Risk Perception and Preventive Behavior Adherence: A Systematic Review and Meta-Analysis in Europe

Abstract Introduction Since the onset of COVID-19, preventive measures (e.g., distancing, hygiene, masks) and vaccination have been key in reducing transmission and public health impact. While these behaviors are effective, their sustainability faces socio-economic challenges. Objectives To investigate the association between risk perception and adherence to preventive behaviors and conduct a meta-analysis comparing these behaviors in vaccinated versus unvaccinated subgroups. Methods A systematic review following PRISMA guidelines identified studies (2021-2024) analyzing risk perception and preventive behaviors. Potential biases were assessed using the AXIS tool. A meta-analysis calculated pooled effect sizes across subgroups. Results Of 1,594 screened studies, 10 met inclusion criteria (6 for meta-analysis, n = 9,115). Populations included adults, students, and healthcare professionals across 24 countries. Most vaccinated individuals maintained preventive behaviors despite stable or declining risk perception, though social distancing and hand hygiene adherence decreased over time. Booster-vaccinated individuals exhibited higher compliance than partially vaccinated or unvaccinated counterparts. Unvaccinated individuals intending to vaccinate reported higher risk perception than those refusing vaccination. Meta-analysis revealed no significant difference in risk perception between vaccinated (70.3%, 95% CI 60.8-79.8) and unvaccinated subgroups (70.8%, 95% CI 61.9-79.6; I²=17.5%), suggesting limited influence on behavior maintenance. Conclusions While vaccination and preventive measures curbed COVID-19 transmission, risk perception alone does not robustly predict sustained adherence, potentially due to risk compensation. Future research should prioritize determinants of long-term behavioral retention in public health strategies. Key messages • Preventive behavior adherence is influenced by multiple factors beyond risk perception. • Vaccinated individuals, especially those with boosters, showed higher adherence to preventive measures.