PONE-D-21-32366Adherence to COVID-19 prevention measures and associated factors in Ethiopia: A systematic review and meta-analysisPLOS ONE

Dear Dr. Gebreheat,

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. 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 #1: Partly

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

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 #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

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 #1: No

Reviewer #2: Yes

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5. Review Comments to the Author

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 #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.

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Reviewer #1: No

Reviewer #2: No

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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.

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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

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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

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

Reviewer #2: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

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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5. Is the manuscript presented in an intelligible fashion and written in standard English?

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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6. Review Comments to the Author

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

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