Enablers and Barriers to Handwashing and Vaccine Uptake in Kenya, Uganda, and Tanzania in Relation to COVID-19 Prevention and Control: A Systematic Review

doi:10.21203/rs.3.rs-2877995/v1

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Enablers and Barriers to Handwashing and Vaccine Uptake in Kenya, Uganda, and Tanzania in Relation to COVID-19 Prevention and Control: A Systematic Review

https://doi.org/10.21203/rs.3.rs-2877995/v1

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Background

The Coronavirus disease 2019 has brought about unprecedented challenges globally, threatening to undo the decades of progress on poverty, health systems and education. Several efforts have been put forward to edge the spread of the covid-19 disease including handwashing and mass vaccination. Despite their proven effectiveness, the uptake is low thus threatening to undermine the future successes of vaccination and handwashing campaigns. This review intends to determine the enablers and barriers to handwashing and vaccine uptake in Kenya, Uganda, and Tanzania in relation to COVID-19 prevention and control.

Methods

This review was carried according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA-P) guidelines. A comprehensive literature search of studies from three databases: PubMed, Direct science and Google Scholar was conducted. Published studies within the period between December 2019 up to end of January 2023 on enablers and barriers on handwashing and vaccine uptake in Kenya, Uganda, and Tanzania in relation to COVID-19 prevention and control were assessed and selected.

Results

A total of 391 research were reviewed, and 21 studies eligible for inclusion in the review. Results indicate that in the three countries: Kenya, Uganda, and Tanzania; the most cited barriers to handwashing and vaccine uptake include concerns on safety, efficacy, and quality of manufactured vaccines and handwashing practices, lack of awareness, lack of trust to the vaccines and handwashing, myths, misconceptions, and risk-perceptions. Enablers to handwashing and Covid-19 vaccine uptake identified were access to knowledge, access to hand hygiene programmes and water, involvement of community leaders to create awareness and socio-economic factors such as education level and cash incentives.

Conclusion

The study has identified enablers and barriers that can influence the success of these interventions in Kenya, Uganda, and Tanzania in relation to COVID-19 prevention and control. Stakeholders should formulate strategize to address the identified barriers leveraging on enablers to motivate the individuals to accept vaccination and practice more hand hygiene through creating awareness and sensitization through community leaders, making the vaccines and clean water or soap available and accessible.

Registration

PROSPERO ID CRD42023396303; registered on 2nd February 2023

Hesitancy

handwashing

acceptancy

uptake

Covid-19 vaccine

barriers

enablers

The Coronavirus disease 2019 has brought about unprecedented challenges globally, threatening to undo the decades of progress on poverty, health systems and education (1). To date, the pandemic has resulted to more than 6.7 million deaths worldwide, loss of jobs equivalent to 114 million globally and about half of the world’s 3.3 billion workforce is at the verge of losing their livelihoods¹², thus raising many concerns in everyone’s, mind especially about how to respond to the pandemic (1).

Different countries around the globe have taken different measures aimed at keeping the pandemic under control including mass vaccination, wearing of masks, setting up vaccination centers and handwashing stations in public places among other measures(2–5). Whilst there have been significant declines in new infections, a vaccine against COVID-19 is widely viewed as the safest health strategy to protect the public against transmission of covid-19(6, 7). The COVID-19 vaccines when taken exhibit a tremendous efficacy ranging between 50–90%, and almost 100% protection from loss of life (6, 7). As such, considerable investments in the manufacturing and roll out of covid-19 vaccines for emergency use has added a huge boost to the fight against COVID-19. Equally, hand hygiene practices such as handwashing continues to be critical strategy in reducing the transmission of COVID-19 and other related respiratory viruses. The World Health Organization (WHO) notes that handwashing with soap is the most effective low-cost strategy to minimize the transmission of SARS-CoV-2. Studies have shown that Hand hygiene when used with effectively has the ability of decreasing transmission of other respiratory infections during COVID-19 pandemic(8).

Given the importance of covid vaccines and handwashing, several studies have been carried out to determine the barriers and enablers on the uptake of vaccine and handwashing. In a study to assess hand hygiene compliance in India, the study findings indicated that spreading out facilities with clean water, soap, basins, and hand rub enhanced the use of hand washing(9). Also, a study to assess hand hygiene practices among Health Care Workers in Riyadh, Saudi Arabia, the study results showed that the participants who had formal hand hygiene instruction used it regularly throughout Covid-19(10). A study in Sub-Saharan Africa to investigate the obstacles to hand hygiene practices revealed that to improve hand hygiene practices, it was necessary to offer education on the topic and sustainable solutions to the water shortage, disinfectants, incentives, among other remedies (11). A study to investigate about hand hygiene obstacles in an intensive care unit of a teaching hospital in southeast Iran showed that lack of high-quality equipment decreased hand hygiene habits(12). According to the study, low-quality soap caused skin to become dry and itchy, and a lack of disinfectants resulted in low hand hygiene compliance. Further, a study to assess public perception in Indonesia revealed that the low hand hygiene compliance witnessed was due to lack of access to water(8).

Previous studies have also explored enablers of vaccine uptake. Evidence-based tactics in overcoming vaccine reluctance among Americans revealed that partnership between policymakers and the community was crucial in reducing vaccination hesitancy(13). In another study on vaccine reluctance, the results showed that usage of public health surveillance systems to collect and process data could provide timely and accurate health information for dissemination and decision-making, such as vaccine distribution(14). In addition, a study to address vaccine reluctance in Africa discovered that, community participation in vaccine distribution boosts vaccine uptake. According to the study, cross-sector cooperation helps people to access vaccines (15).

Previous research has also explored vaccine hesitancy worldwide (15)showed that lack of trust in covid-19 vaccines have resulted to vaccine reluctance (13). Successful vaccination adoption has been hampered by the quick speed of vaccine development and the widespread disinformation on social media and popular culture. A study to investigate COVID-19 hesitation and how to improve uptake, the findings showed that due to identified fear of needles or blood, safety worries, expense, religious convictions, and more had led to low uptake. Most of these factors resulted from false information and misunderstandings (16).

Despite several studies investigations examining the enablers and barriers to Covid vaccination and hand hygiene practices in different countries, the uptake of handwashing and covid-19 vaccines is low thus threatening to undermine the future successes of immunization campaigns. This can be a challenge in building herd immunity. This review aimed at determining the enablers and barriers to handwashing and vaccine uptake in Kenya, Uganda and Tanzania in relation to COVID-19 prevention and control.

^[1] https://www.undp.org/turkiye/publications/covid-19-rapid-impact-assessment-agri-food-sector-and-rural-areas-turkey

^[2] https://www.who.int/news/item/13-10-2020-impact-of-covid-19-on-people's-livelihoods-their-health-and-our-food-systems

The review was undertaken in harmony with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 checklist and the Centre for Reviews and Dissemination (CRD) guidelines (Moher, 2015; Akers et al., 2009). The protocol of the systematic review was registered at PROSPERO with approval ID CRD42023396303.

Inclusion criteria

The review considered all COVID-19 and hand washing, or vaccination published studies conducted in Kenya, Uganda, and Tanzania. Particularly, all published papers reporting on the enablers and barriers to handwashing and vaccine uptake in Kenya, Uganda, and Tanzania relative to COVID-19 prevention and control and duplicate studies were excluded.

Exclusion criteria

The studies were restricted to English language and those published between December 2019 and January 2023 and comparator group was included in the study. The studies were excluded if the authors did not address barriers and enablers to covid 19 in their analysis particular to Covid 19 vaccine and handwashing uptake.

Search strategies

Three databases: PubMed/Medline, Science Direct and Google Scholar were comprehensively used to search and locate published studies. A search strategy was formulated based on the PECOS framework by combining and all possible combinations. The last search was performed on 15th February 2023. The following search terms and words and their synonyms using Boolean operators were used to perform the search review: Enablers, barriers, handwashing, vaccine, COVID-19, prevention, Kenya, Uganda, and Tanzania.

Data screening and selection

Study selection was conducted in two stages. In the first stage, titles and abstracts of the retrieved studies were screened by two independent reviewers. In second stage, the studies that were considered potentially relevant were assessed for eligibility and full texts of the publications were read by the two reviewers and any disagreements were resolved by consensus or by involving a third reviewer.

Data extraction and management

Using the key research question, inclusion, and exclusion criteria as a guide, two independent reviewers extracted information from the research articles using a standardized data extraction form and any discrepancies were resolved by consensus. The extracted data included name of the first author(s) and year of publication, the title of the study, country of focus, study objective(s), study design, outcome definition, main findings highlighting the enablers and barriers to COVID-19 vaccine and hand washing uptake. In the review, the barriers and enablers were defined as reasons encouraging or that restrain uptake COVID-19 vaccine and hand washing uptake. The barriers and enablers were extracted from studies only when they were identified by the literature under review, and were explicitly mentioned and identified by the reviewers, while at the same time taking note of the context, analysis, and results of each study. The extraction process excluded indirectly induced enablers and barriers that referred to other literature. The extracted enablers and barriers to Covid − 19 and handwashing were thoroughly cross-checked and categorized by two independent reviewers.

Quality assessment and risk of bias

Three reviewers independently assessed the quality of included studies to minimize bias. All selected articles were judged for their quality. Two independent reviewers reviewed and appraised the studies, and any discrepancies were resolved by consensus. Essentially, the assessment was undertaken in accordance with the study objectives as opposed to the objectives of the underlying research studies. A third reviewer reviewed the studies to solve any disagreements between the two initial reviews.

Data synthesis and analysis

Using narrative synthesis, main finding was descriptively presented focusing on the specific outcome; findings were be grouped based on the specific outcome; that is barriers and enablers of vaccine and handwashing uptake.

The initial search retrieved 391 research papers from the three databases: PubMed; Science Direct and Google Scholar. After removing duplicates, 152 papers underwent abstract and title screening, which resulted in the exclusion of 73 studies. The remaining 73 studies underwent full text screening resulting in 21 research papers. Figure 1 below shows the selection process.

Characteristics of the studies

The study characteristics of the studies included this systematic review are presented in table 1 at the appendix. 8 studies focused on Kenya, 3 studies in Tanzania, 4 studies in Uganda and 7 studies focused both Kenya, Uganda, Tanzania and other countries.

Enablers to Covid-19 vaccine uptake

Access to knowledge and information

Three reviewed studies(17–19) indicated that access to knowledge and information about the importance of vaccination, the benefits, the side effects, and the risks has helped people to make informed decisions on vaccination. A study in Kenya revealed that due to public awareness on the significance of vaccination against SARS-CoV-2, 63.7% of the respondents from the pooled analysis acknowledged to have received information(19). A study in Uganda indicated that due to increased sensitization, 70.1% respondents in the study were willing to be vaccinated(17). Another review noted that due to awareness, there was willingness to be vaccinated in Low Middle-Income Countries (LMICs) including Uganda as such, messages highlighting vaccine efficacy and safety, delivered by healthcare workers could be effective for addressing any remaining hesitancy in the analyzed LMICs(18).

Involvement of community and religious leaders

One reviewed study (18) acknowledges that the community plays a crucial role in raising awareness and addressing concerns that the community thus building trust. In Uganda, community involvement had increased vaccine uptake. In general, the review noted that 70.1% of the respondents in the study were willing to be vaccinated.

Education levels

One reviewed study (20)focusing Kenya, Uganda, Tanzania, and other countries indicated that vaccination refusal in Kenya had declined dramatically over the course of 2021 from 24 % i February 2021 to 9 % i October 2021. The reduction was associated with education levels beyond the primary level.

Cash Incentives

One reviewed study(18) notes that providing cash incentives, such as direct payments or gift cards, can be an effective way to encourage vaccination uptake. The reviewed study showed that usage of cash incentives combined with vaccination reminders in Kenya had increased childhood immunization coverage.

Enablers to uptake of hand washing

Access to hand hygiene interventions and water

Five reviewed studies (21–25)have acknowledged the importance of access to hand hygiene interventions. A study by Abdullahi et al., (2020) focusing Kenya indicated that access to hand hygiene interventions were effective in reducing the transition of Covid-19 (21). Another review to examine WASH in Kenya’s slums Mathare and Kibera during the pandemic in 2021 indicated that WASH accessibility in Mathare was better than in Kibera an indication that the uptake could be high compared to Kibera where the 77.4% of people have limited to hand wash compared to Mathare which has 60.6%(22). Another reviewed study focusing Kilifi and Mombasa counties noted that 97% of households surveyed were practicing hand washing. In Tanzania, the reviewed study noted that handwashing facility could be accessed up to 80.7% being the highest compared to Kenya at 66.4% and Uganda at 59.2% (25) (25)Similarly, a study focusing Tanzania highlighted that access to effective alcohol-based sanitizers would boost Covid 19 mitigation efforts(23). A study by focusing Sub-Saharan including Kenya, Uganda, Tanzania and other countries indicated that uptake of handwashing ranged between 63–96.4%. In Uganda, the review indicated that 81.4% of the surveyed respondents practiced handwashing with water and soap(24).

Access to knowledge and information on hand hygiene

Three reviewed studies(21, 26, 27) indicated that access to information about the importance of hand washing, the benefits, the side effects, and the risks had indeed influenced handwashing. One of the reviewed studies (26)focusing Kenya indicated that 53.6% of the residents indicated that they had received information on hand hygiene practices. Another reviewed study focusing Tanzania -Dare salaam city(27) showed that 98.4% respondents reported to have been informed on how to effectively wash their hands with water and soap or use alcohol-based sanitizer thus influencing handwashing. Further, another study(21) notes that awareness on the importance of hand hygiene promotes handwashing uptake.

Barriers to uptake of Vaccines

Lack of access to vaccines

Two reviewed studies (28, 29) reported lack of access to vaccines. A study (28)focusing Kenya indicated that understanding geographical access regarding to Covid-19 vaccination locations is key for successful planning of vaccination programmes. A study focusing Kenya, Uganda, Tanzania, and other countries noted that accessibility was based on location-distance to vaccination centers (29).

Awareness barriers

Five reviewed studies show that inadequate awareness about the effectiveness of vaccines had influenced the low uptake. A study(30) focusing Kenya indicated that misinformation and lack of public sensitization about the vaccines had led to vaccine hesitancy. A study(31) focusing Uganda noted that due inadequate awareness on vaccination sites, the overall Covid-19 hesitancy was 58.6%. A study(32) focusing Kenya and other countries highlighted that Covid-19 acceptance rates ranged between 6.9 to 97.9%. Similarly, a study(29) to map uptake of Covid − 19 vaccines in Kenya noted that lack of adequate information had led to low vaccine uptake. Another study(18) highlighted that the vaccine efficacy witnessed in LMC samples including Uganda which averaged 19.2% could reflect lack of information about vaccines.

Fear of side effects

Five reviewed studies noted that concerns on side effects had indeed led to low vaccine uptake. A study to determine the acceptability and acceptancy rates of SARS-CoV-2 vaccine among Kenyans residing inhabitants noted that concerns on safety, effectiveness, and accuracy of information about the manufactured vaccines had resulted to COVID-19 vaccine hesitancy among females in both populations (19). A study focusing Uganda highlighted similar concerns on side effects (33). The findings noted that of the 346 health workers enrolled in the study, 13.3% were vaccine hesitant. A study to examine factors to SARS-CoV-2 vaccine uptake in Kenya indicated that unsubstantiated fear about the side effects and misinformation was still a barrier to vaccine uptake (30). A study(32) focusing Kenya and other countries and another study(34) focusing Kisumu on Kenya reported concerns regarding vaccine safety and side effects. Similarly, a study(29) focusing Kenya, Uganda and Tanzania noted that safety concerns were still a barrier on vaccine uptake among adults.

The lack of trust of COVID-19 vaccine

Three reviewed studies have indicated that lack of trust was one of the greatest challenges to acceptance of Covid-19 vaccine. A study(34) focusing Kenya to explore experiences of key informants noted that lack of trust in the information regarding the efficacy and safety of the COVID-19 vaccines provided by the health authorities had an impact on the uptake. Further, another study(33) noted that lack of trust in on COVID-19 vaccines had led to low uptake of Covid vaccinations in Uganda. Similarly, a study review focusing Kenya, Uganda, Tanzania and other countries indicated that lack of trust in government and public health authorities had led to low uptake of COVID-19 vaccines (29).

Myths, misconceptions, risk-perception

Two reviewed studies noted that myths, misconceptions, and risk-perception had influenced the low vaccine uptake witnessed. A study focusing Kenya, Uganda, Tanzania and other countries noted vaccine hesitancy was influenced by perception of being at low risk (29). In addition, a review (17) focusing on Uganda also mentioned myth busting within the society had influenced vaccine hesitancy.

Barriers to uptake to hand washing

Inadequate access to hand hygiene, water and soap

Four reviewed studies cited several barriers to hand hygiene/ handwashing. One study(26) indicated that lack of access to water and the likelihood of pay water was a challenge to uptake of handwashing in Kenya. Another study focusing on Kenya, Uganda, Tanzania and other countries indicated that lack of access to handwashing stations, water and soap was a big barrier to the uptake of handwashing. The study results indicated that handwashing prevalence declined significantly across regions and in each country with Tanzania recording a 14% decline (Δ84–70%) (35)). Similarly, another study(34) noted that inadequate access to hygiene and safety caused psychosocial stresses among healthcare workers thus affecting the quality of care provided. A study to examine WASH in Kenya’s slums -Mathare and Kibera- during the pandemic in 2021 indicated that accessibility of water was better in Mathare than in Kibera (22). A study(25) focusing Kenya, Uganda, Tanzania and other countries noted that in some areas, hand hygiene facilities including washing stations were still not universal, the results showed that Kenya had Kenya (66.4%), Tanzania (80.7%) and Uganda (59.2%).

Awareness barriers

One reviewed study indicated that lack of awareness and information was one of the biggest challenges to uptake of handwashing. In a study to assess (26) the knowledge about hand hygiene practices during the COVID-19 pandemic among residents in Mombasa and Kilifi counties in Kenya found that that information received on hygiene practices was below 50%. Access of information about hygiene was 42.6%, hand washing was 39.2% and the use of soap was 33.3%.

Fear of side effects

Two reviewed studies have cited fear of side effects was still a big challenge to uptake of handwashing. One of the studies in Tanzania indicated that there were still concerns regarding the safety and efficacy of manufactured handwashing sanitizers. Efficiency and safety concerns of manufactured sanitizers need to be assessed to safeguard public health safety (23). In a study carried in to explore the effects of the Covid-19 on the health care facilities in Kisumu-Kenya, fear of side effects by participants was cited as a barrier to handwashing practices (34)

The lack of trust

Regarding to handwashing, individuals did not trust the government's recommendations or messaging on the benefits of hand hygiene (24, 34). These results emphasis the need to build trust in order to increase hand hygiene uptake.

Myths, misconceptions, risk-perception

A reviewed study focusing Kenya, Uganda, Tanzania, and other countries indicated that due to misconceptions and risk-perception, some individual did not see the need for hand washing or the method of washing hands (24). Another study focusing Kenya, Uganda, Tanzania and other countries indicated that perceptions regarding the effectiveness of handwashing across the study countries had led to declines on handwashing prevalence from 84% to70% in Tanzania (35).

This systematic review aimed to determine enablers and barriers to handwashing and vaccine uptake in Kenya, Uganda, and Tanzania relative to COVID-19 prevention and control. Our results acknowledge that access to vaccines, hygiene programs and water is crucial to uptake of handwashing. The study results are similar previous studies (9) which indicated that providing facilities with clean water, soap, basins, and hand rub, at various places increased hand washing practice. Similarly, previous research on access to knowledge and information about hand hygiene and covid-19 vaccines has presented similar findings as highlighted by (10). The author’s findings revealed that participants who had received formal hand hygiene training applied the practice routinely during Covid-19. In addition, the study findings were consistent to (11) which concluded that improving hand hygiene practices required providing education on hand hygiene practices.

On involvement of community leaders, previous research has revealed similar findings (13). The author’s results were consistent with the study findings which show that when the community leaders collaborate with government, there is increase improve vaccination rates in the long run. Further, the results were similar to(15) which found out that that community involvement in the delivery of vaccines increased vaccine uptake.

Regarding barriers to Covid-19 vaccine and handwashing uptake, previous research findings agree with study findings. A study to investigate hand hygiene barriers in a teaching hospital's intensive care unit in southeast Iran (12), found out that a lack of quality equipment reduced hand hygiene practices. The study revealed poor quality soap resulting in skin dryness and itching, and a shortage of disinfectants led to minimal hand hygiene compliance. Similarly, results revealed that good hand hygiene practices were hindered by a lack of training, inadequate infrastructure, minimal resources, and low awareness. Another study(8) in Indonesia revealed that limited water led to poor handwashing practices. The current findings have reported similar findings, indicating that lack of access to clean water has limited handwashing uptake in the study countries.

In addition, beliefs, safety concerns, misinformation, and a lack of trust in the government has influenced low uptake of vaccines. Previous research has reported similar findings. Rutten et al. (2021) highlighted that lack of trust in covid-19 vaccines have resulted to vaccine reluctance (13). Similarly, the rapid pace of vaccine development and rampant misinformation in social media has hindered successful vaccine uptake. Further, another study to explore COVID-19 hesitancy(16) revealed that fear of needles or blood, safety concerns, costs, religious beliefs, had led to low uptake of vaccine. Most of these factors arise from misinformation and misconceptions.

Limitations

The study was limited to three nations, Kenya, Uganda, and Tanzania, or the East African Region only. This implies the study findings can only be generalized to the region. It may not be applied in studying a similar social phenomenon outside the region due to varying political, environmental, economic, and social factors. As such, future research should entail a more extensive scope of research to increase the generalizability of the study findings. The current study was also limited to a qualitative understanding of the topic of study. There was no causal understanding of the study variables. Therefore, future research should incorporate a quantitative approach to examine how barriers and enablers are related to hand hygiene compliance and vaccine uptake. The study was also inclined towards understanding the social phenomenon using already established research findings, limiting an opportunity for firsthand information. Future research should incorporate primary research using firsthand evidence to comprehend the study topic.

The review has acknowledged that handwashing and vaccine uptake are crucial measures to combat the spread of the pandemic in the three study countries. Nevertheless, the review has identified several barriers and enablers that can influence the success of handwashing and covid vaccinations.

On one hand, barriers to handwashing identified by the review in the three countries include inadequate access to hand hygiene, lack of access to clean water and soap, inadequate awareness in understanding the significance of handwashing, fear of side effects, lack of trust, myths, misconceptions, risk-perception. Similarly, barriers identified that has led to low to uptake of Covid-19 vaccine include lack of access to vaccines, inadequate awareness about the effectiveness of the vaccines, fear of side effects, lack of trust of COVID-19 vaccine and myths, misconceptions, risk-perception.

On the other hand, enablers to handwashing include provision of hand hygiene interventions and water in public places and in low-income areas such as slums, and access to knowledge and information on hand hygiene practices. Likewise, enablers to Covid-19 uptake include access to knowledge and information about usefulness of being vaccinated, involvement of community and religious leaders to create awareness and trust in the safety and efficiency of vaccines and, socio economic factors such as level of education, and use of cash incentives.

The study highlights that to effectively increase vaccine and handwashing uptake, there is need to address all the identified barriers at the same time leveraging on the identified enablers. This requires a multisectoral approach involving the private, government, community and other key persons to ensure that information on the importance of getting vaccinated and the benefits of hand hygiene practices are disseminated so that the citizens can make vaccination decision. Also, there is need in ensuring that the laid down policies are adhered to and that everyone accesses vaccines and hand hygiene facilities, knowledge and other support including incentives that could lead to people adopting these measures. Further, the study findings imply that close collaborations between stakeholders can be create trust thus overcoming identified barriers at the same time capitalizing on the enablers to improve handwashing and vaccine uptake and acceptance in Kenya, Uganda and Tanzania in relation to COVID-19 prevention and control.

COVID-19: Coronavirus disease; PRISMA-P: Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols; PECOS: Population, Exposure, Comparators, Outcomes; IFAD: International Fund for Agricultural Development; UNDP: United Nations Development Programme; WHO: World Health Organization; CDC: Centers for Disease Control and Prevention; HCWs: Health Care Workers (HCWs).

Acknowledgements: To all contributors

Authors’ contributions: All eight authors contributed immensely, read and approved the final manuscript.

Funding: Foreign, Commonwealth & Development Office (FCDO)

Conflicts of interests: The authors declare that they have no competing interests

Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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No competing interests reported.

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Enablers and Barriers to Handwashing and Vaccine Uptake in Kenya, Uganda, and Tanzania in Relation to COVID-19 Prevention and Control: A Systematic Review

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Abstract

Figures

BACKGROUND

METHODS AND MATERIALS

Inclusion criteria

Exclusion criteria

Search strategies

Data screening and selection

Data extraction and management

Quality assessment and risk of bias

Data synthesis and analysis

RESULTS

Characteristics of the studies

Enablers to Covid-19 vaccine uptake

Enablers to uptake of hand washing

Barriers to uptake of Vaccines

Barriers to uptake to hand washing

DISCUSSION

Limitations

CONCLUSIONS

LIST OF ABBREVIATIONS

DECLARATIONS

REFERENCES

Additional Declarations

Supplementary Files

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