ML, Ghandour RM, Stockman JK, Francisco L, Wagman J. The intersection of intimate partner violence against women and HIV/AIDS: a review. Int J Inj Contr Saf Promot. 2008;15(4):221–31. Kouyoumdjian FG, Calzavara LM, Bondy SJ, O’Campo P, Serwadda D, Nalugoda F et al. Intimate partner violence is associated with incident HIV infection in women in Uganda. AIDS. 2013;27(8). Osinde MO, Kaye DK, Kakaire O. Intimate partner violence among women with HIV infection in rural Uganda: critical implications for policy and practice. BMC Womens Health. 2011;11(1):50. Freitas PSS, Soares GB, Mocelin HJS, Lamonato L, Sales CMM, Linde-Arias AR, et al. How do mothers feel? Life with children with congenital Zika syndrome. Int J Gynaecol Obstet. 2020;148(Suppl 2):20–8. Tetui M, Baroudi M, Ssekamatte T, Birabwa C, Kibira SP, Atuyambe L, et al. Total Demand, Use and Unmet Need for Modern Contraceptives Among Women Living in Informal Settlements in Kira Municipality, Wakiso District, Uganda. Implications for Urban Health. Volume 2. Frontiers in Global Women's Health; 2021. Janz T, Augsburg B, Gassmann F, Nimeh Z. Leaving no one behind: Urban poverty traps in Sub-Saharan Africa. World Dev. 2023;172:106388. Farré L, Fawaz Y, González L, Graves J. Gender Inequality in Paid and Unpaid Work During Covid-19 Times. Rev Income Wealth. 2022;68(2):323–47. Aksunger N, Vernot C, Littman R, Voors M, Meriggi NF, Abajobir A, et al. COVID-19 and mental health in 8 low- and middle-income countries: A prospective cohort study. PLoS Med. 2023;20(4):e1004081. Deitz RL, Hellerstein LH, St. George SM, Palazuelos D, Schimek TE. A qualitative study of social connectedness and its relationship to community health programs in rural Chiapas, Mexico. BMC Public Health. 2020;20(1):852. Kawachi I, Berkman LF. Social ties and mental health. J Urb Health. 2001;78(3):458–67. Roberts B, Odong VN, Browne J, Ocaka KF, Geissler W, Sondorp E. An exploration of social determinants of health amongst internally displaced persons in northern Uganda. Confl Health. 2009;3:10. Swahn MH, Nassaka J, Nabulya A, Palmier J, Vaught S. A Qualitative Assessment of Place and Mental Health: Perspectives of Young Women Ages 18–24 Living in the Urban Slums of Kampala, Uganda. Int J Environ Res Public Health. 2022;19(19). Wilkinson A, Ali H, Bedford J, Boonyabancha S, Connolly C, Conteh A, et al. Local response in health emergencies: key considerations for addressing the COVID-19 pandemic in informal urban settlements. Environ Urbanization. 2020;32(2):503–22. Brynne G, Rawlance N, Adalbert T, Vergil de C, Elizabeth M, Alpha AD, et al. Community engagement for COVID-19 prevention and control: a rapid evidence synthesis. BMJ Global Health. 2020;5(10):e003188. Nungsari M, Hui Yin C, Fong N, Pillai V. An agency mapping of marginalized communities and aid providers during the COVID-19 pandemic in Malaysia [version 2; peer review: 1 approved]. Wellcome Open Res. 2022;6(323). Wenham C, Smith J, Morgan R. COVID-19: the gendered impacts of the outbreak. Lancet. 2020;395(10227):846–8. Footnotes The Women RISE initiative supports action-oriented and gender-transformative research on how women's health and their work (paid or unpaid) intersect and interact in the context of preparedness, response and recovery from COVID-19 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4555351","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":315349416,"identity":"9aafcf32-6c07-4bb0-b14c-e15101076e4d","order_by":0,"name":"Moses Tetui","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0UlEQVRIiWNgGAWjYNACAxsoo4AY1WwMjA0MBmlAFjNIL9FaGA6ToEV3fvPxxzwF5xM3HD9/8HGFgY0cA/vhB3i1mB1jS2zmMbiduOFMMrPhGYM0YwaeNPx2mR3jMQRr2XYgmU2yweBwYoMEAeeZHeP/CNRyLnHb+cfsPyFa2D8QsoURqOVA4rYbyWyMEC08hGxJM5w5xyDZeP+Nx8ZAh6UZs/Hk4I8ds8OHH3x488dOdmZ/4sOPDRU2cvzsxzfg1YIJ2EhUPwpGwSgYBaMACwAA48FFLRg/nlAAAAAASUVORK5CYII=","orcid":"","institution":"University of Waterloo","correspondingAuthor":true,"prefix":"","firstName":"Moses","middleName":"","lastName":"Tetui","suffix":""},{"id":315349417,"identity":"10bc08a0-d984-4f62-9e09-c5dc7885cabb","order_by":1,"name":"Na-Mee Lee","email":"","orcid":"","institution":"University of Waterloo","correspondingAuthor":false,"prefix":"","firstName":"Na-Mee","middleName":"","lastName":"Lee","suffix":""},{"id":315349418,"identity":"1c91a9a2-56b2-48af-9f1f-5369d3f0559a","order_by":2,"name":"Laseen Alhafi","email":"","orcid":"","institution":"University of Waterloo","correspondingAuthor":false,"prefix":"","firstName":"Laseen","middleName":"","lastName":"Alhafi","suffix":""},{"id":315349419,"identity":"f764725b-690e-44cd-95ae-792f629395b0","order_by":3,"name":"Lesley A. 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Janes","email":"","orcid":"","institution":"University of Waterloo","correspondingAuthor":false,"prefix":"","firstName":"Craig","middleName":"R.","lastName":"Janes","suffix":""}],"badges":[],"createdAt":"2024-06-10 01:44:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4555351/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4555351/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":63502207,"identity":"c28f50a3-dc85-4fec-b2c6-b9b2cb83c081","added_by":"auto","created_at":"2024-08-29 00:34:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":426512,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4555351/v1/6478715b-e163-4b76-a930-c284ae78296f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Impact of COVID-19 Restrictions on the Health and Well-being of Women Living in Informal Settlements in Uganda.","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe first case of COVID-19 in Uganda was reported on March 21, 2020(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), and as of December 6, 2023, Uganda had reported 171,876 cases and 3,632 deaths(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Daily life was disrupted for many Ugandans, when public health restrictions, including a total lockdown during the early stages of the pandemic, were implemented on April 1, 2020, with imposition of a curfew, closure of schools and workplaces (except for those offering essential services), cessation of public transport, and restrictions on the use of private vehicles(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Although some easing of restrictions occurred a few months later, many were reimposed when the Delta variant emerged in 2021. Schools in Uganda remained closed for nearly two years(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Although the effects of the lockdown measures were far-reaching, residents of urban areas living in poverty were especially affected by these disruptions to daily life.\u003c/p\u003e \u003cp\u003eUrban residents living in poverty often reside in informal settlements characterized by unplanned and unregulated housing, high levels of overcrowding, and limited public infrastructure including roads, schools, and sewerage systems(\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Income levels are much lower in such settlements compared to the rest of the city, with most informal settlement residents living hand-to-mouth and in poor sanitary conditions(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). As a result, residents grapple with complex health and social issues, mainly due to inadequate access to basic resources such as clean water, adequate sanitation, and healthcare.\u003c/p\u003e \u003cp\u003eDuring the pandemic, lockdown related restrictions on mobility greatly affected the Ugandan economy, disrupting the market and production supply chains(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). These disruptions disproportionately affected the Ugandan population, with the most profound effects being on the informal sector, which employs many urban residents living in poverty, most of whom are women and youth(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Individuals reliant on the informal sector include casual laborers, hawkers, tailors, hairdressers, market stall operators, food vendors, urban refugees, and internal migrants, among others. It is estimated that about 23% of urban residents living in poverty lost virtually all of their daily income(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), exacerbating financial hardships as they had little or no savings(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). This loss was felt more greatly by women, who mainly relied on informal money-earning opportunities, earned only one-half of the nominal monthly income as compared to men, and had far fewer savings than men(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Further, the COVID-19 pandemic introduced an additional burden of unpaid work for women in the form of home schooling, additional childcare upon school closures, taking care of the sick, and ensuring extra precautions for hygiene and sanitation within the home(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis increased workload affected gender power relations in the home and in the community, as women experienced emotional and physical exhaustion as they attempted to keep up with new care demands(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). These changes, exacerbated by isolation, also increased the risk of gender-based violence and family abandonment(\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Given these challenges, many women were left particularly vulnerable and had to make difficult decisions about how to support themselves and their families, turning to various strategies including unprotected transactional sex(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Experiences of gender-based violence and participation in transactional sex activities are associated with higher risk of acquiring HIV and poor sexual and reproductive health outcomes(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). These risks are suggested to have increased during the pandemic when health services became more difficult to access(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Uganda, as in many other places, it has been noted that most COVID-19 interventions were top-down and did not consider local contexts, especially the burden that these measures placed on those living in informal urban settlements(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). who are the most vulnerable group with a low capacity to adapt financially when faced with stringent public health measures(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Additionally, a similar study among urban refugees living in Uganda revealed increased income insecurity, sexual and gender-based violence, and anxiety during the initial lockdown(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough it remains difficult to predict the full extent of the long-term socio-economic impacts of the COVID-19 measures on the health and well-being of communities in Uganda, it is important that policy actors consider the effects on the most vulnerable groups, including residents of urban informal settlements living in poverty(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Particular attention should be paid to the experiences of vulnerable women living in informal settlements(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study, a component of the WomenRISE initiative developed and funded by the Canadian International Development Research Centre\u003csup\u003e1\u003c/sup\u003e, explored the strategies that women living in large informal settlements in Kampala and Mbale used to meet basic needs at the individual and household levels amidst COVID-19 related restrictions, and the impact that these may have had on the determinants of health and well-being, including greater risks for HIV infection and transmission. This phase of the study was designed to develop an understanding of the lived experiences of women in these local contexts to co-develop inclusive strategies to address the most significant challenges and to prepare for future pandemics.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eFocus group discussions (FGDs) were conducted with women of different age groups in the four largest informal settlements in Kampala and Mbale. Twelve FGDs were conducted in each city (n\u0026thinsp;=\u0026thinsp;24 groups total), comprised of 144 women in Kampala and 138 women in Mbale. The focus groups were made up of women either unemployed or participating in the informal work and were divided by three broad age ranges in each city: 17\u0026ndash;24 years, 25\u0026ndash;49 years, and \u0026ge;\u0026thinsp;50 years.\u003c/p\u003e \u003cp\u003eDiscussion questions focused on women\u0026rsquo;s social, familial, and financial experiences during the pandemic, as well as their experiences and perceptions of and HIV-related risks and vulnerabilities. The FGDs were conducted in the predominant local languages (Luganda and Lugisu in Kampala and Mbale respectively) by research assistants from the Makerere University School of Public Health. Transcripts were translated into English and analyzed using QSR NVivo software, version 14.\u003c/p\u003e \u003cp\u003eThe FGD data were analyzed both deductively and inductively(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Codes related to pandemic consequences, coping strategies, and HIV were developed based on the research questions and further refined through an iterative coding process involving several researchers (MT, ML, CJ, LA, LJ). The coded transcripts were then analyzed inductively to develop themes that capture the stories and experiences of the women with whom we spoke.\u003c/p\u003e"},{"header":"Findings","content":"\u003cp\u003eThree inter-related themes illustrate the ways by which women living in informal settlements attempted to meet individual and household needs during restrictions associated with the COVID-19 pandemic, each representing a significant determinant of health and well-being. The first theme pertains to individual financial and behavioural strategies that women employed in response to the dire poverty and hunger they experienced. The second captures experiences of women turning to transactional sex or relationships to make money for food and survival. The third highlights strategies for survival as experienced through social networks and communities.\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eFinancial and behavioural strategies\u003c/h2\u003e \u003cp\u003eThis theme is comprised of financial and behavioural strategies employed by women to confront the challenges posed by COVID-19 lockdowns. Two sub-themes emerged: finding new work lockdowns and \u0026ldquo;hustling\u0026rdquo; for survival. Residents of informal settlements had been facing poverty and financial insecurity well before the COVID-19 pandemic. However, when the pandemic measures led to the loss of jobs and increased hunger, women experienced greater livelihood insecurity. Some of the strategies discussed included cutting expenses and learning to save money, rationing food, and changing eating habits or embracing alternative foods in the absence of daily staples.\u003c/p\u003e \u003cp\u003eBecause women are often the decision-makers regarding food and cooking in the home, these strategies had an impact on the entire family. For example, women reported purchasing only basic items when funds allowed, choosing cheaper foods than the family would normally consume, and preparing fewer and smaller meals in a day for themselves and their children. Women were also burdened with the task of finding means to care for their children and other sick family members. When medicines and health services became largely inaccessible and unaffordable due to financial difficulty and restricted transport, women turned to using home-made remedies to treat COVID-19 and other illnesses.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eFinding new work\u003c/h2\u003e \u003cp\u003eThe pressures of caregiving and feeding the family were heightened during the pandemic due to tensions between women and their male partners. Due to closure of workplaces and schools and travel restrictions, men in the informal settlements lost jobs running businesses, practicing trades, driving taxis or motorcycles, or working in schools. In households where men were the primary breadwinners, this effect was damaging to intrafamilial relationships, and tensions were high \u0026ndash;leading to sometimes violent quarreling. Many women reported having been abandoned by their husbands or partners who chose to escape mounting social and family pressures to provide financially. As a result, women were left alone with their children, unable to work owing to the lockdowns and curfews, and struggling to feed themselves and their children.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Families disintegrated and men ran away from their responsibilities. We women remained as the tree to hold the branches (children) that we produced.\u0026rdquo; (FGD 07)\u003c/em\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eMy husband came back but he sits at home and looks on. He is not working so I can't ask him for anything, so I consider myself as a single mother, I take care of my own children.\u0026rdquo; (FGD 10).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eGiven such circumstances, women had to redouble efforts to earn income and at the same time care for family members. Driven by the dire need to care for and feed their families, women turned to trading activities, such as vending food and produce and collecting and selling used plastic bottles to recycling companies, or domestic and janitorial jobs such as sweeping roads and government buildings floors and washing clothes or dishes for other homes and businesses. Some women started to work for the very first time during the lockdown, while others diversified their work and embraced previously shunned work and lower-paying jobs such as vending food or domestic janitorial jobs.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eCOVID found me washing clothes for money, but my husband did not like me washing clothes. He would say that this is for beggars. I would do it stealthily; I go and wash clothes when he is not around, and I would return home before he does. He would ask me whether I had been loitering around the village and I would tell him no, yet I had been washing clothes for people (FGD 09).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eHustling for survival\u003c/h2\u003e \u003cp\u003eIn searching for work, many women turned to proscribed means to make money or find food, circumventing stringent lockdown measures and engaging in illegal activities. For example, they operated and worked in bars, women\u0026rsquo;s salons, and restaurants despite strict and sometimes violent police surveillance of such establishments. In some circumstances, women reported having to bribe police and to hide prohibited activities. Additionally, when restrictions barred transport between cities, women had to negotiate with ambulance drivers or motorcycle riders to secretly carry them or their goods, such as food or supplies for their marketing activities.\u003c/p\u003e \u003cp\u003e\"\u003cem\u003eI had a bar, and some of my customers gave me some advice, saying \u0026ldquo;you have children now, if you close the business how will you survive?\u0026rdquo; So, they took me to the police officer in charge and we talked, so we would give him 40,000 per week so that our businesses could remain operating, so that they do not arrest us, but that was [during the first wave of the pandemic]. [During the second lockdown], it became very difficult, the policemen would disturb us so much. When they arrest you, you must pay money to get out and you also must pay for the customers they find in your bar.\u0026rdquo; (FGD 07)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;our parents in the village, they could not send food because of transport problems. I used an ambulance just to get food, we risked it. If [the police] could check, we could get arrested. That is how we survived\u0026rdquo; (FGD 03)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I had a house with both a rear and front door and I used to tell my customers to come in from behind and tell them not to shout. During that time, not even cats used to shout\u0026rdquo; (FGD 13)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eWomen who were unable to find paid work resorted to extreme measures to survive, such as picking food from garbage bins, consuming unsafe water, cooking grass for sustenance, foregoing meals, begging, and selling personal property. Some of these measures were emotionally draining, increasing vulnerability to mental health problems and propensity to engage in risky behaviours, such as alcohol abuse, unprotected sex, and transactional sex.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eTransactional sex\u003c/h2\u003e \u003cp\u003e Women described participating in transactional sexual activity to meet basic needs. This activity was done temporarily and out of desperation. In the prolonged absence of income, with few other options for survival, and amidst growing mental distress, many women \u0026ndash; especially younger women \u0026ndash; turned to transactional relationships with men to support themselves and their families. In such circumstances, women described feeling a sense of helplessness, being unable to provide for themselves otherwise, or their distress at watching their daughters turn to such measures.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;There were some women who were not working; the spouse also has nothing to offer; the children are crying, so as she is moving, she finds another man, say John, who asks her how life is; she explains that the situation is bad; he gives her 5000 shillings (USD1.4); and then the next time he calls her, still the situation is bad; he tells her to meet him somewhere, and she ends up going with him\u0026rdquo; (FGD 22)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;You could not look on as your child is dying of hunger, so we resorted to \u0026ldquo;detoothing\u0026rdquo; (conning men out of money). We were chased from everywhere that we went to. You find your girl child with a man so old they are suited to be dating you, the mother, and you feel a lot of pity in your heart. Sometimes with a man you have even dated before and now they are wooing your child. You both know you are sick (HIV), and he goes to your child, and you feel very bad at heart. It was a really a hard time indeed\u0026rdquo; (FGD 03)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eParticipating in such sexual activities for survival posed a high risk for HIV and unwanted pregnancies. Women who turned to transactional sex did so out of immediate and urgent need to make money to feed their families and had little bargaining power in transactional relationships. As men had the power to refuse one woman to seek another, women felt as though they could not advocate for safer sex practices, such as inquiring about HIV status and using condoms. Unintended pregnancies were reported to be commonplace, leaving women in a cycle of poverty and financial difficulty when men did not take responsibility for the pregnancies or provide support for the child.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Because of COVID, I did a job that I did not expect to do, and yet it was the riskiest. Those who would come with a lot of money did not want to use protection, and even if you want to use protection, the money will attract you because he will tell you, \u0026lsquo;I have 50,000 shillings (USD13.5) but I don\u0026rsquo;t want protection,\u0026rsquo; so you accept.\u0026rdquo; (FGD 08)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Me, I will never forget the moment I lost my job, and I did not have food so in order to survive I got a man who impregnated me and then he ran away. Up to now, I don\u0026rsquo;t know where he is\u0026rdquo; (FGD 08)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eConversely, some women sought, or were pressured to enter, more traditional or long-term relationships to better their financial circumstances. For example, some women married during the pandemic as an explicit financial strategy, while others were involved in extra-marital affairs or polygamous arrangements. However, such relationships were not always helpful, as women in these situations also experienced partner abandonment and other financial challenges within their relationships.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I decided to get married to a man who cooks chapati because then there is food\u0026rdquo; (FGD 23)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSurvival strategies through social networks and communities\u003c/h2\u003e \u003cp\u003eTwo general kinds of social or community-level support were discussed: social networks and organized support. Social networks included personal relations such as friends, immediate and extended family, neighbors, and community members. Organized support came through formal organizations such as women\u0026rsquo;s savings groups, political leaders, employers, NGOs, churches, and government, which provided space for not only networking but also material and mental support.\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eSocial networks\u003c/h2\u003e \u003cp\u003eWomen recounted turning to family members, friends, neighbours, and church groups to socialize and counsel one another. Being in the company of others was crucial for some women who found strength and stress relief through conversation, games, and communal worship. As a result of relying on such social supports and sharing the experience of difficulty during the pandemic, some women experienced a strengthening of friendship and family relationships.\u003c/p\u003e \u003cp\u003eThese social networks were also a source of practical support. Sharing of food rations or helping with childcare were common, as was finding opportunities for work through social connections. While friends, neighbours, and church communities were often mentioned as helpful, immediate, and extended family members were the most identified source of social support. Residents of both Kampala and Mbale described receiving money and food from family members during times of desperation and hunger.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I had a neighbor whose situation was not as bad as mine because she used to help me. She was there for me, took care of my child\u0026rdquo; (FGD 03)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;In the village, [my family] would try and find means to send me cassava and bananas (Bogoya), so when the bananas would ripen, I would sell them, and the little money I would get was what I would use to buy posho (cornmeal)\u0026rdquo; (FGD 08)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eOther women sent their children to rural areas to stay with immediate or extended family to lessen the burden on themselves. As above, this was done by circumventing lockdown measures, allowing connection between family members and communities in cities and the countryside despite travel restrictions and curfews.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;When Covid came, I couldn\u0026rsquo;t afford rent, so I first sent the children to the village, and I remained with my husband. I could go to town and hustle whatever little I would get, and we would buy some food and send some money to the children in the village\u0026rdquo; (FGD 24)\u003c/em\u003e \u003c/p\u003e \u003cp\u003ePsychosocial support was especially important during these periods of severe mental distress. Some women spoke of finding reprieve from feelings of hopelessness or thoughts of suicide through friends\u0026rsquo; counsel, or of providing the same support to others in similar situations. However, for those who experienced such mental health crises and hopelessness, finding company in friends or family was not a panacea.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;My marriage had come to an end; my family was broken, and I was by myself with two children. I was stranded and hopeless and said to myself, \u0026ldquo;let me just die.\u0026rdquo; My mother found me (trying to take my life) and she talked me out of it saying that this was not the end. My mother was very prayerful so she would take me to church, but later, even the churches were closed, and we were ordered to pray from our own houses. My mother kept encouraging me. Covid greatly affected me, and I have never recovered to date\u0026rdquo; (FGD 24)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAlcohol was consumed as a home remedy for illnesses and protection against COVID-19.\u003c/p\u003e \u003cp\u003e \u003cem\u003eThey told us that when you take alcohol, you don\u0026rsquo;t get COVID, so I started taking alcohol because we were near a hospital and we would see people dying of COVID, so I resorted to taking waragi (alcohol) so that I don\u0026rsquo;t die. It also helped me manage stress because even just inhaling it you would fall asleep and wake up when the stress has decreased. My head would spin, and I forget that there is even COVID\u0026rdquo; (FGD 20)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSome women turned to alcohol and drug use under the stress of lockdowns. While for some, substance use was a new activity, for others, the lockdown restrictions increased existing use The intertwining challenges of substance use, mental health issues, and heightened vulnerability to HIV created by a lack of basic needs comprised a complex social landscape, especially for younger women.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I was a drunkard, and my friends were also drunkards, we would leave home to go, and we drink, got more friends to join us, because we had no food, we would get too drunk, and the men would take us to their rooms\u0026rdquo; (FGD 13)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eOrganized support\u003c/h2\u003e \u003cp\u003eSome families in Kampala and Mbale received assistance from formal organizations such as government, churches, and non-governmental organizations, mostly in the form of food relief distributions. Churches donated and distributed cornmeal (\u003cem\u003eposho\u003c/em\u003e) and beans to supplement the Ugandan government\u0026rsquo;s relief efforts. In some cases, churches also provided financial assistance for some community members requiring aid. Other non-religious, non-governmental organizations were also present in some communities providing food, monetary aid, mental health support, or health services, though this type of assistance was not commonly available to our focus group participants.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;There was a church near us that would give us posho (cornmeal) and some money. The landlord would also buy proteins for us. My spouse also needed treatment because he was discharged before full recovery. The church people really helped with that\u0026rdquo; (FGD 10)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSimilarly, political leaders and some employers supported women during the lockdown periods to overcome some of the challenges they were faced with including providing basics such as food. Political leaders also mediated between landlords and tenants to provide longer grace periods for payment of rent in arrears. In some cases, support came from employers providing short term assistance to their employees.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;One morning the landlord removed the roof of the house as we had been unable to pay the rent. I cried that day and ran to my sister, I explained everything to her, and she promised to help talk to the chairperson which she did and the two went and talked to my landlord, he cooled, and the house was roofed again by God\u0026rsquo;s grace\u0026rdquo; (FGD 01)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;After some time, a MP (Member of Parliament) came and gave us maize flour and I took it home\u0026rdquo; (FGD 03)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eHowever, this organized support was not sufficient and, in some cases, lacking in terms of quality of food or basics provided to households. For example, some women reported that the beans and posho (corn meal) they received from the government were of poor quality and made their situation only worse. This was illustrated in situations where the poor-quality beans needed more scarce and costly cooking fuel to prepare a basic meal.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The food that government gave us, it was maize brand (low grade cornmeal), and the beans were rotten, and they don\u0026rsquo;t get ready (cooked). We almost died of hunger and yet we had children\u0026rdquo; (FGD 01)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eWomen also organized themselves into informal savings groups. The groups acted as an avenue for socializing and relieving stress as well as a means of financial saving by which women pooled resources to meet immediate basic needs. These savings groups were both formal and informal. While some organized themselves into formalized Savings and Credit Cooperative Organizations (require legal registration and are often considered more secure by its members given the formal recognition and clear pathways for resolving conflicts that may arise) savings groups, others pooled resources with friends and neighbours to meet basic needs.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study portrays the challenges faced by women in urban informal settlements in Uganda during COVID-19 lockdown and illustrates the consequent risks to health and well-being. Although many of the challenges resulted in serious livelihood insecurity and related challenges to health, it is also clear from our participants that they were often able to call on personal and social resources to manage difficult situations. As such, the results of the study reflect broader discourses on women's strength in navigating economic hardships and societal expectations, particularly as traditional gender roles collide with the realities of a global crisis increasing the burden of their care work(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Despite significant adversity, women engaged in trading activities, entered the workforce, and embraced new roles to support themselves and their families, albeit in the informal sector in which job precarity, unequal pay, and poor working conditions often reinforce the cycle of poverty among women and expose them to serious health risks and gender-based violence (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). The portrayal of women\u0026rsquo;s lived experiences of Covid-era public health interventions in this study adds depth to discussions on gender inequality, emphasizing the importance of understanding how gender shapes women's experiences during times of crisis.\u003c/p\u003e \u003cp\u003eThe experiences of the women in our study reveal the emotional and physical toll of extreme survival measures, identifying their vulnerabilities to mental health crises and behaviors that place their health at greater risk. These findings are consistent with studies from other low- and middle-income countries, particularly in informal settlements, that report the disproportionate impacts of the pandemic among women in relation to food insecurity, household violence, and access to sexual and reproductive health services(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). In our context, we found that many women experienced abandonment by men (partners), which increased the burden of work and compounded the toll of economic hardships on women\u0026rsquo;s mental and physical well-being.\u003c/p\u003e \u003cp\u003eSome women, grappling with severe financial difficulties and food insecurity, turned to short-term sexual survival strategies(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Long before the pandemic, several studies have highlighted the complex and intersectional relationship between socioeconomic status and sexual health outcomes, including HIV and unwanted pregnancies, within informal settlements in Uganda and other sub-Saharan African countries(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan additionalcitationids=\"CR34\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Engagement in transactional sex and longer-term relationships for economic support illuminates the compromises impoverished women must make, even as it places them at heightened risk of HIV infection. Our findings are in line with other studies that have found that the heightened stress of poverty during the pandemic, combined with a decline access to essential health services and medicines, likely increased the risk of HIV infection or otherwise worsened the health of those already affected(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). This combination of factors has significant consequences for a population with a large burden of HIV and higher rates among women(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Similarly, the current study underscores the vulnerability of women in these transactional relationships, shedding light on unequal power dynamics and compromised ability to negotiate safer sex practices(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). This finding is consistent with literature on gender-based violence that indicates that exploitation within intimate relationships further undermines women\u0026rsquo;s ability to remain healthy in adverse conditions(\u003cspan additionalcitationids=\"CR40\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCOVID-19 restrictions placed households at significant financial and psychological risk, compromising quality of life in low-income households. These conditions can trigger gender-based violence by exacerbating underlying tensions. Studies have shown that the rate of intimate partner violence increased during the COVID-19 pandemic, both in Uganda and other contexts, due to a myriad of factors such as stress from job loss, social isolation, increased time with partners during the lockdown, and broader social and economic instability(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Furthermore, the erosion of social norms and stay-at-home orders may have challenged ideals of masculinity and power within homes and relationships, leading men to resort to violence(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Our results support these findings, whereby women\u0026rsquo;s decision-making power and authority were further compromised by their precarious living situation.\u003c/p\u003e \u003cp\u003eWomen\u0026rsquo;s homelives are made more precarious by the threat of family abandonment. The loss of the primary breadwinner can have a devastating effect on households. Freitas et al. reported similar scenarios during the 2015 Zika outbreak in Brazil(\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Mothers whose children were infected by the Zika virus experienced social and gender inequality and poverty, marital infidelity, violence, and abandonment. In our study, restrictions associated with the COVID-19 pandemic threw women into similar positions. Women had to make difficult decisions about how to care for their families, such as transactional sex as discussed previously. The unintended pregnancies and the ensuing challenges faced by women align with broader discussions in the literature concerning reproductive autonomy and the societal implications of limited access to family planning resources, especially in informal settlements(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). In this way, transactional sex serves as a lens through which to examine the complex interplay of gender, poverty, and power dynamics, contributing to the ongoing dialogue on the challenges faced by marginalized women during times of crisis.\u003c/p\u003e \u003cp\u003eThe study emphasises the multifaceted challenges faced by women in informal settlements in Uganda during the COVID-19 pandemic. Economic precarity was a central theme, resonating with existing literature on urban poverty in informal settlements(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Women engaged in precarious work in informal sectors encounter exacerbated hardships, reflecting broader discussions on the vulnerability of women in informal economies not just in Uganda but in most low-and-middle-income countries(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Such vulnerabilities are only made worse in pandemic situations in which women are required to bear the burden of increased child and general household care(\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e), thereby exposing them to worsening mental health conditions and susceptibility to unsafe means of survival(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOgando, Rogan and Moussie describe how, in some low- and middle-income countries, women\u0026rsquo;s share of the care work can be as much as 75 to 90% higher than men\u0026rsquo;s and that the COVID-19 crisis has intensified this inequality(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Women\u0026rsquo;s vulnerability during the pandemic has increased their vulnerability to the worsening of the gender burden(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Power relations were altered as women lost their income earning opportunities. Even as our research finds that some women were able to establish new forms of securing an income, their unpaid reproductive and community responsibilities increased. From the shock of school closures and increased childcare responsibilities, to heightened hygiene and sanitation precautions, to growing commitments to the community, these care work expectations compromise women\u0026rsquo;s physical and mental health, while also entrenching gender imbalance within the household. As a result, women are placed at greater risk of gender-based violence and family abandonment.\u003c/p\u003e \u003cp\u003eConversely, in the face of such hardships, the significance of social connections and psychosocial support networks emerges as a crucial aspect of women's strategies of survival. This finding aligns with literature emphasizing the importance of community ties for mental well-being in the context of informal settlements(\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). Researchers have previously explored the interconnectedness of social relationships and mental health among Ugandan women, especially during times of crisis(\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). Social networks and capital play a crucial part in sustaining women especially in situations of adversity and underdeveloped mental health services(\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). Additionally, the role of institutions in providing relief mirrors research on the complexities of assistance programs in informal settlements(\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). While institutional support was present, our study underscored the limitations and challenges of such aid efforts, highlighting the importance of tailoring aid to the needs of the population(\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). Broader structural change is needed to provide social welfare support for these communities beyond the pandemic context(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). At the same time, smaller scale adjustments that recognized and adjusted to the burden of school closures, the lockdown measures, and the free reign given to the police to enforce these measures may have also supported marginalized groups.\u003c/p\u003e \u003cp\u003ePlans to address future challenges akin to the COVID-19 pandemic must recognize the precarity of those living hand-to-mouth. Interventions must be inclusive, tailored, and responsive to the needs of marginalized communities. Women, who lose decision-making power and whose voices and priorities are ignored during times of adversity, need to be included in the formulation of these plans and interventions to ensure that they do not suffer a repeat situation of their experiences during COVID-19 in which their physical and mental health was compromised(\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe study identified challenges faced by women in Uganda's informal settlements amid the COVID-19 pandemic. It underscores the intricate interplay of economic struggles, strength, and vulnerability, contributing to the literature on gender roles and crises. Despite economic hardships, women displayed resourcefulness in trading activities and adapting to new roles. However, the reality of transactional sex as a survival strategy was also identified. This strategy exposes unequal power dynamics and contributes to unintended pregnancies, gender-based violence, and vulnerability to HIV infection. Additionally, transactional sex emphasizes urban poverty and the exacerbated hardships faced by women engaged in precarious work within informal sectors. The significance of social connections and psychosocial support networks emerges as crucial for women\u0026rsquo;s survival, highlighting the importance of community ties for mental well-being. While acknowledging institutional support, the study underscores its limitations. Overall, the research deepens our understanding of the multifaceted experiences of women in Uganda\u0026rsquo;s informal settlements during the pandemic, encompassing economic challenges, resilience, and the dynamics of community and institutional aid.\u003c/p\u003e \u003cp\u003eThe study\u0026rsquo;s findings point to several ways to address the challenges faced by women in Uganda\u0026rsquo;s informal settlements during crises. Initiatives focusing on economic empowerment, such as skills training and entrepreneurship programs, can alleviate the economic vulnerability of women engaged in precarious work. Strengthening access to reproductive health services and implementing community-based health programs are crucial to addressing unintended pregnancies and heightened vulnerability to HIV infection resulting from transactional sex. Securing access to education for lower-income girls can create a protective shield against teenage pregnancies and increase chances for a better livelihood. Psychosocial support services tailored to the unique needs of women in informal settlements, along with community building and social networks, can provide essential emotional and mutual support. Advocating for policy changes, refining institutional aid strategies, and promoting further research on women's experiences during crises are integral components for a comprehensive approach to improving the well-being of these women. Important to note is the need to ensure that these changes are grounded in local realities by approaching them through a collaborative co-design approach that centers and reflects community needs and aspirations. By implementing these recommendations, stakeholders can foster resilience and mitigate the multifaceted challenges faced by women not only in Uganda's informal settlements but in similar settings in other low and middle-income countries.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained at three institutions. Makerere University School of Public Health (SPH-2022-323), University of Waterloo (44725) and Uganda National council of science and Technology (HS2458ES). All participants provided written informed consent prior to participating.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe qualitative transcripts used during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study was funded by IDRC (Grant No. 110028-002) awarded to Makerere University, Uganda and the University of Waterloo, Canada.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors\u0026apos; contributions\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMT led the conceptualization and drafting of the manuscript. MT, ML and LAA led the data analysis process, all the other authors iteratively reviewed the coding process and contributed to the overall framing of the findings. SB provided oversight to the data collection process while Kawooya led the data collection. CRJ and SB provided the overall technical guidance to the conceptualization and framing of the manuscript. All authors reviewed drafts of the manuscript, were involved in the iterative data analysis process, provided substantial input, and agreed to the contents of the submitted manuscripts. They approved the submitted version of the manuscript. And \u0026nbsp;have agreed both to be personally accountable for the author\u0026apos;s own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgement\u003c/em\u003es\u003c/p\u003e\n\u003cp\u003eWe would like to all our study participants and project partners including Makerere University, University of Waterloo, Afri-Slum Uganda, and Uganda AIDS commission, Kampala City Council Authority and Mbale City Council.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eUganda MoH. Uganda confirms 1st case of COVID-19. 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Rev Income Wealth. 2022;68(2):323\u0026ndash;47.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAksunger N, Vernot C, Littman R, Voors M, Meriggi NF, Abajobir A, et al. COVID-19 and mental health in 8 low- and middle-income countries: A prospective cohort study. PLoS Med. 2023;20(4):e1004081.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDeitz RL, Hellerstein LH, St. George SM, Palazuelos D, Schimek TE. A qualitative study of social connectedness and its relationship to community health programs in rural Chiapas, Mexico. BMC Public Health. 2020;20(1):852.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKawachi I, Berkman LF. Social ties and mental health. J Urb Health. 2001;78(3):458\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoberts B, Odong VN, Browne J, Ocaka KF, Geissler W, Sondorp E. An exploration of social determinants of health amongst internally displaced persons in northern Uganda. Confl Health. 2009;3:10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSwahn MH, Nassaka J, Nabulya A, Palmier J, Vaught S. A Qualitative Assessment of Place and Mental Health: Perspectives of Young Women Ages 18\u0026ndash;24 Living in the Urban Slums of Kampala, Uganda. Int J Environ Res Public Health. 2022;19(19).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilkinson A, Ali H, Bedford J, Boonyabancha S, Connolly C, Conteh A, et al. Local response in health emergencies: key considerations for addressing the COVID-19 pandemic in informal urban settlements. Environ Urbanization. 2020;32(2):503\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrynne G, Rawlance N, Adalbert T, Vergil de C, Elizabeth M, Alpha AD, et al. Community engagement for COVID-19 prevention and control: a rapid evidence synthesis. BMJ Global Health. 2020;5(10):e003188.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNungsari M, Hui Yin C, Fong N, Pillai V. An agency mapping of marginalized communities and aid providers during the COVID-19 pandemic in Malaysia [version 2; peer review: 1 approved]. Wellcome Open Res. 2022;6(323).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWenham C, Smith J, Morgan R. COVID-19: the gendered impacts of the outbreak. Lancet. 2020;395(10227):846\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e The Women RISE initiative supports action-oriented and gender-transformative research on how women's health and their work (paid or unpaid) intersect and interact in the context of preparedness, response and recovery from COVID-19\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Survival strategies, COVID-19, HIV vulnerability, Informal settlements, Women, Kampala City, Mbale City, Uganda","lastPublishedDoi":"10.21203/rs.3.rs-4555351/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4555351/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eThe COVID-19 pandemic significantly impacted Uganda, with the first case reported in March 2020, resulting in extensive public health restrictions, including a lockdown, curfew, and closure of schools and workplaces. Urban residents, particularly those living in poverty in informal settlements, faced heightened challenges due to inadequate access to basic services, financial hardships, and increased caregiving responsibilities, especially for women. Women faced heightened risks of gender-based violence and engaged in transactional sex as coping mechanisms. This study explored the strategies used by women in Kampala and Mbale cities to meet basic needs during the pandemic and their implications for HIV infection vulnerability.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eResearchers conducted in-depth discussions with 282 women from various age groups in Kampala and Mbale's largest informal settlements, gathering insights into their pandemic experiences. These discussions, held in local languages, explored women's social, family, and financial challenges, as well as their perceptions of HIV risks. Transcripts were translated by local language experts before analysis. The team analyzed the transcripts using NVivo version 14 software, identifying patterns and themes that revealed survival strategies employed by women.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eThe study identified three interconnected themes that capture the complex strategies and challenges faced by women in informal settlements in Kampala and Mbale during the COVID-19 pandemic. Women struggled to cope with financial hardships and increased caregiving responsibilities, often resorting to desperate measures like transactional sex to survive, despite their resilience. The pandemic exacerbated vulnerabilities, heightening risks of HIV transmission and mental health issues, particularly among women living in poverty. While support networks provided some relief, they often fell short of meeting the diverse needs of women in these communities.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e \u003cp\u003eThe study shows that women in Uganda's informal settlements demonstrated resilience by taking on new roles and engaging in trading, but their reliance on transactional sex revealed stark power imbalances, increasing their vulnerability to gender-based violence, unintended pregnancies, and HIV infection. This highlights the urgent need for targeted interventions that address the complex challenges women face in crisis situations, which could enhance their resilience and alleviate their multiple struggles, with valuable lessons for similar contexts in low- and middle-income countries.\u003c/p\u003e","manuscriptTitle":"The Impact of COVID-19 Restrictions on the Health and Well-being of Women Living in Informal Settlements in Uganda.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-27 08:41:00","doi":"10.21203/rs.3.rs-4555351/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a7b50af5-008f-4182-a21e-0307726b597f","owner":[],"postedDate":"June 27th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-29T00:26:00+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-27 08:41:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4555351","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4555351","identity":"rs-4555351","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}