Knowledge and Practice of Personal Protective Measures Against COVID-19 in Africa: Systematic Review

Introduction

Background

After its emergence in December 2019, COVID-19 was declared a pandemic by the World Health Organization on March 11, 2020, and it has spread to almost all countries and regions, including Africa [1,2]. Spreading to the continent through travelers returning from hot spots in Asia, Europe, and the United States, COVID-19 was first recorded in Africa in Egypt on February 14, 2020, and within a few months, the virus had spread throughout the continent [1,3]. As of March 20, 2023, a total of 12,804,191 cumulative cases and 258,623 deaths have been reported in Africa compared with 682,546,389 cases and 6,819,835 deaths across the globe, showing a disproportionately low case fatality rate of COVID-19 in Africa [4].

As in the rest of the world, various response measures were implemented in different African countries to curb the spread of the virus, including statewide lockdowns, restrictions on movement, bans on social gatherings, and school closures [5,6]. Although the continent appears to have a lower absolute number of cases and deaths compared with other regions [7], which might also be related to the lower number of tests administered, the pandemic has had a deep impact on the socioeconomic systems of African countries [8,9]. The pandemic has also strained the weak and fragmented health systems, as shown by the lack of personal protective equipment (PPE), testing kits, and other treatment necessities, especially for patients with COVID-19 who are critically ill [6,8].

With COVID-19 being a newly evolving disease, its less-defined outcomes and unprecedented prevention, treatment, and control modes largely require indisputable collaboration among various stakeholders in the community [9]. Nonpharmaceutical interventions play an important role in the control and prevention of pandemics, including the COVID-19 pandemic, especially in its early phase and wave. Despite the availability of approved vaccines against COVID-19, response measures toward this pandemic still largely depend on the practice of and compliance with personal protective measures (PPMs), including face mask use, social and physical distancing, and hand hygiene [10]. Moreover, knowledge and perceptions of PPMs have been reported as among the key determinants of practice and compliance with PPMs against COVID-19 as they influence people’s behavior [10,11]. These were also considered in this study in the African context.

The pandemic has had a broad range of impacts and challenges across regions, and different communities have responded differently. However, given the diversity of social systems across regions and countries, preparedness and the search for a country- or region-specific practical solution to the pandemic require a better understanding of the challenges of practicing PPMs and hard-learned experiences through comprehensive research [9]. There has been a high research output documenting COVID-19 characteristics, clinical outcomes, response, and impact throughout the world but with much less research coming from African countries [12,13]. The unavailability of research information might be seen as a barrier to successful prevention and further as a sign of inequity between high- and low-income countries and regions [14]. This scant literature poses knowledge gaps on how African countries are responding to the pandemic in terms of PPMs. Nonetheless, a recent review by Nwagbara et al [15] reported that most communities in sub-Saharan Africa had a positive attitude toward and good practices regarding COVID-19. Notably, this review considered studies only from sub-Saharan Africa and those conducted in the first stages of the pandemic, so it lacked insights into the overall practice of PPMs in Africa.

Objectives

Thus, this systematic review aimed to examine COVID-19 PPM research from African countries as documented in the published literature. On the basis of specific keywords, the review looked at the levels and associated factors of (1) knowledge and perception of PPMs and (2) practice of COVID-19 PPMs in various populations (including face mask use, physical and social distancing, and handwashing and hand hygiene).

Methods

Study Design

This systematic review was conducted according to a preregistered protocol in PROSPERO (CRD42022355101) and the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines (Multimedia Appendix 1) [16]. This systematic review considered literature concerning PPMs from African countries. Literature was sourced from the following databases: Scopus, PubMed, and Web of Science. These databases were considered as they sufficiently cover most of the key journals, including most African journals. In addition, 2 of these databases (Scopus and Web of Science) could refine the search based on countries and regions, unlike other databases, which enabled us to specifically assess publications from African countries only.

Search Strategy

We conducted a comprehensive search using a set of appropriate keywords and Medical Subject Heading terms to identify studies reporting on PPMs. For consistency and precision, similar keywords and Medical Subject Heading terms were used and searched for in the article titles across the databases. A comprehensive search of the published literature was performed in each of the 3 selected databases using combinations of key terms and Boolean operators (Textbox 1). These included “mask,” “nose covering,” “personal protective equipment,” “handwashing,” “hand washing,” “hand sanitizer,” “hand sanitiser,” “sanitation,” “hygiene,” “social distance,” “social distancing,” “physical distance,” “physical distancing,” “social acceptance,” “COVID-19,” “2019-nCoV,” “coronavirus disease,” “SARS-CoV-2,” and “corona virus disease 2019.”

Inclusion and Exclusion Criteria

The inclusion and exclusion criteria are listed in Table 1. Only population-based original research studies (including qualitative, quantitative, and mixed methods studies) conducted in Africa, published in English, and reporting on PPMs against COVID-19 were considered in the full review. In addition, multicountry studies were considered if they included an African country as part of their study population. Only English-language articles published between November 1, 2019, and March 4, 2022, were considered.

Data Extraction

After screening, data from the relevant studies were independently extracted by 2 reviewers (JK and PSC) onto a structured data extraction template, and a consensus was reached through discussion in case of disagreements on the extracted data. The following variables were extracted: first author, year of publication, study location, study design, key measurements, study population, sample size. and main findings.

Quality Assessment and Analysis

We assessed the information from the included articles using the Mixed Methods Appraisal Tool (version 2018) with detailed descriptions of the rating [17]. In total, 2 reviewers also independently assessed the quality of the included studies, and in case of discrepancies, a consensus was reached through discussion.

This study used thematic analysis, and the literature in this review was used to understand the practice of PPMs against COVID-19 in African countries. The studies were classified according to four main themes: (1) knowledge and perception of PPMs, (2) mask use, (3) social and physical distancing, and (4) handwashing and hand hygiene, including their respective levels or prevalence and associated factors. In addition, various population groups and challenges faced in practicing COVID-19 PPMs were examined under each of the main themes based on the available information in the analyzed studies. The 4 themes were drafted by a panel of public health experts after a series of discussions to reach a consensus.

The analysis process involved a six-step data synthesis process: (1) in total, 2 reviewers (JK and PSC) extracted relevant information on knowledge and practice of PPMs from each article independently; (2) after extraction, they discussed to reach a consensus on the key information identified in each article; (3) the extracted information was coded under the 4 predefined domains by the 2 reviewers independently; (4) after completing the coding independently, they discussed the results, where any discrepancies were resolved through discussion; (5) the revised coding results were read and checked by the 2 reviewers independently to ensure that all the extracted information was mapped to the 4 domains correctly; and (6) all the information in the codebook was adapted into a tabular format.

Results

Selection of Studies Conducted in Africa

The number of studies identified, reviewed, and selected, including the reasons for exclusion, is summarized in Figure 1. A total of 58 studies were selected through this process and further analyzed [18-75]. The information and main findings extracted from all included studies is detailed in Table 2.

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Distribution and Characteristics of the Studies

Of the 58 analyzed studies that primarily reported on PPMs against COVID-19 in Africa, 47 (81%) were single-country studies and were conducted in only 12 of the 54 African countries, whereas the remaining 11 (19%) involved multiple countries (Figure 2). Of the single-country studies, 36% (21/58) were from East Africa, 21% (12/58) were from West Africa, 17% (10/58) were from North Africa, 7% (4/58) were from Southern Africa, and none were from Central Africa. Ethiopia (16/58, 28%), Nigeria (7/58, 12%), and Egypt (5/58, 9%) were the top contributors and altogether produced 48% (28/58) of the analyzed studies. Thus, no single-country studies regarding COVID-19 PPMs had been conducted in 42 African countries at the time of our literature search (Figure 2).

The 58 analyzed studies included 51 (88%) quantitative studies, 5 (9%) qualitative studies, and 2 (3%) mixed methods studies, and their sample sizes ranged from 20 to 206,729. The 4 themes were represented as follows: knowledge and perception of PPMs (21/58, 36%), mask use (37/58, 64%), physical and social distancing (17/58, 29%), and handwashing and hand hygiene (19/58, 33%), considering that most studies covered more than one theme. Moreover, 34% (20/58) of the analyzed studies were conducted among health care workers (HCWs), 33% (19/58) were conducted among the general public, 5% (3/58) were conducted among patients with comorbidities, 3% (2/58) were conducted among university students, and 22% (13/58) were conducted among other groups. The studies were published between 2019 and 2022, and their overall quality was generally good, meaning that the included studies satisfied most of the criteria. However, lower scores on item 4 (nonresponse bias) and item 5 (appropriateness of statistical methods used) were noted among several quantitative studies (9/51, 18% and 13/51, 26%, respectively), with a similar trend observed among qualitative studies, as detailed in Multimedia Appendix 2.

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Knowledge and Perception of PPMs and Associated Factors

The results of the knowledge and perception of PPMs and other domains are summarized and presented in Table 3. Among the general public, higher rates of knowledge of COVID-19 preventive measures (>60%) were reported in Western Uganda [18] and Northwest Ethiopia [20]. Higher rates of good attitudes and perceptions were also reported in Western Uganda [18] and Egypt [21], but a lower rate of perceived benefits of preventive measures was reported in Addis Ababa, Ethiopia [22]. Similar findings of good perception were also reported in the Greater Kampala Metropolitan area of Uganda and in other 6 countries (Botswana, Kenya, Malawi, Nigeria, Zambia, and Zimbabwe), where a great majority of the residents believed that face masks were effective against COVID-19 spread and infection [23,24]. However, most individuals in Nigeria believed that COVID-19 was more of a hoax than a reality, and in several countries, preventive measures such as social distancing and face masking were perceived as imported policies that negatively affected their compliance with preventive measures to curb the spread of the disease [25,26].

Among African HCWs, higher rates of knowledge and attitude regarding the use of PPE were reported in Ethiopia [40,41] and Egypt [42]. However, a lower knowledge rate of PPE use (<30%) was reported in Nigeria, and in the early stages of the pandemic, a large number of frontline HCWs in Tunisia had not received official training on the correct use of PPE as many believed that they needed additional training [44]. In Egypt, although a substantial proportion (>80%) of house officers (fresh medical graduates doing their 1-year training in different specialties) had good PPE attitudes, <30% had good preparedness and willingness to participate in COVID-19 management and care [42].

Among other groups, only 3% of patients with chronic conditions such as cancer in Egypt, Algeria, and Morocco knew someone who had a COVID-19 infection, but most were worried about contracting the virus [61]. In Ethiopia, although university students had higher rates (>85%) of good attitude toward face mask use, their overall knowledge about mask use was very low (<30%) [64], which contrasts with medical students in Uganda with a better knowledge rate and where close to 70% agreed on the superiority of double masking over single masking for COVID-19 prevention and control [65]. In Nigeria, >50% of mothers perceived masking in children as not an appropriate preventive measure against COVID-19 because of the perceived difficulty in breathing and discomfort among children [66]. Notably, government employees in Ethiopia were reported to have higher rates of good perception of COVID-19 PPMs, whereby approximately 80% perceived consistent mask wearing as highly effective against COVID-19 spread and infection [68]. High COVID-19 vulnerability perception was also reported among commercial drivers in Ghana, mostly among older drivers, who consistently wore face masks and insisted on other persons in their vehicles doing the same [70]. Similar findings were reported among Ethiopian drivers who had good knowledge and positive attitudes [71]. Furthermore, most of the high-risk individuals in Uganda, including market vendors, had received information on face mask use and believed that face masks were protective against COVID-19. Moreover, those who had received information on face mask use were more likely to own face masks and perceive them as protective despite market vendors being more likely to reuse face masks than hospital workers [72].

As possible predictors, educational level, age, income, residence, frequency of PPE practice, PPE attitude, social media exposure, and perceived threat were associated with knowledge and perception of PPMs among the general population, HCWs, and other groups (taxi drivers and government employees) [18,23,24,42,43,68,70,71]. Moreover, practice location was notably significantly associated among HCWs [43] (Table 3).

Mask Use and Associated Factors

Among the general public, largely lower adherence rates (range 20.3%-59.4%) of face mask use were reported in various African countries, including Uganda, the Democratic Republic of the Congo, Somalia [18,27], and Ethiopia [20,22,29]. Notably, adherence rates to mask use were reported to be higher (>60%) after the lifting of lockdown restrictions and in countries where mask use was mandatory, such as Mozambique [27], Uganda [24], Morocco [31], and South Africa [32]. In addition, reusable cloth masks, which are more cost-beneficial and environmentally friendly, were the most used mask type [27]. Interestingly, in South Africa, the prevalence of close others’ mask wearing was reported to affect mask use, and older adults had poor mask use practices despite having a higher mortality risk [32]. In addition, the prevalence of mask wearing was noted to have increased substantially (50% to 74%) from May 2020 to August 2020 as COVID-19 cases increased and lockdown restrictions were eased, but staying at home, physical distancing, and social distancing decreased [32]. Regarding used mask disposal, poor disposal practices were reported in several African countries, including Morocco, where most threw their used masks and gloves in their house trash or trash bins, posing a transmission risk to sanitary workers or stray animals [31].

Among HCWs, varying rates of PPE use were reported in different regions and countries. Generally, lower rates (<60%) were reported in the Northwest [45], Northeast [46], Eastern [47], and Amhara regions [41] of Ethiopia, as well as in Egypt [48]. Nevertheless, higher rates (>60%) were reported in Nigeria [49], Libya [50], and 3 multicountry surveys [51-53]. The main challenges reported were inadequate PPE and side effects. The lack of PPE and, thus, the reuse of single-use PPE, especially facial protective shields and masks, were reported in several African countries, including Tunisia [44], Ethiopia [40,54], Egypt [48], and Nigeria [55], and in a multicountry survey including 4 North African countries [51].

Several side effects because of the use of PPE were also reported among African HCWs, including skin problems; heat; thirst; pressure areas; headaches; inability to use the bathroom; extreme exhaustion; discomfort; and reduced vision, concentration, and performance during or after wearing PPE [40,44,51,56-60]. Moreover, such side effects were associated with longer shift durations, the frequency of use, and medical specialty [51,58-60], and the most affected body areas from wearing PPE were the hands, the auricular area, the nasal bridge, the cheeks, and the whole face [52]. Notably, the most reported adverse reactions particularly because of using sanitizers were skin dryness, skin irritation, and ocular irritation [40,52]. Moreover, bleach immersion was reported to be highly associated with hand reactions, whereas hand cream use more than twice daily was associated with fewer reactions [60]. In contrast, a recent multicountry survey that included Egypt indicated that >70% of HCWs had all the PPE and protective measures they needed, >60% had been recently educated on COVID-19 infection control, and none of the interviewed HCWs refrained from using face masks [53].

Among other population groups, strict adherence to face mask use in public areas was reported among patients with cancer in a multicountry survey that included Egypt, Algeria, and Morocco [61]. In Ethiopia, >50% of adults with chronic conditions intended to practice and had ever practiced the recommended personal preventive measures against COVID-19 [62]. University students in Ethiopia were reported to have a higher adherence rate (>80%) of mask use [64]. Furthermore, approximately 20% of medical students in Uganda practiced double masking, where the lack of trust in the quality of masks was the most compelling factor for double masking [65]. Nonetheless, excessive sweating, the high cost of face masks, and difficulty in breathing were the major barriers to double masking among these medical students [65]. Moreover, poor adherence to mask use was highlighted among quarantined individuals in Ethiopia, where nearly half of them did not wear a face mask when leaving home [67]. However, high rates (>80%) of mask use were documented among government employees in Ethiopia [68]. Similar findings of high mask use (>70%) were also observed among taxi drivers [70] and patrons of convenience shops in Ghana [74] but with contrasting observations among commuters and in shopping centers, where less compliance with face mask use was reported [69,73].

Adherence to mask use was associated with gender, age, educational level, marital status, working status, profession, place or community of residence, knowledge and attitude, history of having COVID-19, perceived benefit, strictness of containment and health policies, subjective norms, perceived risk, barriers, cues to action, and self-efficacy among the general public, HCWs, and other groups (Table 3) [22,27,29,32,44-49,55,62,64,65,67,70]. Moreover, work experience, medical specialty (being a nurse or midwifery professional), hours of work, previous training on COVID-19 prevention and PPE use, having COVID-19 management guidelines, and ease and safety when using standard precautions were outstanding predictors among HCWs [44-49,55], and the field of study was a strong predictor of mask use among university students [64]. Surprisingly, mask use among children in Nigeria was highly dependent on the mother’s opinions and characteristics, whereby it was associated with the mother’s age, the age of the child, and the parental level of education [66].

Social and Physical Distancing and Associated Factors

Generally, lower adherence rates (range 18%-59%) of social distancing were reported in various African countries, including Egypt [21], South Africa [28], and Ethiopia [20,22,29,30]. Nonetheless, physical distancing policies disrupted social life and infringed on people’s sociocultural rights, causing adverse socioeconomic and health consequences, especially for low-income urban or suburban slum dwellers [26,34]. Although the imposition of COVID-19 distancing regulations led to a substantial decrease in extrahousehold social contacts (close physical and conversational contacts) in several African countries, including South Africa, there was ongoing contact within intergenerational households, highlighting a potential limitation of social distancing measures in protecting older adults [35]. In contrast, such restrictive policies improved feeding habits through increased meal planning and selection and preparation of healthy foods among residents of various countries [36].

Regarding the implementation and adoption of physical distancing measures, despite the implementation of various mitigation measures, the internally displaced people in Mali still faced several challenges, including the proximity in which internally displaced people live, the lack of toilets and safe water, and the lack of financial resources [38]. Similar findings were reported among prisons in Zimbabwe, where there were several challenges in the adoption of COVID-19 PPMs, such as severe congestion, interrupted water supply, outdated infrastructure, and inadequate hygiene and sanitation [39]. Moreover, although prisoners had adequate COVID-19 awareness and prison health professionals received training on COVID-19 control measures, PPE supply was inadequate, with no routine COVID-19 testing in place beyond thermal scanning; isolation measures were compromised by accommodation capacity issues; and social distancing was impossible during meals and at night [39].

Among other population groups, strict adherence to social and physical distancing was documented among patients with cancer, and most preferred web-based medical appointments over regular visits. In addition, some adopted healthier diets, used dietary supplements, and recited the Quran or supplications [61]. Similar findings of good practice of social distancing were also reported among patients with chronic conditions in Ethiopia [62]. Moreover, in Egypt, patients preferred teledermatology services to the usual physical clinic visits as they perceived them as reliable and safe during the pandemic [63]. Government employees in Ethiopia also had higher rates (>80%) of good practice of physical distancing [68], and the same applied to commuters in Ghana, who had high compliance rates with social distancing guidelines [69].

Adherence to social and physical distancing was associated with gender, age, educational level, working status, place or community of residence, family size, knowledge and attitude, strictness of containment and health policies, perceived risk and barriers, cues to action, and self-efficacy among the general public and other groups (patients with chronic diseases; Table 3) [20-22,28-30,62].

Handwashing and Hand Hygiene and Associated Factors

Regarding community adherence to hand hygiene, lower rates (<60%) were reported in 12 sub-Saharan countries, where the likelihood of handwashing mainly varied with the level of concern about COVID-19 [33]. In resource-restricted settings, a recent study indicated that >60% of the slum dwellers in Nairobi, Kenya, had limited water, sanitation, and hygiene facility accessibility and opportunity, making adherence to COVID-19 PPMs impossible [37].

Concerning hand hygiene adherence among African HCWs, varying rates were reported in different regions and countries. Generally, lower rates (<60%) were reported in the Northwest [45], Northeast [46], and Eastern [47] regions of Ethiopia. Nevertheless, higher rates (>60%) were reported in Nigeria [49], Southwest Ethiopia [40], and 2 multicountry surveys [52,53].

Regarding other groups, strict adherence to proper hand hygiene was reported among patients with chronic conditions in various African countries, including Egypt, Algeria, Morocco [61], and Ethiopia [62]. A similar observation was made among government employees [68] and taxi drivers [71] in Ethiopia, both of whom had higher rates (>60%) of frequent handwashing and hand hygiene as a means of protection against COVID-19. However, poor adherence to COVID-19 safety protocols at shopping centers in Ghana was reported, whereby, although shops complied with providing handwashing facilities, most of the customers did not practice handwashing before entering the shops and did not wear face masks during shopping, and neither did the shop attendants [73]. Similarly, a very low rate (10%) of appropriate handwashing was reported among patrons of convenience shops in Accra, Ghana [74]. In contrast, an increase in proper handwashing performance was reported among bank visitors in Ethiopia after watching a handwashing demonstration [75].

Handwashing and hand hygiene during the COVID-19 pandemic was associated with gender, age, educational level, marital status, profession, place or community of residence, knowledge and attitude, exposure and adherence to handwashing guidelines, strictness of containment and health policies, type and availability of water sources, and perceived risk and barriers among the general public, HCWs, and other groups (Table 3) [19,22,29,33,45-47,49,62,71,74,75]. Moreover, work experience, medical specialty (being a nurse or midwifery professional), previous training on COVID-19 prevention and PPE use, feedback on safety, having COVID-19 management guidelines, and ease and safety when using standard precautions were notable predictors among HCWs [45-47,49].

Discussion

Principal Findings

To our knowledge, this is the first systematic review to evaluate PPMs against COVID-19 among various population groups in Africa. This systematic review has important implications as it reflects cognitive behavioral issues (knowledge and practice) regarding PPMs in some African countries during an infectious disease outbreak. Future outbreaks or waves of COVID-19 may force people to use PPMs again. The review used a multidimensional approach involving the systematic evaluation of evidence based on region, country, and population group. Moreover, comprehensive coverage of the literature was attained, and a reproducible search methodology was applied using a predefined framework, all of which are strengths of this review.

Among the general community, the review showed varying levels of knowledge, attitudes, and perceptions, which in turn influenced the practice levels of and compliance with COVID-19 PPMs, especially face mask use, hand hygiene, and physical and social distancing. This finding is in agreement with a previous study from sub-Saharan Africa [15], and similar findings have been reported in other regions where communities’ cognition directly affected the practice and uptake of COVID-19 PPMs [76]. Nonetheless, the observed difference in the practice and adherence to PPMs across African countries may be due to the differences in COVID-19 control policies, income (gross domestic product), and the situation of the pandemic among the countries. Notably, the compliance rates of face mask use reported in most African communities were generally lower compared with those reported in studies from high-income countries [77,78]. This may partly be explained by the inability to afford to buy face masks and the differences in the strictness of such preventive measures [22,29,79]. Nevertheless, poor adherence to face mask use was also reported in some high-income countries such as Australia, Norway, and Sweden [80], the reasons for which may be other than just the inability to afford face masks. Moreover, lower rates of handwashing and hand hygiene were also reported in several African communities, especially among low-income urban and slum dwellers. This was partly due to a lack of safe and clean water in slum communities [37]. Moreover, buying soap or hand sanitizers was an additional financial constraint for low-income urban dwellers and, thus, may be seen as a luxury.

The results indicate a reduction in the rates of PPM practice (mainly mask use and social and physical distancing) noted in several African countries following the lifting of restrictive lockdown measures and the rollout of COVID-19 vaccination programs. This can be partly explained by pandemic fatigue as more people become demotivated and exhausted to follow the recommended infection prevention and control measures owing to the prolonged impact and existence of COVID-19 [81]. As COVID-19 PPMs complement the vaccination protective advantage, this implies a need for continued community sensitization and education programs to rectify the reluctance to practice PPMs amid the relaxation of preventive restrictions. Moreover, prompt management of infodemics in the current and future infectious outbreaks is needed to address the misinformation about PPMs [82].

Among African HCWs, generally good knowledge of PPE use was reported but with varying levels of practicing PPMs, and the low practice rates were attributed mainly to the lack of PPE and the side effects of prolonged PPE use. With HCWs being at the frontline of screening and managing suspects and patients with COVID-19, the lack of PPE increases the risk of infection when doing their work. Nonetheless, the lack of PPE has also been documented in other countries and regions outside Africa [83]. Furthermore, this review showed that most patients with comorbidities in Africa reported strict adherence to COVID-19 PPMs, which may be due to their perceived high vulnerability to COVID-19 infection and complications. Other studies outside Africa have reported similar findings among patients with comorbidities [84,85].

The study findings show that several cognitive (including knowledge, attitude, and perception), demographic, and socioeconomic factors were associated with the practice of and compliance with COVID-19 PPMs among African communities. COVID-19 being a newly evolving disease with varying cross-cutting impacts implies a need for consideration of such cognitive, demographic, and socioeconomic differences in the design of targeted response measures against the pandemic. Nonetheless, similar findings on the association of sociodemographics with the practice of COVID-19 PPMs have been reported in other regions outside Africa [80].

This review has some practical recommendations for improving COVID-19 control programs in Africa. Efforts are needed to improve the local capacity to produce and supply PPE, especially to HCWs, as the lack of PPE was the main barrier to PPE use. In the early phase of the pandemic, most countries were overwhelmed by the increased demand for PPE, which disrupted the global supply chain, and this had dire consequences for countries with inadequate local manufacturing and supply capacity [83]. In addition, providing free or subsidized face masks and soap, especially to low-income earners, would be a helpful strategy for improving PPM practice and adherence. Moreover, the consideration of vulnerable groups such as low-income urban dwellers and internally displaced people and targeted responses tailored to their socioeconomic dynamics are paramount for effective pandemic control programs. Knowledge and perception influenced the practice of PPMs, implying a need for continuous infodemic management, community education, and sensitization, and this should be tailored to address the existing misconceptions and barriers to PPM adherence. Notably, although several of the analyzed studies (11/58, 19%) evaluated the association between age and the practice of COVID-19 PPMs and showed varying rates and results, no single study focused on exploring COVID-19 PPMs among the older adult population of Africa. Given the known vulnerability of older people to severe COVID-19, efforts are needed to explore this special group to help fully understand their behavioral response to the pandemic, which is vital for guiding targeted responses.

The review also reveals substantial inequalities in terms of research output from different regions of Africa, with PPM studies mostly coming from East, West, and North Africa and only 3 countries (Ethiopia, Nigeria, and Egypt) producing >40% (28/58, 48%) of all the studies. This finding coincides with the study by Nwagbara et al [15], which showed the dominance of East and West Africa in COVID-19 research. The high PPM research output from North and West Africa could be because they were the first regions to record COVID-19 cases in the continent [86]. Although South Africa is known to lead African research with sound and more vibrant research institutions in the continent [14], its contribution to COVID-19 PPM research is far lower, as indicated by the study results. Regarding other African countries, the observed pattern may be explained by the differences in research capabilities and resources. Nonetheless, such research inequalities pose gaps in understanding how such countries and regions respond to the COVID-19 pandemic. This implies a need for more focus, funding, and involvement in behavioral health research, which is as important as clinical research and vital in guiding evidence-based and country-specific or tailored policies and responses in addressing the dynamics of the current COVID-19 pandemic.

Limitations

This systematic review has some limitations. Although we used a comprehensive keyword search strategy, some relevant studies might have been missed as only 3 databases and only English-language articles were considered. In addition, we did not consider gray literature and preprints in this review; thus, they should be considered in future or updated reviews on PPM practice for a more comprehensive search. Although a comprehensive search was performed, no relevant studies were found from 42 of the 54 African countries; thus, the findings might not provide a comprehensive picture of the knowledge and practice of PPMs across the entire continent. Moreover, the findings and conclusions of this review are based on studies that were mostly web-based surveys, which, although this was inevitable because of the restrictive preventive measures and lockdowns, are prone to selection bias based on internet accessibility. Owing to the self-report nature of these surveys, recall and social desirability bias cannot be overlooked. Moreover, assessments of statistical analyses of associations with the practice of COVID-19 preventive measures, as well as meta-analyses, were not performed as these were not the main focus of this review. Despite these limitations, this study provides valuable insights into the facilitators of and barriers to the practice of PPMs in Africa.

Conclusions

This review evaluated the knowledge and practice of COVID-19 PPMs in African countries. The findings, conclusions, and recommendations of this review specifically apply to the included countries and, thus, should be interpreted with caution. The results indicate that African communities, including various population groups, have varying levels of practice and compliance with COVID-19 PPMs, with the lack of PPE (mainly face masks) and side effects of PPE use being the major reasons for poor compliance, especially among HCWs. In addition, various cognitive, sociodemographic, and economic factors were associated with the practice of COVID-19 PPMs. Therefore, this review highlights a need for enhancing the local capacity to produce and supply PPE. The consideration of various cognitive, demographic, and socioeconomic differences, with extra focus on low-income urban dwellers and those who are less advantaged, is vital for inclusive and more effective strategies against the pandemic. Moreover, more focus, involvement, and funding of community behavioral (including protective measures) research is needed to fully understand and address the dynamics of the current pandemic in Africa.