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Describe the sample and the population for the study. The

Describe the sample and the population for the study. The purpose of this paper was to synthesize and review the evidence for children and adolescent’s practice of COVID-19 preventive behaviors in comparison to adult samples. A secondary purpose was to review current evidence for the demographic, psychological, and social and environmental correlates of the preventive practice among children and adolescents during the pandemic (Table 2). The results are the first quantitative summary statistics for this age group and give new insights into designing effective interventions and making relevant policy-decisions to promote children and adolescents’ preventive behaviors in the fight against the COVID-19 and future pandemics.Collectively, this review represents 23 studies with over 25,000 children and adolescents from diverse regions. The majority of studies included in the quantitative anal-ysis were rated as good and high quality (16/17, 94.1%) and there was no statistically significant publication bias for all included studies. The majority of the included studies (18/23, 78.3%) measured the multiple preventive practice combining not only the three major preventive behaviors (i.e., hand hygiene, facemask wearing, physi-cal distancing) but also other preventive measures (e.g., covering coughs, house disinfection, intake vitamin C). In addition to the combination of multiple preventive behaviors, seven studies provided examinations on cer-tain specific behavior, including hand hygiene (n = 4), facemask wearing (n = 2), and physical distancing (n = 5).For the prevalence of combined preventive behaviors, 16-94% of children and adolescents adopted relevant preventive measures in response to the COVID-19 pan-demic. In terms of three major preventive measures, the compliance rate was 76-89%, 60-88%, and 31-87% for hand hygiene, facemask wearing, and physical distancing, respectively. When comparing the preventive practice across different age groups, we found a poorer preven-tive practice of children and adolescents compared with that of younger adults, while there were non-significant behavioral differences relative to the older adults. This highlights an urgent need of relevant interventions and policies for promoting preventive behaviors in children and adolescents during the pandemic. As the compul-sory policy of school closure has been enacted in many countries, the contact pattern and activity of children and adolescents are mainly community and family inter-actions [44] and personal protection is more expected accordingly. The under expectation of precautionary practice rises the concern that children and adolescents may threaten other susceptible individuals within com-munity and family with virus transmission.For the demographic correlates of preventive behav-iors, a significant association with small effect size was found between gender and preventive behaviors, where girls showed a higher behavioral compliance during the pandemic. Consistent findings were reported in previ-ous studies, which indicated that girls were more inac-tive and cautious to decrease outdoor activities during other respiratory epidemics [45], while boys had a high risk-taking tendency [46]. Interestingly, previous review studies with adult populations also indicated a higher level of preventive behaviors [45, 47] and utility of pre-ventive care service [48] in females. Thus, there seems to be a robust gendered affect across all ages in terms of the pandemic preventive practice. One potential interpreta-tion might be the personality difference that females tend to be higher in agreeableness [49]. Another explanation might be the difference in the general social position and social roles between males and females (e.g., females are more sanitary in general, who are more likely to be car-egivers and thus take precautions more seriously; females spend more time at home and thus more social distance, etc.) [50]. This suggests that more targeted messaging for men and boys is likely needed and further examination on this assumption is needed. In contrast to gender, other demographics such as age, education levels, and ethnic-ity were not identified as significant correlates of preven-tive behaviors among children and adolescents, hinting that the same types of intervention approaches may be administered without targeting by these demographic factors. Nevertheless, these findings are concluded nar-ratively due to the limited evidence and more empirical studies on this aspect are warranted.For psychological correlates of preventive behaviors, only attitudes and perceived severity were identified as consistently significant correlates of COVID-19 preven-tive behaviors in children and adolescents. As suggested by various psychosocial theories, e.g. TPB and HBM [13, 14], individuals’ health beliefs, cognitive and emo-tional appraisals for certain behaviors, and risk percep-tion towards the diseases play a crucial role in initiating behaviors. The findings of this study are consistent with previous review articles investigating adult populations [51]. We also found that children and adolescents showed a comparatively lower level of knowledge and attitude than adults. The findings presented here to some extent may provide an explanation as to why children and ado-lescents demonstrate inferior behavioral compliance during the COVID-19 pandemic. However, it is worth noting that more than half of the included studies did not report the theoretical framework and there was limited data to quantitatively analyze the effect size of other psychosocial correlates (e.g., social norms, intention, self-efficacy). Based on relevant theories and evidence, these factors are important and deserve more research and attention, especially targeting children and adoles-cents [52]. The above findings particularly suggest the use of psychological theories in future interventions on promoting children and adolescents’ preventive behav-iors in fight against the pandemics. For example, “threat” components or information about negative disease con-sequences could be used sparingly in the interventions. Further, a focus on causal explanation arguments of high positive expectancy benefits and appropriate persuasive peripheral cues (e.g., aiming to form positive attitudes) could be provided [53]. In addition, more research on the maintenance of preventive behaviors is needed by taking several factors other than cognitions (e.g., habit, social identity, self-regulation) into account.For the family and social correlates of preventive behav-iors, mixed results were revealed for a series of factors, such as parental education levels and family residence. It is notable that the community/city sanitation levels were narratively identified as an important correlate of pre-ventive behaviors in children and adolescents and more empirical evidence is needed for quantitative synthe-sis. In addition, we found a non-significant relationship between family economic status and preventive behav-iors among children and adolescents. The findings were inconsistent with previous studies in adult populations. The reason might be that adults determine family eco-nomic status rather than the children and adolescents, so the influence of economic status on children and adoles-cents’ behaviors is relatively weak [54]. This might be also attributed to measurement issues (i.e., implicit measures for family economic status, and diverse types of preven-tive behaviors).Despite notable findings in this review, there are several limitations. First, due to the limited data, we were not able to conduct moderator analyses (e.g., cultural con-texts, types of preventive behaviors, chronic health con-dition of children) and future research including testing of potential moderators is warranted. Next, despite our best efforts to implement a thorough literature search of the limited databases, we may have omitted suitable stud-ies by not including key terms over the time span that was searched. The current review only summarized the evidence during the initial stage of the pandemic and fur-ther updates are needed, especially for the key correlates of behavioral maintenance. Moreover, a high degree of heterogeneity, and the small number of included studies could result in cautious interpretation of the synthesized results. As a result, any generalizations of the findings to different cultural contexts should be applied with caution Page 11 of 13Li et al. BMC Public Health (2022) 22:1201 and this point deserves further investigation. As the rele-vant evidence continues to increase, future research syn-theses may be able to detect effects of more demographic, psychological, parental, social, and environmental fac-tors of children’s preventive behaviors. Finally, this paper only targeted the general practice of preventive behaviors during the initial stage the COVID-19 pandemic while the synthesis for specific behavior has not been under-taken due to limited evidence. Further examination on the characteristics and distinction of different preventive behaviors is needed

 
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