Frequency and determinants of COVID-19 prevention behaviours: assessment of large-scale programmes in seven countries

  1. Sarah Bick
  2. Sian White
  3. Astrid Hasund Thorseth
  4. Max N D Friedrich
  5. Ian Gavin
  6. Om Prasad Gautam
  7. Robert Dreibelbis

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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 challenges

  • Identifying effective strategies to promote adoption of key behaviours in diverse contexts over a period of rapid change will be key for future pandemic preparedness

What 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 norms

How 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 response

  • Learning 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.

Article activity feed

  1. Rapid Reviews Infectious Diseases

    Soojung Jo

    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. 

  2. Rapid Reviews Infectious Diseases

    Franklin Amuakwa-Mensah

    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. 

  4. PREreview

    This Zenodo record is a permanently preserved version of a Structured PREreview. You can view the complete PREreview at https://prereview.org/reviews/10259034.

    Does the introduction explain the objective of the research presented in the preprint? Yes Yes, the introduction of the preprint does explain the objective of the research. It begins by highlighting the vulnerabilities of residents in low- and middle-income countries (LMICs) to infectious disease pandemics due to pre-existing health and economic challenges. The abstract then points out the obstacles faced by these populations, such as limited access to hygiene facilities, water, soap, and masks, as well as dense living environments, which hinder effective preventive behaviors against COVID-19.
    Are the methods well-suited for this research? Highly appropriate The methods seem thoughtfully designed to capture a holistic view of hygiene prevention behaviors in the context of the COVID-19 pandemic, especially in low- and middle-income countries where the challenges may differ from high-income settings.
    Are the conclusions supported by the data? Highly supported The conclusion seems well-grounded in the findings of the study, offering insights and actionable recommendations based on the observed patterns in COVID-19 prevention behaviors across the surveyed countries.
    Are the data presentations, including visualizations, well-suited to represent the data? Somewhat appropriate and clear The methods section is quite detailed and provides a comprehensive overview of how the research was conducted. It covers the survey design, sampling methods, measures, and data analysis procedures. The use of mixed-effects regression analyses, Poisson regression, and logistic regression for different outcomes demonstrates a thoughtful approach to analyzing the diverse data collected. Additionally, the inclusion of exploratory bivariable and multivariable regressions adds depth to the analysis. However, the sheer volume of information and technical details might be overwhelming for readers who are not familiar with epidemiological and statistical methods. Breaking down the methods into subsections with clear headings and providing explanations for specific statistical approaches could enhance the readability for a broader audience.
    How clearly do the authors discuss, explain, and interpret their findings and potential next steps for the research? Very clearly The authors present their findings clearly, providing detailed information on respondent characteristics, prevalence of COVID-19 preventive behaviors, and the relationships between demographics, behavioral determinants, and exposure to COVID-19 communications. The interpretation of results in relation to demographic characteristics, behavioral determinants, and exposure to COVID-19 communications is well-discussed. The authors effectively link the findings to potential implications for public health interventions, such as the need for a renewed focus on younger and poorer populations and the importance of addressing specific barriers and promoting targeted messaging. The potential next steps for research are briefly mentioned, emphasizing the importance of promoting novel behaviors alongside established ones and addressing the ongoing burden of COVID-19. While the discussion of potential next steps is present, it could benefit from a bit more elaboration on specific recommendations for future research directions or practical interventions.
    Is the preprint likely to advance academic knowledge? Highly likely Yes, the preprint is likely to advance academic knowledge, particularly in the field of public health and behavior change interventions for infectious disease prevention. The multi-country analysis provides valuable insights into the prevalence of key COVID-19 preventive behaviors, their determinants, and the impact of communication strategies.
    Would it benefit from language editing? No
    Would you recommend this preprint to others? Yes, it's of high quality Yes, I would recommend this preprint to individuals with an interest in public health, infectious disease prevention, and behavior change interventions. The research provides valuable insights into the prevalence and determinants of COVID-19 preventive behaviors across multiple countries, especially in low- and middle-income settings. Understanding the factors influencing hygiene practices, mask-wearing, and physical distancing is crucial for designing effective public health interventions.
    Is it ready for attention from an editor, publisher or broader audience? Yes, as it is

    Competing interests

    The author declares that they have no competing interests.

  5. Version published to 10.1101/2023.11.03.23298032v1 on medRxiv