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Review 1: "Frequency and Determinants of COVID-19 Prevention Behaviours: Assessment of Large-scale Programmes in Seven Countries"

In general, the reviewers found this study to be important, but that the methodology could be described more clearly and the contributions to the existing literature more explicitly stated. 

Published onDec 12, 2023
Review 1: "Frequency and Determinants of COVID-19 Prevention Behaviours: Assessment of Large-scale Programmes in Seven Countries"
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key-enterThis Pub is a Review of
Frequency and determinants of COVID-19 prevention behaviours: assessment of large-scale programmes in seven countries
Frequency and determinants of COVID-19 prevention behaviours: assessment of large-scale programmes in seven countries

Abstract Pre-existing health and economic challenges mean residents of low- and middle-income countries (LMICs) are likely to be particularly vulnerable to infectious disease pandemics. Limited access to hygiene facilities, water, soap and masks, and dense living environments impeded effective practice of preventive behaviours – handwashing with soap (HWWS), mask wearing and physical distancing – a key line of primary defence against COVID-19. Here we describe a multi-country analysis of prevalence of key hygiene prevention behaviours and their determinants associated with an international non-governmental organisation (WaterAid) hygiene behaviour change programmes for COVID-19 prevention. The goal of this analysis is to inform future outbreak preparedness and pandemic response in LMICs. Cross-sectional household surveys were conducted in October-November 2020 in seven countries where WaterAid worked (Ethiopia, Ghana, Nepal, Nigeria, Rwanda, Tanzania and Zambia). Multivariable mixed-effects regression analyses were used to explore relationships between self-reported behavioural outcomes of interest (handwashing with soap, physical distancing, and mask use) and demographic characteristics, behavioural factors (knowledge, norms, barriers, motives), and exposure to COVID-19 communications. Most respondents (80%) reported increasing their handwashing behaviour after the pandemic, but practice of HWWS at COVID-19-specific prevention moments was low. Mask wearing (58%) and physical distancing (29%) varied substantially between countries. Determinants of key behaviours were identified, including age and socioeconomic status, perceived norms, self-regulation, and the motive of protecting others. These findings highlight that leveraging behaviour-specific emotional drivers and norms, reducing common barriers and promoting targeted messages about specific behaviours and actions individuals can take to reduce risk are necessary to support large-scale behaviour change. Learning from the COVID-19 response to more effectively integrate novel behaviours into existing health promotion will be vital for disease prevention and outbreak resilience.Key messages What is already known on this topic Facilitating COVID-19 prevention behaviours of hand hygiene, mask use and physical distancing in low- and-middle income countries comes with unique challengesIdentifying effective strategies to promote adoption of key behaviours in diverse contexts over a period of rapid change will be key for future pandemic preparednessWhat this study adds This multi-country analysis of areas where WaterAid implemented an initial mass media COVID-19 response in 2020 observed lower practice of handwashing at novel COVID-19 prevention moments compared to established moments and variable physical distancing behaviour, and examined behaviour-specific determinants and normsHow this study might affect research, practice or policy Renewed focus on identified key drivers of behaviour: targeting critical age-groups and vulnerable populations, increasing descriptive norms and motives of protecting others and respect, and reducing common barriers, with targeted messaging for novel handwashing moments, may be key to ongoing COVID-19 responseLearning from the rapid COVID-19 response on how well we are able to promote novel behaviours alongside established ones in a variety of contexts can inform future disease prevention and outbreak resilience.

RR:C19 Evidence Scale rating by reviewer:

  • Reliable. The main study claims are generally justified by its methods and data. The results and conclusions are likely to be similar to the hypothetical ideal study. There are some minor caveats or limitations, but they would/do not change the major claims of the study. The study provides sufficient strength of evidence on its own that its main claims should be considered actionable, with some room for future revision.



Based on the objectives of the study, the authors found the following: a) most individuals in the seven countries of study reported increasing handwashing behavior after COVID-19 pandemic but demonstrated low handwashing with water and soap practice which aims at COVID-19 infection prevention and b) key COVID-19 prevention behaviors (i.e. handwashing with soap, physical distancing, and mask use) are determined by age and socio-economic status, perceived norms, self-regulation, and motives of protecting others.

The study describes a multi-country (that is, 7 low- and middle-income countries (LMICs)) analysis with a focus on the prevalence of three hygiene prevention behaviors (that is, handwashing with soap, wearing a mask, and physical distancing) and the factors that drive these practices, based on a program by an international non-governmental organization (WaterAid) with the aim of behavioral change for COVID-19 prevention. This was achieved using data from a cross-sectional household survey collected between October and November 2020 from the 7 seven LMICs with an average sample size of about 430 per country. Although the sample is small, the authors claim that their Cochran's calculation with a confidence level of 95% and expected frequency of 50%, predicted a minimum sample size of 384. However, it is unclear how the sample is representative of the population for each country. One would expect the authors to compare their sample with national census or survey data based on some socio-economic and demographic characteristics. Further, to make their sample reflective of the population in each country, they could have applied survey weighting in the regression analysis based on the population distribution of age, gender, and administrative area in each country.

Although the authors state their aim, they were not very clear about their contributions to the literature. There are other studies that looks at COVID-19 prevention behaviors in LMICs such as Hatab et al. (2023) (COVID-19 risk perception and public compliance with preventive measures: Evidence from a multi-wave household survey in the MENA region), Amoah (2023) (Know, comply, and live: the implications of protocols for COVID-19 management in sub-Saharan Africa) and even some in the reference list of the current study. I believe the authors' current study has more to contribute but this is not pointed out clearly in the paper. Given the possible heterogeneity in terms of COVID-19 prevention behavior across gender, geographical area, age, and economic status, one would expect the determinants analysis to consider that. As the authors mentioned that their study is to inform future outbreak preparedness and pandemic response in LMICs, the conclusion of the paper could provide more highlights and discussions on how their findings could achieve that aim. This is important in the sense that one would claim that the study is not timely since we are no longer in the COVID-19 pandemic. 

In general, the paper is well written and provides more details on their sampling design and descriptive analysis in the supplementary documents.

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