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

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Background Uganda experiences recurring cholera epidemics. Current interventions prioritize strengthening health systems, neglecting community resilience. This paper explored pathways to enhancing community resilience against cholera. Methods 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. Findings 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. Conclusions 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.

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