Practice Level and Associated Factors Towards the Preventive Measures of COVID-19 Among the General Population; A Systematic Review and Meta-Analysis

Background Studies conducted on the practice of COVID-19 preventive methods across the world are highly inconsistent and inconclusive. Hence, this study intended to estimate the pooled preventive practice and its determinants among the general population. Methods This study was conducted using online databases (PubMed, HINARI, Scopus, EMBASE, Science Direct, and Cochrane library database), African Journals online, Google Scholar, open gray and online repository accessed studies. The quality of the included studies was assessed using Newcastle-Ottawa Quality Assessment Scale (NOS). STATA 14.0 software for analysis. The existence of heterogeneity between studies was checked using Cochran Q test and I2 test statistics and then, the presence of publication bias was detected using both funnel plot and Egger's test. Results 51 studies were included and the pooled level of practice toward the preventive measures of COVID-19 was 74.4% (95% CI: 70.2–78.6%, I2 = 99.7%, P < 0.001] using a random effects model. Being female [OR = 1.97: 95% CI 1.75, 2.23; I2 = 0.0%, P < 0.698], rural residence [OR = 0.53: 95% CI 0.44, 0.65; I2 = 73.5%, P < 0.013], attending higher education level [OR = 1.47: 95% CI 1.18, 1.83; I2 = 75.4%, P < 0.001], being employed [OR = 2.12: 95% CI 1.44, 3.12; I2 = 91.8%, P < 0.001], age < 30 [OR = 0.73: 95% CI 0.60, 0.89; I2 = 73.9%, P < 0.001], and knowledgeable [OR = 1.22: 95% CI 1.09, 1.36; I2 = 47.3%, P < 0.077] were the independent predictors of adequate practice level. Conclusions nearly three-fourths of the general population has an adequate preventive practice level toward COVID-19. Thus, the global, regional, national, and local governments need to establish policies and strategies to address the identified factors.


BACKGROUND
Severe acute respiratory infection (SARS) is a group of respiratory tract infections caused by a beta coronavirus (SARS-COV2) (1)(2)(3). Corona Virus Disease-2019 ("COVID-19") is a family of SARS caused by Novel Coronavirus and was first detected in December 2019 in Wuhan, China. Since, the World Health Organization (WHO) has declared it as a pandemic; the virus has been distributed rapidly across the world and it causes high mortality and morbidity (2)(3)(4)(5). Globally, there is an estimated 32. million cases and nearly a million (991, 705) deaths at the end of September 2020 (6). As a result, nations across the globe have taken different preventive measures. These include movement restrictions, mask-wearing, hand washing, confinement at home, closure of schools, and other social services (7)(8)(9). Hence, appropriate knowledge, attitudes, and practices on preventive measures are mandatory to halt the spread of the COVID-19 outbreak in countries (10,11). However, studies revealed that the communities have shown still poor knowledge and negative attitude toward the preventive measures of COVID pandemic (12,13). Besides, studies conducted across the globe have been investigating the knowledge, attitude, and practices on preventive measures of COVID-19 pandemic predominantly focused on health care workers and patients (14)(15)(16). However, the studies conducted to date were highly variable and inconsistent to generate evidence regarding the determinants of preventive practice of the general population toward COVID-19. Therefore, this study intended to determine the pooled practice level and its determinants toward the preventive measures of COVID-19 among the general population.

METHODS AND MATERIALS
We have used the Preferred Reporting Items for Systematic review and Meta-analyses (PRISMA-2009) (17) to screen the included studies and PRISMA-P 2009 statements to report the findings (Additional File 1) (18).

Search Strategy
Different online databases (PubMed, HINARI, Scopus, EMBASE, Science direct, Cochrane library database, and African Journals online), Google Scholar, other open gray literatures, and online university repositories were retrieved to include articles conducted on preventive practice toward COVID-19. We have developed different Boolean operators to have comprehensive datasets on preventive practice toward COVID-19. Search MeSH terms: Wuhan coronavirus" OR "COVID-19" OR "novel coronavirus" OR "2019-nCoV" OR "coronavirus disease" OR "SARS-CoV-2" OR "SARS2" OR "severe acute respiratory syndrome coronavirus 2" AND "preventive practice" OR "practice" AND "associated factors" OR "risk factors" OR "determinants") [ conducted across the globe to assess the level of practice toward preventive measures of COVID-19 among the adult population.

Eligibility Criteria to Include Studies
In this systematic review, all observational studies (i.e., crosssectional, case-control, and cohort), studies reported the level of preventive practice toward COVID-19 and its determinants, and studies published in English language were eligible for this study. Besides, it also included all studies involving the adult population without restriction on the year of publication. However, we excluded studies other than observational studies (case reports, conference reports, and expert opinions) and the studies did not undergo a peer review process.

Outcome Measurement
This study had two main outcomes. The first outcome was to determine the pooled level of practice toward preventive measures of COVID-19 among the general population. In this study, the adequate practice level was measured by including studies that were correctly classified the level of practice using the median (50%) score or above. Then, the pooled estimate of preventive practice was calculated by dividing the number of population with adequate practice by the total sample size multiplied by 100. The second outcome of the study was to identify determinants of preventive practice using the pooled odds ratio with the corresponding 95% confidence interval.
Note: in this study, the general population is defined as all population other than health care professionals who are assumed to have better knowledge and practice toward COVID-19 compared to the general population.

Data Extraction and Quality Assessment
We had collected the findings of all online databases and eligible articles and it was exported to Microsoft Excel 2016 spreadsheet. Two authors (AWT and SB) extracted the data and reviewed all screened articles. The quality of the included articles was assessed using the Newcastle Ottawa Quality Assessment Scale (NOS) for observational studies (i.e., cross-sectional, case-control, and cohort) was employed (19,20). The studies with NOS scores of six or more were considered a "good" quality study (low risk) while studies scored less than six were considered as "poor" quality study (high risk) (20) [Additional File 3]. However, all retrieved articles had a score of six or more NOS scores.

Data Analysis
The extracted data were entered into a Microsoft Excel Database and then it was imported into STATA version 14.0 software with meta-analysis package for further analysis. We had performed a narrative description of the study population, the studies included, the risk factors identified, and the determinants of preventive practice toward COVID-19. The pooled estimate of the level of preventive practice toward COVID-19 was calculated using the random-effects models (21) at 95% confidence intervals. Moreover, the pooled odds ratios were determined with the corresponding 95% confidence intervals for its determinants.

Heterogeneity and Publication Bias
The Cochran's-Q statistic and I 2 statistic tests with the corresponding p-values (22) were used to determine the existence of heterogeneity between studies. In this study, a value of I 2 25, 50, and 75% were used to declare the heterogeneity test as low, moderate, and high heterogeneity, respectively (22). As a result, we had conducted subgroup analyses, meta-regression, and sensitivity analysis to handle the heterogeneity.
Publication bias was examined by visual inspection of funnel plots (23) and Egger's test (24). Hence, a p-value of < 0.05 was considered indicative of statistically significant publication bias.

Description of the Included Studies
In this review, 1,431 studies were retrieved from international databases, African Journals, online, Google Scholar, open gray, and online repositories. The accessed articles were focused on the level of practice toward the preventive measures of COVID-19 and its determinants among the general population. Furthermore, extended references were reached from the published articles. All of he retrieved articles were exported into endnote X8 reference managers and 1,180 articles were removed due to duplication and 152 articles were excluded after review of their titles and abstracts. Therefore, 99 full-text articles were assessed for eligibility and 48 articles were also excluded due to different reasons (i.e., abstracts, case-reports, conference reports, language, and experimental studies). Finally, 51 studies were met the inclusion criteria to undergo the final systematic review and meta-analysis (Figure 1). In this review study, 88,255 study participants were included from 51 observational studies conducted across the world.

The Pooled Level of Practice Toward the COVID-19 Preventive Measures
The level of practice toward the preventive measures of COVID-19 varies from country to country. In this study, 51 observational studies conducted across the world were included to estimate the level of practice toward preventive measures of COVID-19 among the general population (13,

Subgroup Analysis
Different techniques were applied to handle the high level of heterogeneity between the included studies. These include using random effects model, subgroup analysis, meta-regression, and sensitivity analysis.
In this study, subgroup analysis was done based on the region category (i.e., low-income, middle-income, and high-income) of the countries where the included studies were conducted and sample size category (i.e., sample size <380 and sample size ≥380). As a result, the pooled level of practice toward

Publication Bias
To identify the presence of publication bias, both a funnel plot and Egger's test were performed. Visual inspection of the funnel plot showed an asymmetrical distribution, which indicated the presence of publication bias (Figure 2). The finding of publication bias was confirmed following the Egger's test (p < 0.013).

Trim and Fill Analysis
In this review, the authors confirmed that the presence of significant publication bias that may be subjected to unpublished small studies. Thus, to handle this problem, the authors did trim and fill analysis and 19 studies were filled (Figure 3).

Sensitivity Analysis
We conducted a sensitivity analysis to assess the effect of any individual study on the pooled effect size. However, the sensitivity analysis done using a random effects model revealed

Meta-Regression Analysis
To investigate the possible source(s) of variation across the included studies, we performed meta-regression analysis using region (high, middle, and low-income), sample size, and quality of the score as covariates of interest. Thus, the results of this meta-regression analysis showed that region category was significantly associated with the presence of heterogeneity (p < 0.028) ( Table 1).

Sex of the Participants
In this meta-analysis, twenty-one studies were included to assess the association between sex of the participants and preventive practice toward COVID-19 (13, 27, 28, 33, 34, 37, 39, 41, 42, 45, 50-56, 60, 65, 67, 73). Hence, female participants in middle-income countries were twice more likely to have adequate practice on the preventive measures of COVID-19 [OR = 1.97: 95% CI 1.75, 2.23: I 2 = 0.0%, P = 0.698] compared to male participants (Figure 4). In this meta-analysis, there was heterogeneity between the included studies while we applied random-effects model and then subgroup analysis by region was done to handle the variation between studies.

Knowledge Level as A Factor of Preventive Practice Toward COVID-19
In this study, thirteen studies were included to assess knowledge level as a predictor of practice of preventive measures toward COVID-19 ( (Figure 5).

Education Level and Practice of the COVID-19 Preventive Measures
Seven studies were included to assess education level as an independent predictor of level of practice toward COVID-19 the preventive measures (13,26,33,37,41,46,50). The meta-analysis results revealed that participants who had attended higher education levels were 47% more likely to practice preventive measures toward COVID-19 compared to their counterparts [OR = 1.47: 95% CI 1.18, 1.83: I 2 = 75.4%, P < 0.001]. We applied random-effects model to handle the variation between studies (Figure 7).

Employment Status and Practice of the COVID-19 Preventive Measures
In this study, eight studies were included to assess being employed as a predictor of adequate practice toward the preventive measures of COVID-19 globe (27,28,33,41,42,48,50,53). As a result, employed participants had twice higher odds of adequate practice compared to unemployed participants [OR = 2.12: 95% CI 1.44, 3.12, I 2 = 91.2%, P < 0.001] using a random-effects model analysis (Figure 8).

Age of the Participants and Practice of the COVID-19 Preventive Measures
In this study, nine studies were included to assess the association between the age of the participants and the level of practice of preventive measures toward COVID-19 (13,27,28,34,37,46,50,54,55 Figure 9].

DISCUSSION
In this systematic review and meta-analysis, 51 observational studies were retrieved across the world focusing on the level of practice toward the preventive measures of COVID-19 and its determinants. In this review, the overall pooled level of adequate practice on the preventive measures of COVID  (13), and Pakistan (57.3%) (15). The differences in the practice of preventive measures could have been subjected to variation in the cut-off values to classify good or poor practices. For instance, most of the previous studies have been used the score of 80% and above to classify adequate practice, while the current study was classified based on the median score (50% or more), to consider studies with a good level of practice toward the preventive measures of COVID-19. In addition, the discrepancies might be due to differences in sample size, in which the current study involved a large sample sizes. Therefore, further investigation should be done to identify the main reasons for this variation across the regions. On the other hand, the subgroup analysis indicated that the pooled level of practice toward the preventive measures of COVID-19 in low-income, middle-income, and high-income countries was 69, 81, and 78%, respectively. This indicated that substantial heterogeneity of the level of preventive practice across countries. Such differences might be subject to low adherence of preventive practice toward COVID-19 in low-income countries. The other reason for the lower prevalence in these regions might be due to more studies were included in the review process. This study revealed that females from middle-income countries had twice higher odds of adequate practice on the preventive measures of COVID-19 [OR = 1.97] compared to male participants, which was similar to the findings of studies conducted across the world (13, 27, 28, 33, 34, 37, 39, 41, 42, 45, 50-56, 60, 65, 67, 73). In most of the countries, females are more responsible to take care than the family members. Besides, females are more likely to obey the regulations and rules of the government so that they are more likely to adhere the practice of preventive measures toward COVID-19 compared to males. In this study, knowledge level was the independent predictor of adequate practice on the preventive measures of COVID-19. Hence, the subgroup analysis showed that participants from high-income countries and with adequate knowledge had 22% more likely to have adequate practice toward COVID-19 [OR = 1.22] compared to their counterparts. Evidences across the world revealed that (26,28,34,37,41,42,44,46,49,53,73,74) adequate knowledge level positively correlated with adequate practice scores toward the preventive measures of COVID-19.
The meta-analysis results revealed that participants who had attended higher education levels were 47% more likely to have adequate practice toward the preventive measures COVID-19 compared to their counterparts [OR = 1.47]. Evidences of several studies conducted in different countries 19 (13,26,33,37,41,46,50) supported this finding. When the education level of the participants increases, they will have good knowledge regarding the preventive measures of COVID-19. This in terms improves the practice of the participants on preventive measures upon COVID- 19. In this study, the subgroup analysis by region category pointed out that participants from middle-income countries and those living in rural areas had 47% less likely to have adequate practice toward preventive measures of COVID-19 compared to their counterparts [OR = 0.53]. This finding is similar to the findings from different studies conducted in several countries (13,26,39,44,45,48,49,(51)(52)(53)74). In most countries, people living in rural settings are not accessible to the preventive measures provided by the government so that they are less likely to practice the preventive measures of the COVID-19 compared to people in urban settings.
This study indicated that the odds of adequate practice toward the preventive measures of COVID-19 was twice higher among employed participants compared to unemployed participants [OR= 2.12]. This finding is similar to studies conducted across the globe (27,28,33,41,42,48,50,53). Employed individuals have the chance to be exposed to preventive measures since the  Frontiers in Public Health | www.frontiersin.org employers safeguard their employees to be free of the impact of the COVID-19 pandemic. Thus, employed people are more likely to have adequate practice on the preventive measures of COVID-19 compared to non-employed individuals.
Worldwide, studies revealed that people under 30 years of age are less likely to be adhered to the preventive practice of COVID-19 (13,27,28,34,37,46,50,54,55). In our study, young age (<30 years of age) participants had 27% lower odds of adequate practice toward the preventive measures of COVID-19 compared to their counterparts [OR = 0.73]. In adulthood, people are less likely to adhere to the preventive measures recommended by the government so that they will have less compliance with practice of the COVID-19 preventive measures.

Limitations of the Study
The first limitation of the study was only English articles or reports were considered to carry out the analysis. Even though the quality of each study was assessed by using The Newcastle-Ottawa Scale, inter-author bias might be occurred with the leveling of the scale of each article. Reviewing of different characteristics of the involved cases with different sampling methods was also the other limitation of this study.

CONCLUSIONS
In this review, nearly three-fourths of the participants worldwide had a pooled levels of adequate practice toward COVID-19. Being female, rural residence, higher education level, being employed, age <30, and above median knowledge score were independent predictors of preventive practice toward COVID-19. Thus, the national and local governments should develop effective and inclusive prevention strategies to address students who are at home due to COVID-19 pandemic.

DATA AVAILABILITY STATEMENT
The data analyzed in this study is subject to the following licenses/restrictions: we will provide the dataset based on request when necessary.
Requests to access these datasets should be directed to abaywonday@su.edu.

AUTHOR CONTRIBUTIONS
AWT, SBA, KUM, SMT, and GB have conceived the title, write the significance of the study, generate the research questions, and write the methods section. AWT and SBA have done the data extraction and quality assessment. All authors critically reviewed and approved the final manuscript.