Adherence to COVID-19 preventive measures and associated factors in Ethiopia: A systematic review and meta-analysis.

BACKGROUND: Reluctance to the COVID-19 preventive measures have been repeatedly reported in Ethiopia although compliance with these actions is the key step to minimize the pandemic's burden. Hence, this systematic review and meta-analysis aims to address the gap in the literature by determining the pooled magnitude of adherence to COVID-19 preventive measures and identifying its associated factors in Ethiopia.
MATERIALS AND METHODS: The electronic databases used to search articles were PubMed/MEDLINE, CINAHL, Web of Science, ScienceDirect, Research4Life and other sources of grey literature including Google Scholar and World Health Organization (WHO) database portals for low- and middle-income countries. Full English-language articles published between 2019 and 2022 were eligible for the review and meta-analysis. Relevant data extracted and descriptive summaries of the studies presented in tabular form. The methodological quality of articles assessed using the Joanna Briggs Institute (JBI) quality assessment tool. The pooled magnitude of adherence determined by applying a random-effects model at a 95% CI.
RESULTS: Of 1029 records identified, 15 articles were included in the systematic review and 11 were selected for meta-analysis. The pooled estimate of adherence to COVID-19 preventive measures in Ethiopia was 41.15% (95% CI:32.16-50.14%). Furthermore, perceived COVID-19 disease severity (AOR:1.77, 95% CI: (1.40-2.25)), attitude (AOR:1.85, 95% CI: (1.36-2.53)) and knowledge (AOR:2.51, 95% CI: (1.67-3.78)) to COVID-19 preventive measures showed significant association with adherence to COVID-19 preventive measures.
CONCLUSION: The magnitude of adherence to COVID-19 preventive measures in Ethiopia appeared to be low. Therefore, the government of Ethiopia and other stakeholders should mobilize resources to improve the adherence level of the community to the COVID-19 preventive measures and decrease public fatigue.

Introduction

The current pandemic, COVID-19 disease, is a highly contagious viral infection caused by novel coronavirus called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Person-to-person spread is the main means of transmission, when any infected person sneeze or cough respiratory droplets of the virus, and these droplets enter the lungs of a nearby person via inhalation. Besides, environmental contamination is another way to spread the virus, resulting in an unprecedented threat to global health and well-being. Patients infected from SARS-CoV-2 infection often presented with dry cough, fever, sputum production and shortness of breath and upper airway congestion [1,2].

The WHO has recommended multiple COVID-19 prevention and control measures including proper hand washing, physical distancing, covering mouth and nose when coughing and sneezing, avoiding touching face and staying at home [3]. Several countries have implemented the WHO recommendations to prevent and control COVID-19 infection [4]. The earlier announcement of lockdown and the stricter the adherence was believed to lead to fewer infected total cases and deaths. Hence, it was expected to accelerate the containment of the virus and lessen the consequences of the mitigating measures [5]. Unfortunately, globally, as of 1 August, 2022, there were more than 577 million confirmed cases of COVID-19, including 6.4 million deaths, reported to WHO [6].

In Ethiopia, following the confirmation of the first case of COVID-19 in March 2020, the Ethiopian ministry of health and public health institute have taken several initiatives to decrease the burden of COVID-19 [7]. Among these, hand hygiene, facemask and social distancing were the primary three preventive measures that the government communicated to the community through various media platforms [8]. Furthermore, measures were imposed to close schools, restrict major gatherings and movements of people, and even lockdown. Despite this, the preventive measures were being ignored by the community and leaders at different level [9].

Poor adherence towards COVID-19 mitigation measures has continued as an escalating problem in Ethiopia [10]. According to the study conducted among Hossana residents, nearly half of them had poor adherence to the COVID-19 preventive measures [11]. Likewise, in a recent study in the capital of Ethiopia, Addis Ababa, nearly 40% of the community has shown poor implementation of COVID-19 preventive measures [12]. Surprisingly, in a study of Oromia region of Ethiopia, the overall adherence level of the community to the recommended safety measures of COVID-19 was 8.3% [13], which seems far lower than the other studies. The main barriers to effective implementation of public health measures were resistance to change, lack of community engagement, negligence, insufficient training for front line workers, poor law enforcement, poor supportive supervision, and lack of continuous community awareness creation [14].

However, there is no pooled evidence on the magnitude of adherence to COVID-19 preventive measures and its associated factors in Ethiopia. Thus, this meta-analysis aims to estimate the magnitude of adherence to COVID-19 preventive measures and its associated factors. More importantly, the systematic review and meta-analysis results will help decision-makers to plan and implement effective action against the COVID-19 pandemic.

Materials and methods

Search strategies

Research articles were accessed through electronic web-based database searches and reference list reviews using the Preferred Reporting Items of Systematic Reviews and Meta-Analysis (PRISMA) checklist guidelines [15]. Literature that reported adherence status to COVID-19 preventive measures and/or its associated factors in Ethiopia were searched from both main electronic databases and grey literature sources. The electronic databases used to search articles were PubMed/MEDLINE, ScienceDirect, Web of Science, CINAHL, Research4Life and other World Health Organization (WHO) database portals for low- and middle-income countries. In addition, the researchers found related articles through a desk review of the doctoral dissertations available at Ethiopian university libraries and institutional repositories, and from reviewing the reference lists of related articles. Electronic database searches were conducted from July 20, 2022, to July 23, 2022. The main terms used during electronic database search were: (“Adherence” OR “Compliance” OR “Associated factors” OR “Determinants” OR “Predictors”) AND (“COVID-19 prevention measures” OR “COVID-19 preventive measures”) AND (Ethiopia). Please see S1 Table for a detail article searching process, terms used in each database and search results.

Inclusion and exclusion criteria

All English-language, full-text, original research articles conducted in Ethiopia from January1, 2019 to July 23, 2022 and published in peer-reviewed journals or filed as completed dissertations were considered for inclusion. Moreover, the article should measure the adherence level and/or associated factors of COVID-19 preventive measures in Ethiopia. However, case series, opinion papers and reports were excluded.

Studies screening and selection process

All electronic search results were transferred into Mendeley reference manager software version 1. 19.8. Next, we organized all these articles into a single folder for duplicate citation removal and further management of articles. After removing duplicate citations with the software, two authors (GG, RP) independently screened the articles, based on preset eligibility criteria. The article screening process had three sequential stages, title, abstract and full-text screening. Through title screening, studies entitled with terms directly/indirectly measure the adherence level and/or associated factors of COVID-19 preventive measures in Ethiopia, were selected for abstract screening. And, in abstract screening, articles were read their abstract if they could measure either of the review and meta-analysis outcomes. Consequently, full-text screenings were carried out with four independent authors. The final decision whether to include an article were reached on the consensus of all the authors. The screening and selection of articles were guided according to the PRISMA guideline (Fig 1).

Fig 1

A PRISMA flow chart that shows the process of article selection.

Critical appraisal of studies

Quality of studies was critically evaluated for the validity of results. The methodological quality of the papers was assessed using the JBI quality assessment checklists for cross-sectional analytical studies [16]. This JBI critical appraisal checklist has eight elements, which mainly addresses the methodological area of each article. It focused on the appropriateness of the statistical analysis, objective, inclusion criteria, study population and setting, exposure and outcomes measurement, and management of confounding factors. The evaluation and decision of each article was finalized on the consensus of all authors. Accordingly, articles with positive answers (yes) for more than 50% of the eight-elemental checklist (i.e., yes for five or more) were included in this systematic review and meta-analysis (S2 Table).

Data extraction

After all authors agreed on the articles to be included in the review and meta-analysis, we set an extraction template in the Microsoft Excel sheet. The study description in Table 1 was formulated to summarize the study design, study setting, sample size, aim, key finding (magnitude of adherence to COVID-19 preventive measures), and secondary outcome (associated factors with Adherence to COVID-19 preventive measures). Data extraction was carried out by two authors (GD and RP) and double checked by the other authors. The extracted numerical data were documented and stored in a Microsoft Excel separate sheet (S3 Table).

Table 1

Characteristics and main findings of the articles included in the systematic review and meta-analysis.

Author, Year	Aim	Study population	Study design	Sample size	Response rate (%)	Adherence level (%)	Factors associated with adherence to COVID-19 preventive measures
Abeya et al., 2021 [13]	To assess the level of adherence to COVID-19 preventive measures and associated factors in the study area	Community	Cross-sectional	2751	95.5	8.3	Age, illiteracy, read and write, attended primary, occupation and knowledge were factors associated with level of adherence to COVID-19 preventive measures
Asnakew et al., 2020 [30]	To assess the community’s level of risk perception of COVID-19, their compliance with recommended precautionary measures, and factors that influence compliance behavior	Community	Cross-sectional	521	NA	NA	Being female, higher perceived effectiveness of recommended preventive measures, and higher perceived reliability of media facilitated compliance with preventive measures. Increasing age, being single, lower education level and living at a lower administrative level were barriers to be compliant.
Azene et al., 2020 [10]	To assess the community’s adherence towards COVID-19 mitigation strategies and its associated factors	Community	Cross-sectional	635	98.1	51.04	Being female, good level of information exposure, good knowledge about COVID-19, favourable attitude towards COVID-19 prevention measures and high-risk perception of COVID-19
Bante et al., 2021 [25]	To assess communities’ adherence with COVID-19 preventive measures and its associated factors	Community	Cross-sectional	648	99.4	12.3	Urban residence, favourable attitude towards COVID-19 prevention measures and fear of stigma due to COVID-19
Etafa et al., 2021 [22]	To assess healthcare workers’ compliance with measures to prevent COVID-19, and its potential determinants in public hospitals	Health professional	Cross-sectional	422	95.3	22	Spending most of caring time at bedside, receiving training on infection prevention/COVID-19, reading materials on COVID-19 and getting support from hospital management
Hailu et al., 2021 [29]	To assess the compliance, barriers, and facilitators to social distancing measures for the prevention of COVID-19 in Northwest Ethiopia	Community	Cross-sectional	425	94.4	NA	Poor compliance with social distancing measures. Age, older persons more likely than younger to comply with social distancing guidelines.
Kayrite et al., 2020 [21]	To measure the compliance with COVID-19 preventive and control measures	Community	Cross-sectional	324	97	55.50	NA
Kebede et al., 2021 [27]	To assess healthcare provider’s adherence to COVID-19 preventive practices during childbirth in northwest Ethiopia	Health professional	Cross-sectional	406	96.4	46.1	Healthcare providers who had job satisfaction, had smartphone and/or computer, ever received training on infection prevention, earned higher monthly income, and worked at health facility in the urban area had a significant association with adherence to COVID-19 preventive practices.
Keleb et al., 2021 [19]	To determine the magnitude of compliance and associated factors of personal protective equipment utilization and hand hygiene practice among healthcare workers in public hospitals of South Wollo Zone, Northeastern Ethiopia.	Health professional	Cross-sectional	489	96.8	NA	About 32 and 22.3% of healthcare workers were compliant with personal protective equipment utilization and hand hygiene practice, respectively. Feedback for safety, training on COVID-19 prevention, and perception to infection risk were significant factors of good compliance with personal protective equipment utilization.
Shewasinad et al., 2021 [24]	To identify the predictors of adherence to COVID-19 prevention measure among	Community	Cross-sectional	683	100	44.10	Perceived usefulness of safety measures, absence of perceived barriers to COVID-19 safety measures and perceived non susceptibility of COVID-19
Silesh et al., 2021 [26]	To assess compliance with COVID-19 preventive measures among pregnant women attending antenatal care at public facilities of Debre Berhan town, Ethiopia	Community (pregnant mothers)	Cross-sectional	402	98.5	56.1	Maternal age, husband educational status, chronic disease, and knowledge were significant predictors to have good compliance with COVID-19 preventive measures.
Temesgan et al., 2022 [28]	To assess adherence to COVID-19 preventive practice and associated factors among pregnant women in Gondar city, northwest Ethiopia	Community (pregnant mothers)	Cross-sectional	678	97.8	44.8	Age, education, having ANC follow up and adequate knowledge towards COVID-19 were significantly associated with good adherence to COVID-19 preventive practice
Temesgen et al., 2021 [11]	To determine adherence to covid-19 prevention measures	Community	Cross-sectional	384	98.2	50.4	Age < 20 years, married, household size 7 and above and having information about the complication of COVID-19
Zenbaba et al., 2021 [23]	To assess the compliance towards COVID-19 preventive measures and associated factors	Health professional	Cross-sectional	660	99	49.9	Working in referral hospital, age 24 or younger years old, 3–6 years of work experience, good knowledge regarding COVID-19 preventive measures, knowing the presence COVID-19 Prevention Committee, having functional handwashing facilities and continuous water supply at workplace
Zewude et al., 2021 [20]	To examine compliance to personal protective behavioral recommendations to contain the spread of COVID-19 among urban residents engaged in the informal economic activities in Wolaita Sodo town, Southern Ethiopia	Community	Cross-sectional	384	100	NA	Regular wearing of a mask was significantly associated with regular attendance of the media regarding the preventive mechanisms of COVID-19, knowledge of someone ever infected by COVID-19, the belief that COVID-19 causes a severe illness, and perception of the likelihood of dying as a result of infection by COVID-19

Outcome of interest

The primary outcome of interest was the pooled magnitude of adherence to COVID-19 preventive measures in Ethiopia. The magnitude of adherence was measured as the number of adhering study subjects divided by the total sample size multiplied by 100. Secondly, we have also pooled the odds ratio of each factor to see if there was a statistical association with adherence to COVID-19 preventive measures in Ethiopia.

Data analysis

The raw data in the Microsoft Excel spreadsheet template was transferred to STATA™ version 16 software for analysis. A pooled magnitude of adherence to COVID-19 preventive measures in Ethiopia was estimated at a 95% confidence interval (CI). Furtherly, we conducted a regional subgroup analysis. Also, a pooled odds ratio of different variables was calculated using a RevMan version 5.4.1 to check if there was an association between independent variables and the dependent variable (adherence to COVID-19 preventive measures). The heterogeneity of study outcomes was assessed using the I2 statistic [17]. Accordingly, studies with high heterogeneity were estimated using a random-effects model, and fixed effect model was run in variables showed low heterogeneity (<50%). Parallelly, a publication bias was checked using a funnel plot asymmetry and Egger’s and Begg-Mazumdar Rank correlation tests [18]. Eventually, the statistical analysis and the results were double-checked by all authors.

Results

Identification and description of studies

A total of 1029 citations were collected through electronic database search and other sources (Fig 1). Of these, we excluded 359 items due to duplication. From the remained 670 collections, 578 items were excluded through title screening, while 70 were excluded after the abstract screening. Next, 22 full articles were reviewed according to the predefined eligibility criteria. Eventually, 15 articles were found fully eligible for systematic review, of which 11 articles were included in meta-analysis. All of them were conducted using a cross-sectional study design [10,11,13,19-30]. Nearly half (n = 7) of these studies were conducted in Amhara region [10,19,24,27-29,31], four articles in SNNP (Southern Nations, Nationalities, and Peoples’) region [11,20,21,25], three in Oromia region [13,22,23] and the remained one study was conducted in Addis Ababa [30]. The maximum sample size recorded was 2751 subjects [13], while the minimum was 324 [19]. Furthermore, majority of the studies had more than 95% response rate (Table 1).

Quality appraisal of the review

The JBI quality assessment tools were used to evaluate the methodological quality of the articles, based on the consensus of the two evaluators (RP, GD). We included studies with clear eligibility criteria for inclusion in the sample, a detailed description of the context, a reliable and valid measure of exposure, and adequate statistical analysis. Both authors agreed that articles with ≥ 50% of the total score to be included in the systematic review and meta-analysis. As a result, 15 studies were of high methodological quality for the primary outcome of interest [10,11,13,19-30] (S2 Table).

Publication bias

Publication bias was evidenced on both the funnel plots of precision asymmetry and the Egger’s test of the intercept. We run a trim and fill analysis in the random-effects model [32]. The magnitude estimates did not differ significantly between the initial and, trim and fill models (Figs 2 and 3).

Fig 2

Funnel plot with pseudo 95% confidence interval limits.

Fig 3

Filled funnel plot with pseudo 95% confidence interval.

Adherence to COVID-19 preventive and control measures

Fifteen articles [10,11,13,19-30] discussed the participants’ level of adherence to COVID-19 preventive measures in Ethiopia. Of these, four articles [19,20,29,30] discussed the adherence level of participants to each preventive measures separately while the remained 11 articles [10,11,13,21-28] estimated the overall compliance or adherence level. In two articles, the compliance percentage to hand hygiene was 22.3 [19] and 97.1 [30]. W. Hailu, et al. reported that 55.4% of the participants had poor compliance with social distancing measures [29]. In another article, 35.4% of respondents reported to be adherence with regular mask wearing [20]. Furthermore, 11 articles [10,11,13,21-28] were included to estimate the pooled magnitude of adherence to COVID-19 preventive measures in Ethiopia. The magnitude of adherence to COVID- 19 preventive measures in Ethiopia was ranged from 8.3% in Oromia [13] to 56.1% in Amhara [26]. Hence, the I2 statistic for heterogeneity has shown significant differences between the studies (I2 = 99%, p<0.05). Therefore, we have decided to fit DerSimonian and Laird random-effects model to estimate the pooled magnitude of adherence to COVID-19 preventive measures. Our decision was based on the theoretical assumptions that the heterogeneity (difference between the studies) might be because of the settings and socio-economic contexts [33,34]. The model also shows the weight of each study as per its sample size and effect size [35]. Accordingly, highest weight was reported in Silesh et al, 9.72% [26] while the lowest weight was recorded in a study conducted by Abeya et al., 7.96% [13] (Fig 4). The pooled estimate of adherence to COVID-19 preventive measures in Ethiopia was 41.15% (95% CI:32.16–50.14%) (Fig 4).

Fig 4

Forest plot studies assessing the magnitude of adherence to COVID-19 preventive measures in Ethiopia.

Also, the sub-group analysis of study setting showed that the pooled magnitude of adherence to COVID-19 measures in Amhara, SNNP and Oromia regions of Ethiopia was, 48.8% (95% CI:42.59–55.12%), 40.22% (95% CI:16.46–63.97%) and 27.35% (95% CI:2.24–52.46%), respectively (Fig 5).

Fig 5

Forest plot of studies assessing region-based magnitude of adherence to COVID-19 preventive measures in Ethiopia.

Factors associated with adherence to COVID-19 preventive measures in Ethiopia

Twelve articles have discussed about the associated factors of adherence to COVID-19 preventive measures in Ethiopia [10,11,13,19,20,23-26,28-30]. Of these, 8 articles were included in our meta-analysis to identify the associated factors of adherence to COVID-19 preventive measures in Ethiopia [10,11,13,23-26,28]. Sex [10,11,23-25,30], age [11,24,25,29], perceived COVID-19 severity [10,11,19,20,24,25], attitude [10,11,13,25-26] and knowledge [10,11,13,23,25,26,28] to COVID-19 preventive measures were found to have a statistically significant association with adherence to COVID-19 preventive measures (Figs 6–10).

Fig 6

Association between sex and adherence to COVID-19 preventive measures in Ethiopia.

Fig 10

Association between perceived disease severity and adherence to COVID-19 preventive measures in Ethiopia.

Sex

In this meta-analysis, the sex of the study participants was found to be a statistically significant factor in the adherence level of COVID-19 preventive measures. Male participants were 36% less likely to adhere to COVID-19 preventive measures than female participants (AOR:0.64, 95% CI: (0.54–0.78)). The heterogeneity between these studies was low (Fig 6).

Age

Also, age was another factor that had a statistically significant correlation with the adherence status of study participants to COVID-19 preventive measures in Ethiopia. People who were younger than 40 years old had 1.6 odds of adherence to COVID-19 preventive measures (AOR:1.6, 95% CI: (1.04–2.46)) (Fig 7).

Fig 7

Association between age and adherence to COVID-19 preventive measures in Ethiopia.

Knowledge of COVID-19 preventive measures

The present meta-analysis also found that people’s knowledge about COVID-19 preventive measures significantly associated with their adherence status to the COVID-19 preventive measures. Those who had good knowledge about COVID-19 were 2.51 more likely to adhere to COVID-19 preventive measures than those who had poor knowledge, (AOR:2.51, 95% CI: (1.67–3.78)) (Fig 8).

Fig 8

Association between knowledge and adherence to COVID-19 preventive measures in Ethiopia.

Attitude towards COVID-19 preventive measures

People who had a favourable attitude towards COVID-19 preventive measures were 1.85 times more likely to adhere to the preventive measures, (AOR:1.85, 95% CI: (1.36–2.53)) (Fig 9).

Fig 9

Association between attitude and adherence to COVID-19 preventive measures in Ethiopia.

Perceived severity of COVID-19 disease

Perceived COVID-19 severity was also another significant variable that correlated with the peoples’ adherence status to the COVID-19 preventive measures in Ethiopia. People who had perceived the severity of COVID-19 infection were 1.77 times more likely to adhere to the COVID-19 preventive measures than those who had not this perception (AOR:1.77, 95% CI: (1.40–2.25)) (Fig 10).

Discussion

This systemic review and meta-analysis attempted to estimate the pooled magnitude of adherence to COVID-19 preventive measures and its associated factors in Ethiopia. We found 41.15% of the people were adhered to the COVID-19 preventive measures in Ethiopia. This is consistent with a previous review in the country where the pooled level of health professional’ practice, towards WHO COVID-19 management and personal protection recommendations, estimated to be 40.3% [36]. This low level of adherence to COVID-19 preventive measures could be related with public fatigue, ignorance, misinformation, personal or social norms and perceived behavior control [37-40].

Another aim of this study was to identify the associated factors of adherence to COVID-19 preventive measures. Accordingly, sex, age, perceived COVID-19 severity, attitude, and knowledge of COVID-19 preventive measures were found to have a statistically significant association with the adherence to COVID-19 preventive measures.

Regarding sex, male participants were 36% less likely to adhere to COVID-19 preventive measures than female participants (AOR:0.64, 95% CI: (0.54–0.78)). This finding is consistent with previous studies conducted in Canada, China, Brazil, Uganda and Somalia, where male participants had had lower compliance with the COVID-19 preventive measures [41-45]. In the context of Ethiopia, men are the one often who runs the outdoor day-to-day activities that may lead to break the COVID-19 preventive measures.

People who were younger than 40 years old had 1.6 odds of adherence to COVID-19 preventive measures (AOR:1.6, 95% CI: (1.04–2.46)). We believe that Ethiopia has a higher educated adult population than it had before decades. Therefore, related with the recent digital technology advancements, the young generation might have better awareness and adherence to COVID-19 preventive measures than the old population. Conversely, studies from Brazil and Switzerland indicated that young adults are non-compliant [41,46]. This controversy might be because of the socio-demographic differences of study participants between Ethiopia and, Brazil and Switzerland.

In our meta-analysis, those who had good knowledge about COVID-19 preventive measures were 2.51 more likely to adhere to COVID-19 preventive measures than those who had poor knowledge, (AOR:2.51, 95% CI: (1.67–3.78)). This finding is complementary to that of the Democratic Republic of the Congo [47]. In connection, knowledge of restrictions can also predict positive attitudes towards restrictions and increase perceived ability to adhere to the mitigating measures as well [48]. Therefore, in this review, people who had a favourable attitude towards COVID-19 preventive measures had had 1.85 times more likely to adhere to the preventive measures (AOR:1.85, 95% CI: (1.36–2.53)). In line with this, a study from Iran established the positive relationship between positive attitude towards the effectiveness of preventive measures and adherence to them [49]. Therefore, the participants’ awareness and attitude could have an impact on their level of compliance to the rules and regulation of COVID-19 preventive measures.

Our finding also revealed that people who perceived the severity of COVID-19 had 1.77 odds of adherence to the COVID-19 preventive measures, (AOR:1.77, 95% CI: (1.40–2.25)). In previous studies, perceived susceptibility to COVID-19 infection and perceived severity of health-related consequences were linked to engagement in disease-preventive behaviors. Consequently, there is a possibility of a positive relationship between perceived severity and adherence [50-53]. Also, according to previous Health Belief Model (HBM)-based studies, people’s perception of the seriousness of having COVID-19 infection can dictate them to comply with recommended preventive measures [54-57].

Limitations

Our systematic review and meta-analysis had some limitations. First, all included studies were cross-sectional by design. Instead, it would have been more impactful if studies with variety of design had been included in the review. Secondly, the presence of heterogeneity between studies may not be supportive to draw inclusive inference about the general population.

Conclusion

This systematic review and meta-analysis found that the level of adherence to COVID-19 preventive measures in Ethiopia was low, below 50%. Furthermore, sex, age, perceived COVID-19 severity, attitude and knowledge to COVID-19 preventive measures were found to have a statistically significant association with adherence to COVID-19 preventive measures. Therefore, the government of Ethiopia and other stakeholders should mobilize resources to improve the adherence level of the community to the COVID-19 preventive measures and decrease public fatigue.

Search strategy.

(DOCX)

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Critical appraisal.

(DOCX)

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Extracted raw data.

(XLSX)

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PRISMA checklist.

(DOCX)

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STATA dataset for adherence level.

(DTA)

Click here for additional data file.

RevMan dataset for factors associated with adherence to COVID-19 preventive measures.

(RM5)

Click here for additional data file.

20 Jul 2022

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Reviewer #1: I selected 'partly' for the first question given my question in my review about the search terms used for identifying relevant articles. Depending on the answer to that question, I would change my selection to either yes or no.

I selected 'yes' for the second question, with the small caveat of whether odds ratios are the best way to examine the relationships between continuous variables (see my review).

I selected 'yes' for the third question as the authors indicated that all data is freely available.

I selected 'no' for the fourth question given that "PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous.". While I would describe the manuscript as intelligible, I also think, as I note in my review, that there are many parts that require further clarification.

The manuscript “Adherence to COVID-19 prevention measures and associated factors in Ethiopia: A systematic review and meta-analysis” (PONE-D-21-32366) estimated the rate of adherence to COVID-19 prevention measures in Ethiopia. To do so, the authors conducted a systematic review of relevant literature, concluding that the adherence rate was ~41%, with adherence predicted by sex, age, perceived severity, attitude, and knowledge.

My research experience has focused on health behavior more than systematic reviews, as the focus of my review shows. This paper may further benefit from a reviewer with more experience conducting systematic reviews.

I found the research question important and worthy of investigation. Additionally, I appreciated the authors’ contextualization of the study findings within the broader literature, as well as comparing Ethiopia to other national contexts when discussing the relatively low rate of adherence.

I also have concerns about the paper which, at least until they are addressed, prevent me from recommending publication. These are listed below, though in no particular order.

1. As is, the introduction does not adequately introduce the topic or prepare the reader for the study. It often reads like a list of facts, rather than a coherent perspective on the research topic. Some reorganizing and rewriting should be done to help guide the reader from the general topic to the specific research question. Relatedly, toward the end of the introduction, the authors raise the possibility that “non-adherence to COVID-19 prevention measures could have a negative impact on the health and socio-economy of Ethiopia” (p. 4). While this is an important question, it is not one addressed by the present study. This stage of the introduction should be narrowing in on the research question; I recommend the authors move or remove this sentence.

2. Much of the introduction (p. 3-4) lists the results of studies examining adherence to COVID-19 preventive measures in Ethiopia. These studies indicate that adherence rates are relatively low, with some explanations being “resistance to change, lack of community engagement...and lack of continuous community awareness creation” (p. 4). However, in the next paragraph the authors write that “the evidence bases remained inconsistent and inconclusive”. The extant literature seems consistent, so I’m unsure of where the inconsistency is thought to be.

3. According to the supporting information documents, the authors used the search term “prevention measures” to identify relevant articles. It is unclear whether this strategy would also return articles using the term “preventive measures”, which in my understanding is preferred by many people (I published a paper on this topic and was requested by the editors to use “preventive” rather than “prevention”). If so, please clarify. If not, then there may be relevant articles not included in this systematic review.

In addition to these larger concerns, I have some smaller recommendations for improving the paper.

● It is unclear who “we” refers to on p. 2 where the authors write that, “...we continued to face a shortage of medicines...”. Please clarify.

● On p. 2, why is the number of COVID-19 cases and deaths reported as of July 9, 2021 at 5:29 pm? This seems like a very precise time, though no indication is given as to why it was chosen.

● There are some sentences/phrases which could be improved. Some examples are included below:

○ “After a moment of patience...” (p. 3). This is too vague; I recommend the authors state more specifically what this patience refers to.

○ “...the sex of the study participants found a statistically significant factor...” (p. 10). I believe this is intended to mean “...the sex of the study participants was found to be a statistically significant factor”, though please clarify.

○ “...the study participants are either health professionals or general population who could have an impact to lower the pooled effect size of the adherence level” (p. 12). I believe this is intended to mean that non-health professionals would be expected to have lower adherence rates, though please clarify.

● I was surprised to see that such a small percentage (~1%) of the identified articles were included in the final analysis. This is where a reviewer with more experience in systematic reviews would be helpful.

● Sometimes the authors imply causality when discussing correlations. In one example on p. 10, the authors write that “...age was another factor that had a significant impact on the adherence status...”. Words like impact, influence, etc., suggest a causal relationship, but that’s not quite accurate. I recommend changing these wordings to reflect the correlational nature of the evidence.

● In the analyses of factors associated with adherence to COVID-19 prevention measures (starting on p. 10), I am confused about reporting odds ratios when a simple correlation seems to be more informative. This makes sense for categorical variables (i.e., sex), but less so for continuous variables (i.e., age, knowledge, attitudes, and perceived severity). I recommend that the authors report the correlations, or specify why odds ratios are preferred.

● In the limitations section, the authors state that one limitation is that the review contained no qualitative studies “that would have explored the determinants of adherence to COVID-19 prevention measures” (p. 14). It is unclear why qualitative studies would inform this question, as it seems like a quantitative question.

● In the conclusion section, the authors recommend the government of Ethiopia to “mobilize resources to improve the adherence level of the community to the COVID-19 preventive measures and decrease public fatigue” (p. 14). This is first mention of public fatigue outside of the abstract. If this is to be part of the policy recommendations, it should be discussed in the paper.

● Given that perceived severity was examined, I was surprised to see that there was no mention of the health belief model. I think this is fine if the model did not direct the authors’ thinking, though some reference to it may be warranted.

● I found the comparisons between this systematic review and individual studies in other national contexts (p. 12) somewhat unhelpful given the present purpose was to avoid relying on individual studies. Comparing the present findings to other systematic reviews would be more informative.

● In the interpretation section, the authors claim that “the magnitude of adherence to COVID-19 prevention measures in Ethiopia seems lower than the present findings” (p. 2). However, this study conducts a systematic review of these present findings, so it is unclear how there could be a discrepancy between this study and previous studies. Please clarify.

Reviewer #2: This manuscript describes a systematic review and meta-analysis to estimate the adherence to COVID-19 prevention measures in Ethiopia, and to study the socioeconomic factors associated with adherence. In this study several large electronic databases were used to search articles published between 2019 and 2021. In total, 699 articles were identified in the literature search, and finally seven studies were included in the study after a rigorous screening and selection process. The analyses followed a PRISMA standard for meta-analysis, the methodological quality of articles assessed using the Joanna Briggs Institute (JBI) quality assessment tool, and the inter-study heterogeneity was assessed using I^2 statistics.

However, I have some concerns:

1. It would be helpful for the author to evaluate the potential biases (such as publication bias and reporting bias).

2. The literature search in this study is till July 14, 2021. Given the rapid development of COVID-19 related studies, it would be helpful to have an updated literature search.

Overall, the study method is solid and rigorous. This study identified the key factors associated with adherence to COVID-19 prevention measures, which could provide important insights into improving the adherence level of the community.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

**********

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20 Aug 2022

Date 18/08/2022

Subject-response to comments given on our review manuscript.

Dear, Editors and Reviewers

Thank you very much for your kind consideration of our manuscript titled “Adherence to COVID-19 preventive measures and associated factors in Ethiopia: A systematic review and meta-analysis” and with manuscript ID number of PONE-D-21-32366. On behalf of my all authors, I would like to express my great appreciation to you and reviewers.

As per the constructive comments and suggestions given from the editorial office and reviewers, we have made detail revision and modification to the manuscript. Overall, this version is more detailed and better in terms of language utilization, coherence, format and subject matter.

In this version,

-Literature searching strategies and databases are updated, as suggested

-We have included 8 more articles over the existed 7 articles, a total of 15 articles.

-The manuscript is revised according to the author instructions provided by PLOS ONE.

-All the figures are corrected using the PACE tool and previously missed table is included in this manuscript.

-Detailed revision has been made in almost all sections of the manuscript.

-Linguistic errors are managed by experienced academician and native English, one of the authors (Professor Ruth Paterson)

-Suggested terminological changes are incorporated

In brief, all the amendments are explained in the point-by-point response table given below.

I thank you in advance.

With kindest regards,

Gdiom Gebreheat

Question, comment, or suggestion Response

Editor Thank you so much for the constructive comments! All the concerns are addressed accordingly.

�  1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming

We have revised our manuscript accordingly.

-All figures, table and supportive information are updated

-Headings are updated

�  2. We suggest you thoroughly copyedit your manuscript for language usage, spelling, and grammar. If you do not know anyone who can help you do this, you may wish to consider employing a professional scientific editing service.

This revised manuscript is updated accordingly. Moreover, we have made detail and repeated revisions for possible linguistic errors. Initially, the manuscript was checked on free online linguistic error checkers such as Grammarly, Ginger and grammarCheck.net.

-Then, it was also revised by one of the authors who is native to English (Ruth Paterson) for possible linguistic errors.

�  3. PLOS requires an ORCID iD for the corresponding author

I have linked my ORCID iD as per the request.

�  4. Please amend either the abstract on the online submission form (via Edit Submission) or the abstract in the manuscript so that they are identical

We have amended the abstract accordingly.

�  5. Please upload a new copy of Figures 3-9 as the detail is not clear. Please follow the link for more information:

All figures are revised accordingly

-All figures are updated using PACE

�  6. Please include a copy of Table 1 which you refer to in your text on page 7. -Table 1 is provided within the revised manuscript (P.9-14)

Reviewer #1 Thank you so much for the constructive comments! All the concerns are addressed accordingly.

�  1. As is, the introduction does not adequately introduce the topic or prepare the reader for the study. It often reads like a list of facts, rather than a coherent perspective on the research topic. Some reorganizing and rewriting should be done to help guide the reader from the general topic to the specific research question. Relatedly, toward the end of the introduction, the authors raise the possibility that “non-adherence to COVID-19 prevention measures could have a negative impact on the health and socio-economy of Ethiopia” (p. 4). While this is an important question, it is not one addressed by the present study. This stage of the introduction should be narrowing in on the research question; I recommend the authors move or remove this sentence.

We have made amendments to the introduction section (P.2-4).

In particular;

-Reorganizing and rewriting

-Adding and removing of statements as necessary

-Moreover, we have made detail and repeated revisions for possible linguistic errors. Initially, the manuscript was checked on free online linguistic error checkers such as Grammarly, Ginger and grammarCheck.net. Then, it was revised by one of the authors who is native to English (Ruth Paterson).

-quoted statement is removed, as suggested

�  2. Much of the introduction (p. 3-4) lists the results of studies examining adherence to COVID-19 preventive measures in Ethiopia. These studies indicate that adherence rates are relatively low, with some explanations being “resistance to change, lack of community engagement...and lack of continuous community awareness creation” (p. 4). However, in the next paragraph the authors write that “the evidence bases remained inconsistent and inconclusive”. The extant literature seems consistent, so I’m unsure of where the inconsistency is thought to be.

We have made amendments on the last paragraph of the introduction section (P.3-4).

-Suggested statements and ideas are corrected to be consistent.

�  3. According to the supporting information documents, the authors used the search term “prevention measures” to identify relevant articles. It is unclear whether this strategy would also return articles using the term “preventive measures”, which in my understanding is preferred by many people (I published a paper on this topic and was requested by the editors to use “preventive” rather than “prevention”). If so, please clarify. If not, then there may be relevant articles not included in this systematic review.

In this version of the manuscript, we have made a detail search of literature with additional databases and searching terms. During our search for articles, we have used both terms (prevention, preventive). P.4-5

-As suggested, we have also preferred to use the term “preventive” throughout manuscript.

In addition to these larger concerns, I have some smaller recommendations for improving the paper Thank you so much for the constructive suggestions and comments! All the suggestions are incorporated.

�  It is unclear who “we” refers to on p. 2 where the authors write that, “...we continued to face a shortage of medicines...”. Please clarify.

We have removed the statement as part of the revision to the introduction section. P.2-4

�  On p. 2, why is the number of COVID-19 cases and deaths reported as of July 9, 2021 at 5:29 pm? This seems like a very precise time, though no indication is given as to why it was chosen.

The mortality and morbidity rates of COVID-19 are being reported at daily base. The first version of our manuscript has been more than a year since last updated (July 9, 2021). So, we had reported the data available by then.

-We have made some amendments and update on this version, though. P.2-4

�  There are some sentences/phrases which could be improved. Some examples are included below:

○ “After a moment of patience...” (p. 3). This is too vague; I recommend the authors state more specifically what this patience refers to.

○ “...the sex of the study participants found a statistically significant factor...” (p. 10). I believe this is intended to mean “...the sex of the study participants was found to be a statistically significant factor”, though please clarify.

○ “...the study participants are either health professionals or general population who could have an impact to lower the pooled effect size of the adherence level” (p. 12). I believe this is intended to mean that non-health professionals would be expected to have lower adherence rates, though please clarify.

All the suggested statements and terms are corrected and adopted accordingly.

-P.3, line 58-64

-P.17, line 221-222

-P.18, line 256-258

�  I was surprised to see that such a small percentage (~1%) of the identified articles were included in the final analysis. This is where a reviewer with more experience in systematic reviews would be helpful.

We have updated our article searching strategies considering reviewer #2’s suggestion that there might be new publications since submission of the manuscript to PLOS ONE. Our article searching strategies and selection procedures are reproducible, and clearly explained in the method section. In particular, this can be cross-checked on

-Figure 1 (PRISMA flow chart)

-S1 table

-page 4, 5 and 7 of the manuscript

�  Sometimes the authors imply causality when discussing correlations. In one example on p. 10, the authors write that “...age was another factor that had a significant impact on the adherence status...”. Words like impact, influence, etc., suggest a causal relationship, but that’s not quite accurate. I recommend changing these wordings to reflect the correlational nature of the evidence.

All terms are revised, as suggested.

P.17, line 227 & P.18, line 246

�  In the analyses of factors associated with adherence to COVID-19 prevention measures (starting on p. 10), I am confused about reporting odds ratios when a simple correlation seems to be more informative. This makes sense for categorical variables (i.e., sex), but less so for continuous variables (i.e., age, knowledge, attitudes, and perceived severity). I recommend that the authors report the correlations or specify why odds ratios are preferred.

It is well-accepted suggestion, but majority of the authors, of the included articles, transformed the continuous variables into categorical variables during their analysis. That means, these suggested variables were reported as a categorical variables, for instance, age (20-30, 30-40, above 40), knowledge (poor vs good), attitude (favorable vs unfavorable),,,. In our analysis, we found them impossible to manage as continuous variables unless the raw data (dataset) of each article is accessed. Eventually, we decided to manage them as they are reported in each article, as categorical variables. In this case, we have reported the findings also in odds ratio.

�  In the limitations section, the authors state that one limitation is that the review contained no qualitative studies “that would have explored the determinants of adherence to COVID-19 prevention measures” (p. 14). It is unclear why qualitative studies would inform this question, as it seems like a quantitative question.

The limitation section is reformed accordingly. We have included more articles (15 articles in systematic review and 11 articles in meta-analysis) in this version. Therefore, absence of qualitative papers could not be a concern in this version of the manuscript. As you said, qualitative articles could not be included in meta-analysis but in the systematic review part. P.20

�  In the conclusion section, the authors recommend the government of Ethiopia to “mobilize resources to improve the adherence level of the community to the COVID-19 preventive measures and decrease public fatigue” (p. 14). This is first mention of public fatigue outside of the abstract. If this is to be part of the policy recommendations, it should be discussed in the paper.

we have updated the conclusion section accordingly. Plus, we have added a detail in the discussion section concerning public fatigue as well.

P.20-21

P.19, line 259-261

�  Given that perceived severity was examined, I was surprised to see that there was no mention of the health belief model. I think this is fine if the model did not direct the authors’ thinking, though some reference to it may be warranted.

As part of the rework in the discussion section, we have included research articles underpinned by Health belief Model (HBM), to support the concept of perceived disease severity.

P.20, line 293-298.

�  I found the comparisons between this systematic review and individual studies in other national contexts (p. 12) somewhat unhelpful given the present purpose was to avoid relying on individual studies. Comparing the present findings to other systematic reviews would be more informative.

We have updated the discussion section as suggested. We have also removed the comparisons of findings with individual studies. Instead, in this version, we have added more systematic review articles in our comparisons (discussion).

P.18-20

�  In the interpretation section, the authors claim that “the magnitude of adherence to COVID-19 prevention measures in Ethiopia seems lower than the present findings” (p. 2). However, this study conducts a systematic review of these present findings, so it is unclear how there could be a discrepancy between this study and previous studies. Please clarify.

Thank you for your recommendations and we have updated this section accordingly. In particular, we have reworded the mentioned statement as “The magnitude of adherence to COVID-19 preventive measures in Ethiopia appeared to be low”.

P.21, line 305-306

Reviewer #2 Thank you so much for the constructive comments and suggestions! The concerns are addressed as follows:

�  1. It would be helpful for the author to evaluate the potential biases (such as publication bias and reporting bias).

-The Publication bias for the articles included in the meta-analysis of Adherence level is explained in text and figures on page 15, Fig2 and Fig3. We have reported the publication using SE against the effect size i.e Adherence level

-We can also report the publication bias in every associated factor undergone meta-analysis if necessary. But, the articles will be still those of already included in the above publication bias reporting. If we do this, the readability of the paper might be affected because the manuscript will have around 17 figures. Instead, we have submitted the RevMan dataset, from which it is easy to see the publication bias of every associated factor when necessary (i.e for sex, age, attitude, knowledge, attitude).

�  2. The literature search in this study is till July 14, 2021. Given the rapid development of COVID-19 related studies, it would be helpful to have an updated literature search.

Overall, the study method is solid and rigorous. This study identified the key factors associated with adherence to COVID-19 prevention measures, which could provide important insights into improving the adherence level of the community.

We have updated our article searching strategies and databases. Accordingly, we found 8 more articles over the existed 7 articles, a total of 15 articles. In this version of the manuscript, therefore, we have included 15 articles in the systematic review. Of these, 11 articles were included in the meta-analysis.

P.4-5

P.7-8, line 153-164

Figure 1, Table 1, S1-S3

Finally, we greatly appreciate the editor and reviewers for their careful and kindly review again.

We are also very happy to accept any further comments and suggestions.

Thank you so much again!

Submitted filename: Response to reviewers.docx

Click here for additional data file.

14 Sep 2022

Adherence to COVID-19 preventive measures and associated factors in Ethiopia: A systematic review and meta-analysis

PONE-D-21-32366R1

Dear Dr. Gdiom Gebreheat,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Carlos Alberto Zúniga-González, Ph.D

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Dear my sincere congratulations!!!!! I have checked that all reviewers' observations were incorporating on the manuscript.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

**********

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The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

**********

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PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

**********

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Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: (No Response)

**********

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If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

**********

19 Sep 2022

PONE-D-21-32366R1

Adherence to COVID-19 preventive measures and associated factors in Ethiopia: A systematic review and meta-analysis

Dear Dr. Gebreheat:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

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