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Review 2: "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 2: "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:

  • Potentially informative. The main claims made are not strongly justified by the methods and data, but may yield some insight. The results and conclusions of the study may resemble those from the hypothetical ideal study, but there is substantial room for doubt. Decision-makers should consider this evidence only with a thorough understanding of its weaknesses, alongside other evidence and theory. Decision-makers should not consider this actionable, unless the weaknesses are clearly understood and there is other theory and evidence to further support it.



This preprint examines the factors associated with COVID-19 prevention behaviors in low- and middle-income countries across Africa. While the topic is intriguing, there are several areas that require clarification and improvement.

The authors should provide a concise introduction to WaterAid. This will help set the context for readers unfamiliar with the organization and its programs. Additionally, the aim of the study is currently not clear. It appears the manuscript is evaluating WaterAid's program, but this needs to be explicitly stated or revised to reflect the true objective of the study.

The methodology section could be more detailed, particularly regarding the measures used. The inclusion of Principal Component Analysis (PCA) in the measures section is confusing. Its role in the methodology should be clarified. Additionally, the methods were hard to follow and exploratory results of the PCA might be better suited to be included in the analysis.

The authors indicated using binary indicators for several variables, but it is unclear whether each variable was treated as binary in the analysis or if the data was collected as a binary variable. It would be clearer to separate them out. 

A clear explanation of the RANAS model is needed for readers who may not be familiar with it. Additionally, when the Likert scale is used, the type and the level scale should be specified. Clarity is also needed on the number of items in each measure and the scoring system. It is mentioned that bivariable regression was conducted, but the results are not evident in the manuscript- these should be included in the findings. In the multivariable regression analysis, it appears that outcomes are being treated as predictors. This needs to be rectified or clarified for accuracy.

The authors should also provide justification for conducting separate analyses for 'exposure', 'behavioral factors', and 'demographic factors'. Also, the authors can consider combining these covariates into a single analysis for a more comprehensive understanding and adding other control variables.

Given the beforementioned issues, the discussion section will likely need revision to align with the new analysis and findings. Addressing these points will greatly enhance the clarity and impact of the manuscript.

The most important takeaway from this manuscript is the identification of key factors associated with COVID-19 prevention behaviors in low- and middle-income African countries, which highlights the need for tailored public health strategies and policies in these regions. Understanding these factors is crucial for policymakers and health authorities to develop effective, culturally appropriate interventions to increase the spread of emerging respiratory infectious diseases such as COVID-19 in the communities.

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