Community Resilience to Cholera Epidemics in Uganda: A Realist-informed review of Vulnerability and Intervention mechanisms.

Keywords Cholera, Community Resilience, Uganda, Realist-Informed Review ALL Metrics - Views Downloads How to cite this article Namakula J, Aryaija-Karemani A, Sseviiri H et al. Community Resilience to Cholera Epidemics in Uganda: A Realist-informed review of Vulnerability and Intervention mechanisms. [version 1; peer review: 1 approved]. NIHR Open Res 2025, 5:79 (https://doi.org/10.3310/nihropenres.13983.1) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente Select a format first ▬ ✚ Review [version 1; peer review: 1 approved] Justine Namakula https://orcid.org/0000-0002-6784-2996 1, Adelaine Aryaija-Karemani1, Hakimu Sseviiri https://orcid.org/0000-0001-6896-7056 2, [...] Revocatus Twinomuhangi https://orcid.org/0000-0001-5906-2626 2, PARES consortium3, Susannah Mayhew https://orcid.org/0000-0002-2433-3809 3, Freddie Ssengooba1Justine Namakula https://orcid.org/0000-0002-6784-2996 1, Adelaine Aryaija-Karemani1, [...] Hakimu Sseviiri https://orcid.org/0000-0001-6896-7056 2, Revocatus Twinomuhangi https://orcid.org/0000-0001-5906-2626 2, PARES consortium3, Susannah Mayhew https://orcid.org/0000-0002-2433-3809 3, Freddie Ssengooba1 PUBLISHED 15 Sep 2025 Author details Author details 1 Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda, 7072, Uganda 2 Department of Geography, Geoinformatics and Climatic Sciences, Makerere University College of Agricultural and Environmental Sciences, Kampala, Central Region, 7072, Uganda 3 Department of Global Health and Development, London School Hygiene and Tropical Medicine, London, WC1H 9SH, UK 2 Department of Geography, Geoinformatics and Climatic Sciences, Makerere University College of Agricultural and Environmental Sciences, Kampala, Central Region, 7072, Uganda 3 Department of Global Health and Development, London School Hygiene and Tropical Medicine, London, WC1H 9SH, UK Justine Namakula Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Adelaine Aryaija-Karemani Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Hakimu Sseviiri Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Validation, Writing – Review & Editing Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Validation, Writing – Review & Editing Revocatus Twinomuhangi Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Supervision, Validation, Writing – Review & Editing Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Supervision, Validation, Writing – Review & Editing PARES consortium Roles: Conceptualization, Funding Acquisition, Methodology, Validation Roles: Conceptualization, Funding Acquisition, Methodology, Validation Susannah Mayhew Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Validation, Writing – Review & Editing Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Validation, Writing – Review & Editing Freddie Ssengooba Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW REVIEWER STATUS Uganda experiences recurring cholera epidemics. Current interventions prioritize strengthening health systems, neglecting community resilience. This paper explored pathways to enhancing community resilience against cholera. We utilized a realist-informed review approach, employing the conceptual framework of Pawson and Tilley (1997) for data extraction, synthesis, and presentation and Blanchet et al. 2017’s theoretical framework to interpret Mechanisms and Outcome patterns necessary for community resilience. Data sources included peer-reviewed and other literature about Non-Governmental Organizations (NGOs) and government interventions. Current literature on cholera focuses heavily on aspects like community vulnerability, outbreak surveillance, and response strategies and less on broader concepts of community resilience. Kinship resilience literature helped fill the gaps around valuable perspectives on how communities navigate and bounce back from cholera outbreaks. Contextual vulnerability factors include weak detection systems, limited community health worker capacity, and sub-optimal Water, Sanitation, and Hygiene(WASH) practices and inadequate WASH infrastructure within refugee, fishing, and slum communities. Upstream water sources contamination impacts the spread of cholera to downstream areas, while cross-border movement of infected individuals worsens its transmission and spread. Preventive resilience mechanisms involve health system interventions focused on capacity building, WASH programs, community engagement and WASH infrastructures establishment crucially bolster community resilience. Community knowledge acquired through training or experiential learnings in managing cholera, alongside social cohesion reduce vulnerability. While most mechanisms focus on building absorptive resilience capacities, it is not clear how these mechanisms lead to intermediate health outcomes and broader resilience capabilities like adaptation and transformation. Realist evaluations provide deeper understanding of how interventions guide effective cholera prevention strategies, leading to resilience. However, further research about community-led actions and external interventions that effectively build resilience is needed. Integrated approaches combining health system strengthening with community-based interventions need to be prioritized, while enhancing social capital, and supporting adaptive and transformative mechanisms for resilience. Cholera is a dangerous disease that spreads easily in areas with poor sanitation and unsafe drinking water. In Uganda, many communities, especially those in fishing areas, refugee settlements, and flood-prone regions, face frequent cholera outbreaks. This study examined how these communities respond to cholera and what can help them become more resilient over time. The research team reviewed over 100 published and unpublished documents, using a method called “realist review” to understand which actions work, in what settings, and why. They also applied a resilience framework that examines how communities absorb shocks, adapt to challenges, and transform to prevent future outbreaks. The findings indicate that most cholera interventions emphasize emergency health responses, such as treating cases and enhancing surveillance. However, these actions alone are insufficient to foster long-term resilience. The study found that cholera continues to flourish in areas with overcrowding, inadequate hygiene practices, and limited infrastructure for clean water and sanitation facilities. Communities also face difficulties when there is a scarcity of trained health workers and ineffective disease detection systems. Despite these challenges, some communities have found ways to cope and recover. These methods include drawing on past experiences with cholera, collaborating closely with community health workers, and sharing knowledge through local networks. Community engagement, trust, and collaboration, what the study calls social capital, play a crucial role in strengthening resilience. The study concludes that more attention should be given to community-led solutions alongside national health efforts. Programs that combine clean water and hygiene improvements with local leadership and education tend to be more effective. The authors recommend further research to understand how these efforts can be scaled up and sustained. Ultimately, making communities stronger requires not just health interventions, but also meaningful involvement of the people most affected. Cholera, Community Resilience, Uganda, Realist-Informed Review Corresponding Author(s) Justine Namakula ([email protected]) Grant information: This project is funded by the National Institute for Health Research (NIHR) under its [‘Research for Patient Benefit (RfPB) Programme’ (Grant Reference Number PB-PG- NIHR 133333)]. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2025 Namakula J et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Namakula J, Aryaija-Karemani A, Sseviiri H et al. Community Resilience to Cholera Epidemics in Uganda: A Realist-informed review of Vulnerability and Intervention mechanisms. [version 1; peer review: 1 approved]. NIHR Open Res 2025, 5:79 (https://doi.org/10.3310/nihropenres.13983.1) First published: 15 Sep 2025, 5:79 (https://doi.org/10.3310/nihropenres.13983.1) Latest published: 15 Sep 2025, 5:79 (https://doi.org/10.3310/nihropenres.13983.1) The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Cholera epidemics continue to stress health systems worldwide, with sub-Saharan Africa and Mediterranean regions contributing to the highest number of endemic countries by the end of 20221,2. The global burden of Cholera is estimated at 2.9 million cases, and 95,000 deaths occur annually1,2. In 2010, the World Health Organization ranked Uganda among the 11 countries in the African region with recurring cholera epidemics for the period 2004–2008. From the year 2011 to 2015, Uganda registered 9,954 cholera cases. The highest number of cases was recorded during the 2012 outbreak accounting for 6,226 cases with 135 deaths3. At the global level, a strategy to eliminate cholera by 2030 with a target to reduce cholera deaths by 90% was launched in 2017. The Global Task Force for Cholera Control (GTFCC) plans to focus on 20 countries including Uganda for its elimination target. The priority strategies for phasing out cholera epidemics include; early detection and response, prevention especially in cholera outbreak hotspots, increased coverage of cholera vaccine and global support with technical and financial resources4. In Uganda the National Integrated and comprehensive Cholera prevention and control plan5 has been developed in line with the GTFCC guidance. Operational plans and tools to monitor progress show a mixed picture. For instance, the cholera score card development by Uganda’s Ministry of Health reported a 50% reduction in the cholera endemic districts - from 38 to 18 districts. Cholera elimination – (4-year absence) was reported in 72% of districts (out of 146) for the period 2015 to 2021 while cholera recurrence was reported in 42 districts for the same period6. Although oral cholera vaccine (OCV) was expected to play a major role in the national elimination plan, its coverage was only 10% (16 districts) for the period 2015 to 2023 and restricted to the districts categorised as hotspots for cholera. In terms of human toll, 8,500 cholera cases were reported for the period 2015 to 2021, with a mortality rate of about 5%. The number of outbreaks has averaged 9 per year with 28 outbreaks reported in 2016 alone6. Every health outbreak presents a shock to the affected communities as well as the local health systems. The COVID-19 pandemic magnified the major vulnerabilities presented by disease shocks to the health of communities and the systems that deliver health care. The focus on communities and their capabilities for withstanding these shocks has catalysed the quest for community resilience and its mechanisms across all social systems7,8. Mayhew et al. [2021] for example has identified major gaps in how the capabilities of communities are leveraged in dealing with health and environmental shocks9. Evidence shows that the top-down efforts rooted in the medical models to control the Ebola epidemic in West Africa did not achieve effectiveness until the community views where integrated into the response9. Similar findings have been reported for COVID-19, Ebola and Yaws outbreaks7. As countries around the globe seek to achieve sustainable development, the question of how to mainstream resilience to environmental shocks and disease outbreaks like cholera becomes pertinent. While the global health security aims to build strong and resilient public health systems that can prevent, detect, and respond to infectious disease threats, wherever they occur in the world, attention to building community resilience to these threats has been limited. Community resilience is in this context defined as the capability to anticipate risk, limit impact, and bounce back rapidly through survival, adaptability, evolution, and growth in the face of turbulent change or crisis8,10,11. This paper employs a realist evaluation conceptual framework by Pawson and Tilley (1997). The framework applies four main linked concepts for explaining and understanding programs or interventions: “Context”, “Mechanism”, “Outcome pattern” and “context- mechanism-outcome pattern configurations”. The concepts enable us to explain and understand what interventions work, for which communities, in what circumstances/respects and why12. According to Pawson and Tilley [1997], “Context” describe the features of the conditions in which programs are introduced, that are relevant to the operation of the program mechanism. “Mechanisms” describe what it is about programs or interventions that can bring about any effect12,13. “Outcome patterns” comprise the intended and unintended consequences of programs or interventions resulting from the activation of the different mechanisms in different contexts. Lastly, “context-mechanism-outcome pattern configurations” describe how different components of a program need to be harmonised to bring about alterations in behavioural/ event/ state regularities in different contexts12. This paper focuses on cholera outbreaks in Uganda, the different contexts in which cholera emerges, various cholera related interventions and their intended or unintended effects thereof. Communities where cholera is recurrent are exposed to repetitive effects arising from outbreaks. International efforts have recently targeted cholera elimination through deployment of the cholera vaccine14 but the recurrency of outbreaks has remained high especially among communities that have received the vaccination6. How these communities cope with the shocks and the extent resilience is developed is the subject of national health security and a public health concern. Furthermore, we utilise a broader theoretical framework by Blanchet et al. [2017] to help us interpret Outcome patterns that lead to broader resilience of communities15. Blanchet et al. [2017] draw attention to four community level capabilities/ mechanisms that drive community resilience to shocks. These include mechanisms that; 1) generate knowledge capacity – combine and integrate different knowledge systems; 2) generate capacity for interdependency – handle multiple and dynamic engagements; 3) build legitimacy – capacity to develop socially acceptable norms and institutions; and 4) deal with uncertainty – capacity to anticipate and cope with unplanned events. These concepts are applied to the literature on cholera outbreak management and control in Uganda. Blanchet et al. [2017] conclude that the mentioned capabilities or mechanisms can lead to three main categories of resilience to shocks – absorptive, adaptive, and transformative capacities. In this paper, we seek to answer the question- how do we build resilience to cholera outbreaks among local communities in Uganda? To answer this question, we undertook a realist-informed review of literature. This section details the methodology of the review. This was a review article where the main source of data was secondary documents, patients and the public were not involved in any way. Electronic searches were done across three electronic databases (PubMed, EBSCO, and Scopus). Searches were also done on the Ministry of Health(MoH) website. Searches were first conducted in 2022 and then updated in January 2024. Purposive search for reports about cholera and resilience were also done using Google search engine. In our search the following search syntax was used: (“Community” OR “Local” OR “Society” OR “Health Systems”) AND (“Resilien*” OR “respon*” OR “Community Resilience” OR “adaptation” OR “cope” OR “Mitigation” OR “Social Action” OR “Shared Responsibility” OR “Social Capital”) AND (Cholera, OR “Vibrio Cholerae” OR “Cholera Epidemic” OR “Cholera Outbreak” OR “Public Health Emergenc*”) AND (“Uganda”) AND (East Africa) Furthermore, we identified kinship literature (N=18) to help us understand the broader concepts related to community resilience. The kinship papers were identified based on program theories from Non-government Organizations (NGOs) and government Ministries, Departments and Agencies (MDAS) that informed the programing and evaluations about Uganda and beyond. Types of kinship literature included grey literature like social action and interventions reports and/or program evaluations. The initial search was not restricted by year of publication but was limited to title and abstract only in each database to ascertain eligibility. After screening the titles and abstracts, we conducted a secondary search to retrieve full paper/articles. JN, AAK and HS read and extracted data from the eligible/included studies. The inclusion criteria for the papers to review were that they are; 1) original studies, 2) peer reviewed, 3) accessible without cost, 4) in English language, 5) included information about cholera, community engagement, health systems and resilience and 6) in Uganda and East Africa. However, for kinship literature, documents reviewed were beyond Uganda but perceived rich in conceptual explanations for broader resilience. The search results were exported to a reference manager (Endnote X9) to check for duplicates. After removing duplicates, we identified a total of 123 publications for screening after removing duplicates. Initially, JN and AAK screened all titles and abstracts, and a random sample (10%) was checked by FS. The full text of the eligible studies was then retrieved and reviewed by JN, AAK, HS, RT and FS. Where there was disagreement, the team discussed agreeing on a consensus. After screening 31 studies met the inclusion criteria for data extraction and synthesis. Excluded studies were due to several reasons including lack of access to full text, not including resilience and community engagement, does not include Uganda or East Africa. Figure 1 illustrates the study identification, screening and inclusion. We conducted data extraction and analysis following a six-stage process (Figure 2tiff). We were guided by the realist evaluation framework and related concepts of “Context”, “Mechanisms”, “Outcomes and configurations to extract into a matrix, organize and present findings from the literature as well as synthesize and make logic of interventions and related outcomes. At the first stage, the team developed an excel matrix to collect the following information: Author, Year Published, Title, Country Focus, Health/Environmental focus, Methods, Information on Context, Information on Mechanisms, and Information on Outcomes (CMO). Thereafter the team extracted broader information around the attributes above, with a lot more detail relating to Context, Mechanisms, and Outcome (CMO) in relation to Cholera (see annex 1). A detailed excel sheet is attached as supplementary information. Table 1 summarizes what was done at the second and third stage. The second stage involved a summary of stage-1 information, with specific focus to synthesis of data related to CMOs. For each of the knowledge products under review, we synthesized contextual or setting issues, mechanisms in form of vulnerabilities and interventions that worsened or reduced the risk to cholera. At the third stage, we collated data about similar CMOs emerging across all the literature in the excel file and created a fourth column for references with similar or related information. Mechanisms leading to vulnerabilities (negative outcome) were indicated with a “V”- i.e. M1(V) and mechanisms leading to resilience (positive outcome) were indicated as “R” - i.e. M4(R). The fourth and fifth stages involved a synthesis of all Context, Mechanisms, Outcomes, Configurations (CMOCs) and development of a narrative for the general midrange theory of change along the CMOCs (Table 2). The CMOCs were then shared with overall consortium during a literature review workshop to generate additional comments. The sixth stage involved bundling of CMOCs into resilience and vulnerability mechanisms. Lastly, we held a meeting to discuss and agree on the final CMOCs and then developed a general Cholera resilience theory of change/ causal framework (Figure 3). Figure 3 indicates plausible pathways to various forms of resilience for the main mechanisms that we extracted from the literature. We found a sizable body of epidemiological literature that was focused on the vulnerability mechanisms – factors responsible for the spread or transmission of Cholera2,16–22. Maps developed by Bwire et al. (2023) indicate that Uganda has several districts that have been confirmed as hotspots for cholera epidemics between 2011–20216. According to the Ministry of Health, districts that have experienced cholera outbreaks include; Kasese, Rukungiri, Bulisa, Nebbi, Mbale, Hoima, Arua, Zombo, Bududa, Butaleja, Sironko, Manafwa, Ntoroko, Busia, Namayingo, Moyo, Bulambuli and Kapchorwa5,19. Communities that are at great risk of cholera include fishing communities, peri-urban slum dwellers, border communities, migratory farm workers, landslide and flood victims, refugees, prisoners and the mentally ill3,16. This implies that the location of communities and districts increases the likelihood of transmission and cholera outbreak. The highly at-risk communities are characterized by weak WASH infrastructure such as lack of latrines and existence of open water sources. Specific to communities in land slide and flood prone communities namely Butaleja district, there are poor sanitation conditions with latrines filling up with water or inability to construct latrines due to the high-water tables and consequently faecal matter spilling over to the open water sources3,16,17,19. Community poor sanitation practices such as open defecation, use of leaves and sand as anal cleansing material and lack of hand washing was found to increase the susceptibility to cholera transmission and spread7,20. Furthermore, the vulnerability of such communities is aggravated by the limited capacity of Uganda’s health care system to implement early warning systems to enhance detection of cholera outbreaks18. There are also limited capacities among community health workers. Despite being the first responders and focal contact persons for existing community level early warning systems, they have not been sufficiently trained in effective cholera epidemic surveillance, investigation, response and reporting20. Training of formal health workers In the context of weak health system capacity, where early detection and response was perceived as weak, low numbers of health workers was a main factor for communities to experience high morbidity mortality from cholera and diarrheal diseases5,19. Studies that sought to build coping capabilities against cholera outbreaks implicitly and explicitly tried to improve surveillance, lessen the time needed to effectively respond to the outbreak3,5,20,23. For both these outcomes, health workers were increased in numbers, skills or provided with tools as the central mechanisms. Training upstream health workers (epidemiologist and laboratory technicians) in outbreak detection and response and epidemic management3,24, were also important components for this mechanism. Training of Community Health Workers (CHWs) In the context of weak health system capacity and few formally trained health workers, substitutes in the form of CHWs were engaged to assist in the roles of disease surveillance and response3,18,24–26. CHW’s embeddedness in the community was seen as helpful and more culturally sensitive to mobilise and support health promotion in communities during disease outbreaks9,16,25,27. For this reason, CHWs were seen as a helpful mechanism in mitigating the shocks arising from cholera and other epidemics. Community knowledge Specifically, residual knowledge from prior experience about cholera was reported as a vital asset for adaptive resilience7,18,27. This asset, if well managed can help communities to take appropriate actions in time to mitigate the epidemics. This was linked to transformative resilience in the typology above. Lived experiences and the recall and re-enactment of the WASH behaviours and practices to ameliorating disease outbreaks such as cholera was a major mechanism in the community resilience pathway22. Health promotion of WASH practices WASH practices such as washing hands with soap before and after food, boiling or chlorinating drinking water, treatment of open water sources and good toilet practices especially among groups at high risk – refugees, fishing communities, IDPs and slum settlements – is likely to improve WASH practices and reduce outbreaks/recurrence3,5,7,16,17,22,27,28. Community action towards WASH interventions was expected to reduce vulnerability to transmission as well as outbreaks/recurrence. Peer-to-peer engagement, community solidarity/bonding was reported in a few studies as vital for engineering desirable or positive norms and practices such as personal and homestead hygiene7,9. Community cohesion Community cohesion was also found to have a high likelihood of improving adaptive and transformative means to reduce vulnerability to cholera effects3,5,7,21. Two mechanisms related to community cohesion seem to operate through engagements, bonding and linking types of social actions – broadly terms as social capital29–32. Under the bonding type, internally the community can form close solidarity to work together7 and (ii), the linking type enables external engagement, where community can partner/connect with external entities to get support to build infrastructure and other WASH facilities22,27,28. As Observed by Mayhew et al. (2021), construction of infrastructure (e.g. Toilets, hand washing facilities, water source protection) through community engagement and peer-to-peer support is likely to reduce outbreak risk9. Furthermore, formation of peer-to-peer groups was identified as a mechanism of improve WASH infrastructure and practices that required joint actions such as protecting water sources, building toilets, and creating awareness about sanitation and safe disposal of waste. Peer- to- peer groups were more likely to create or enhance adaptive measures that help reduce risk of outbreaks especially among refugee settlements and areas prone to landslides7,9,19,22. Working with community health workers also hinged on their social embeddedness to the communities they serve. As earlier noted, kinship literature was added to enhance our understanding of broader resilience as well as supporting how to make logic of the outcomes relating to interventions in relation to Blanchet et al. (2017)’s resilience capacities; absorptive, adoptive and transformative. Majority of the literature focused on several interventions including; livelihoods and economic empowerment, community resilience to infectious diseases and shocks, pandemic preparedness of community health workers, governance and capacity for managing health system resilience, realistic evaluation and guiding frameworks for chorea interventions in Uganda. Below, we summarize take away messages from kinship literature. Social safety nets33 in form of; financial or asset transfers like Send-A-Cow (SAC) project, Social Assistance Grant for Empowerment (SAGE) programme, Northern Uganda Social Action Fund (NUSAF) especially in the context of good community social capital and group efficacy, can improve resilience of vulnerable communities at risk of cholera and other shocks11. In this literature, resilience was defined as the ability to bounce back or thrive in case of occurrence of disasters10,11,15. However, corruption, poor financial management, mistrust, delays of disbursement of financial resources, and the lack of social acceptability, the mechanism may not be sustained. In other cases, social safety nets were also said to encourage dependency on external hand-outs instead of sovereign community sustenance34,35. Coordination, cooperation, joint community actions and peer monitoring are positive social mechanisms that arise from social capital and social networks. These can help to instill positive social norms and trust31,32. This literature is more about the difficulty of dealing with epidemics including cholera in situations where communities are consumed by rivalries, mistrust, and conflicts. The literature also observe that the mission at the core of the social network, if not positive (e.g. tribal and ethnic rivalries) can weaken resilience and bring about more vulnerability28. Health system transformation such as decentralization can affect the performance of frontline health workers in their preparedness for epidemic control36. The granular mechanisms relate to recruitment and retention of health workers in decentralized settings. Prior mechanisms are necessary to build resilience overtime and these are, planning with broader goals including Sustainable Development Goals (SDGs)37, and everyday planning i.e. change management for health systems resilience36. Having the knowledge and technology to detect, plan and respond to crises/stressors calls for flexibility in institutional norms and practices. That is, ability to change quickly as and when it is necessary36. The multi-dimensionality of crisis requires many capabilities/whole of society action/co-creation/multi-stakeholder action/coalitions. There is need for smart dependency/up and downstream linkages and support3,5,22,38. Again, this aligns with the importance of bridging types of social capital to achieve transformative resilience. Drawing from the findings indicated in 3.1 and 3.2, the team developed a general Cholera resilience conceptual model indicating plausible pathways to various forms of resilience (Figure 3). This was guided by capacities for resilience management15, that are absorptive capacity, adaptive capacity, and transformative capacity as elaborated by Blanchet, Nam et al. (2017). This typology of vulnerability is also acknowledged by studies related to health systems resilience to disease outbreaks9. Overall, the realist-informed review found five mechanisms that enhance resilience against cholera outbreaks in Uganda, and these are enabled by either external support or community action. There were two absorptive mechanisms against vulnerability to cholera, one adaptive mechanism and one transformative mechanism. However, there was also one mechanism that consisted of both adaptive and transformative features. The relationships between the various mechanisms are very interlinked. This implies that to achieve a particular resilience outcome, a combination of mechanisms is necessary. The last columns are the ultimate resilience outcomes and capacities as highlighted by Blanchet et al. (2017). The relationship between the intermediate outcomes and ultimate resilience was not possible to demonstrate since most retrieved papers were less inclined to link to these ultimate resilience measurements but had custom-made intermediate outcomes that we found useful in depicting the pathways for change. The mechanisms we identified were grouped into two main categories, 1) external support – arising outside of the communities and 2) community action – endogenously derived from the community. This realist-informed review aimed at identifying Contexts, Mechanisms, and Outcomes (CMOs) that contribute to community resilience especially in the context of health shocks due to cholera outbreaks. The concept of resilience as espoused by Blanchet et al. (2017) – community capabilities for absorptive, adaptive, and transformative were less direct in the literature. Many of the principal concerns prevalent in this literature were attempts to identify factors responsible for vulnerability to the transmission, spread and bad outcomes from those infected with Cholera. In such circumstances, Pawson and Tilley (1997) recommend reverse engineering of the vulnerability mechanisms and outcomes12 by probing what the resilience outcomes ought to be, in order to construct causal loops to resilience. Accordingly, the research team worked with vulnerability–rich literature to identify mechanisms and vital contexts that present opportunity to build resilience– partly by reducing or mitigating the community vulnerabilities to cholera. Overall, the study identified categories of contexts that made cholera outbreaks emerge. Firstly, these were mostly associated with weak health systems– with the workforce (in number and skills) as the major bottleneck to undertake vital epidemiological services such as surveillance and prompt outbreak response3,5,20. The second major context relates to congested populations– of migrants, refugees, inner cities (slums) and fishing communities3,7,20,21. These settings overwhelm the capacity to provide essential services such as safe water or create conditions of poor sanitation that ultimately make cholera transmission emerge. Physical features such as low-lying areas - prone to floods or unable to support basic sanitation infrastructure like latrines, provide a context that is vulnerable to poor sanitation and contamination of water systems7,16,17,19,21. Although these features form the context in our syntheses, some other literature provides different starting points or framings of the contextual features. Several of epidemiological studies tended to frame contextual features in form of poor WASH behaviors, norms and practices16,17,19 while other literature had these as mechanisms for outbreak transmission or outcomes for interventions seeking to change WASH behaviors5,17. The mechanisms that we extracted from the literature were partly guided by seeking to improve resilience as an immediate outcome. However, for most papers, the aim was to mitigate vulnerabilities or factors that were exposing the communities to the higher risk of Cholera16,19,22,25. Therefore, the mechanisms that are identified in this report need to be viewed from this perspective. The bias of the papers towards surveillance and response to outbreaks may have limited the harvest of effective mechanisms that engender community action, health promotion and environmental transformations. The mechanisms we extracted relate well to the workforce-mediated actions such as training, density and task-shifting of roles to CHWs25,26. There were also mechanisms related to community engagements to promote WASH practices and norms and infrastructure to support community sanitation3,5,7,16. Community knowledge acquired through training and prior experience of dealing with cholera and other disease epidemics was also part of the mechanisms at play to mitigate vulnerability20,25,39 and ultimately improve community resilience from the cholera epidemic. Although we did not find many papers that have a direct link to the community resilience as an outcome, we further reviewed kinship literature10,11,18,22,28,3235–37,39–41. The latter helped us to understand the community characteristics and resources available outside or within the community and how these can be utilized to enable success of mechanisms for building resilience. Issues identified included; social capital, trust, bonding, and linkages11,35,40. For example, social capital can enable the community to have bonding advantages from within the community (community action) hence strengthening group efficacy as well as leverage on linkages outside (external support) the community to build resilience. However, Morgan (2020) note that some of the advantages of linkages with external support may not always be sustained39. Finally, we were able to map out mechanisms that relate to the three main dimensions of resilience namely adaptive, absorptive and transformative15. The intermediate outcomes on this pathway were captured by filling workforce gaps, improving early detection through information systems that support surveillance and early response, making sanitation infrastructure accessible and engineering engagements for community action, norms, and trust. The exclusion of literature on interventions and surveys that are not in Uganda and not focused on cholera represents a limitation as this could have enriched or diversified our synthesis of published literature on the subject matter. However, the strength in narrowing the focus and context was to ensure in-depth review of the issue in the country and provide some preliminary lessons as well as insights on broader community resilience in the event of health shocks, using cholera as an example. From our realist-informed review, a few lessons and conclusions can be highlighted in relation to community resilience. Most of the literature on cholera is biased towards what makes communities vulnerable, surveillance or response to outbreaks. Hence, use of kinship resilience literature can help bridge the gap around the broader concepts, to which inferences can be made in relation to community resilience to cholera. Further research is also needed to identify 1) effective community led and external (i.e. NGO, Government etc.) mechanisms that enhance resilience to cholera and engender community action, health promotion and environmental transformations. Interventions to enhance community resilience towards cholera outbreaks are either internal (from within the community) or external (driven by NGOs.). Those with a detailed description of community led interventions or community led actions are limited. More research is needed around the specific community actions that could contribute to WASH infrastructure development, use, effectiveness, and sustainability in different settings. It is unclear the processes through which the various resilience mechanisms lead to intermediate outcomes and ultimately to the broader resilience capabilities hypothesized by Blanchet et al. (2017), hence the dotted lines indicated in Figure 3. Therefore, further research, using a realist evaluation framework is needed to identify how mechanisms/interventions bring about positive changes in the community and under what conditions or community motivations. Additional research that shows characteristics or specific mechanisms leading to different forms of broader resilience capabilities namely adaptation and transformation is also critical. Lastly, this realist-informed review has broadened our understanding that resilience might not be an outcome per se, but rather a continuous process of activating various mechanisms, interventions or programmes that communities, NGOs, and governments implement and redesign to attain it. No data are associated with this article. Bibliographic information has been uploaded to a repository with details below. Name of repository: Mendeley Data, V1 Title of dataset: Community Resilience to Cholera Epidemics in Uganda: A Realist-informed review of Vulnerability and Intervention mechanisms. Persistent identifier: doi: http://dx.doi.org/10.17632/fk3vsyrxd8.1. This project contains the following underlying data: Title of file. (Manuscript 13983 extended data ver 25-04-2022.xlsx)-Description of data in file(This dataset supports a realist-informed literature review examining mechanisms that contribute to or reduce vulnerability to cholera outbreaks in Uganda. The data were extracted from documents, including peer-reviewed articles, grey literature, and program evaluations. A six-stage data synthesis approach was used, guided by realist evaluation (Pawson & Tilley, 1997) and resilience frameworks (Blanchet et al., 2017).The dataset includes: 1. An Excel matrix of 31 studies capturing Context–Mechanism–Outcome (CMO) patterns 2. Synthesized CMOC configurations 3. Thematic groupings of resilience and vulnerability mechanisms Data is available under the terms of [CC-BY- 4.0]. We acknowledge the members of the PARES Research Consortium for peer- to -peer guidance about our work during the consortium-wide meetings. PARES Global Health Research Group members are: Gelila Abraham, Adelaine Aryaija-Karemani, Lawrence S. Babawo, Dina Balabanova, Negalign Berhanu, Sander Koenraadt, Mohamed Ambrose Koroma, Rashid Amzak Kpaka, Harro Maat, Diribe Makonene, Susannah H. Mayhew (PI), Joseph Christian Mboma, Vik Mohan, Esther Mokuwa, Justine Namakula, Edith Ngunjiri, Marion Nyakoi, Paul Richards, Mateus Sahani, Freddie Ssengooba (co-PI), Hakimu Sseviiri, Revocatus Twinomuhangi, Ahmed Vandi, Mirkuzie Woldie. We also acknowledge support from Dr. Alison Kinyengyere and Dr. Eboku, and Dr. Ekwaru Obuku of the African Centre for Systematic Review & Knowledge Translation for their support and training in literature search. We further acknowledge Dr. Phillip Wanduru, a literature review expert, for peer review and for providing an opinion on how to structure the methods. Faculty Opinions recommendedReferences - 1. Ali M, Nelson AR, Lopez AL, et al.: Updated global burden of cholera in endemic countries. PLoS Negl Trop Dis. 2015; 9(6): e0003832. PubMed Abstract | Publisher Full Text | Free Full Text - 2. WHO: Disease outbreak news-Cholera global situation. World Health Organisation (WHO), 2022. Reference Source - 3. MOH: Prevention and control of cholera: operational guidelines for the National and District Health Workers & Planners. Ministry of Health, Editor. Government of Uganda: Kampala, 2017. Reference Source - 4. GTFCC: Ending cholera-a global roadmap to 2030. 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PubMed Abstract | Publisher Full Text | Free Full Text Author details Author details 1 Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda, 7072, Uganda 2 Department of Geography, Geoinformatics and Climatic Sciences, Makerere University College of Agricultural and Environmental Sciences, Kampala, Central Region, 7072, Uganda 3 Department of Global Health and Development, London School Hygiene and Tropical Medicine, London, WC1H 9SH, UK 2 Department of Geography, Geoinformatics and Climatic Sciences, Makerere University College of Agricultural and Environmental Sciences, Kampala, Central Region, 7072, Uganda 3 Department of Global Health and Development, London School Hygiene and Tropical Medicine, London, WC1H 9SH, UK Justine Namakula Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Adelaine Aryaija-Karemani Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Hakimu Sseviiri Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Validation, Writing – Review & Editing Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Validation, Writing – Review & Editing Revocatus Twinomuhangi Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Supervision, Validation, Writing – Review & Editing Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Supervision, Validation, Writing – Review & Editing PARES consortium Roles: Conceptualization, Funding Acquisition, Methodology, Validation Roles: Conceptualization, Funding Acquisition, Methodology, Validation Susannah Mayhew Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Validation, Writing – Review & Editing Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Validation, Writing – Review & Editing Freddie Ssengooba Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information This project is funded by the National Institute for Health Research (NIHR) under its [‘Research for Patient Benefit (RfPB) Programme’ (Grant Reference Number PB-PG- NIHR 133333)]. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright © 2025 Namakula J et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. metrics VIEWS $counts.viewCount downloads Citations CITE how to cite this article Namakula J, Aryaija-Karemani A, Sseviiri H et al. Community Resilience to Cholera Epidemics in Uganda: A Realist-informed review of Vulnerability and Intervention mechanisms. [version 1; peer review: 1 approved]. NIHR Open Res 2025, 5:79 (https://doi.org/10.3310/nihropenres.13983.1) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. track receive updates on this article Track an article to receive email alerts on any updates to this article. Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 15 Sep 2025 Views 0 How to cite this report: Mbewe N. Reviewer Report For: Community Resilience to Cholera Epidemics in Uganda: A Realist-informed review of Vulnerability and Intervention mechanisms. [version 1; peer review: 1 approved]. NIHR Open Res 2025, 5:79 (https://doi.org/10.3310/nihropenres.15201.r37436) The direct URL for this report is: https://openresearch.nihr.ac.uk/articles/5-79/v1#referee-response-37436 https://openresearch.nihr.ac.uk/articles/5-79/v1#referee-response-37436 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Reviewer Report 13 Nov 2025 Approved VIEWS 0 This is a well-written article and brings forth important information to explore community resilience to cholera, as opposed to the usual vulnerabilities-only approach. Unfortunately, the findings show how limited the scope of available evidence is in the space of resilience, ... Continue reading I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close This is a well-written article and brings forth important information to explore community resilience to cholera, as opposed to the usual vulnerabilities-only approach. Unfortunately, the findings show how limited the scope of available evidence is in the space of resilience, and hence the need for further studies. I especially liked the use of the realist model which is necessary for real world practise as opposed to the current status quo that realies heavily on systematic reviews. Congratulations to the authors for this work - Is the topic of the review discussed comprehensively in the context of the current literature? Yes - Are all factual statements correct and adequately supported by citations? Yes - Is the review written in accessible language? Yes - Are the conclusions drawn appropriate in the context of the current research literature? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: cholera epidemiology CITE HOW TO CITE THIS REPORT Mbewe N. Reviewer Report For: Community Resilience to Cholera Epidemics in Uganda: A Realist-informed review of Vulnerability and Intervention mechanisms. [version 1; peer review: 1 approved]. NIHR Open Res 2025, 5:79 (https://doi.org/10.3310/nihropenres.15201.r37436) The direct URL for this report is: https://openresearch.nihr.ac.uk/articles/5-79/v1#referee-response-37436 https://openresearch.nihr.ac.uk/articles/5-79/v1#referee-response-37436 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. Alongside their report, reviewers assign a status to the article: - Approved - Approved with reservations - Not approved | Invited Reviewers | | |---|---| | 1 | | | Version 1 15 Sep 25 | read | Sign up for content alerts You are now signed up to receive this alert Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. 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