Attitudes, Perceptions of Risk, and Behavior Change of Students During Pandemics: A Systematic Review

Students in higher education institutions such as universities are at a unique risk for COVID-19 because learning takes place in a manner that warrants frequent social interaction. This systematic review of 18 studies examined the awareness, risk perception, and health behaviors among students in higher education institutions across 15 high- and low-resource countries. We found that accurate knowledge of the disease varied across different countries. We also found that students were more likely to use informal networks and social media to obtain quick and easy-to-understand information about the infection. However, a “casual” or low risk attitude was prevalent from the start of each pandemic of outbreak. This casual attitude circumscribed the adoption of prevention behaviors. We conclude our paper by using the Information-Motivation-Behavioral Model to recommend how to maximize the impact of the design and delivery of public health interventions in the student population.

pandemic where only 7.3% of students indicated wearing a mask when going out and 27.8% of students did not abide by physical distancing recommendations (Alhamid, 2020).
University students -as well as workers in the eld of education -are a community that require unique public health interventions that promote the adoption of individual hygiene behaviors. Individuals in educational institutions are at a higher risk of contracting disease because traditionally, learning takes place in a manner that facilitates high social contact. However, there is a need for clarity on how these groups respond to pandemics, epidemics, and outbreaks, which may aid in optimizing existing interventions in higher education institutions to improve the reach and uptake of physical distancing and other individual hygiene behaviors. This systematic review will examine the awareness, risk perception, and health behaviors among students in higher education institutions during three major pandemics and outbreaks in the 21st century: Ebola Virus Disease, In uenza A/H1N1, and MERS.

Approach
We conducted a systematic review to examine the awareness, risk perception, and health behaviors among university students and other workers in higher education institutions during three major pandemics and global outbreaks that occurred in the 21st century: Ebola, In uenza A/H1N1 and MERS. We included qualitative, quantitative, and mixed-methods studies that analyzed awareness, risk perception and hygiene behaviours during pandemics and global outbreaks in higher educational institutions such as universities and colleges.

Searching
We recently published a scoping review that examined the response of various individuals and communities of ve major pandemics, epidemics and outbreaks in the 21st century: Ebola, In uenza A/H1N1, MERS, SARS, and COVID-19 (Majid et al., 2020b). We decided to remove articles that looked speci cally at university students and other workers in higher education institutions from that review because they constitute a rather unique group that may differ from the general public. We used the articles retrieved in that review for this systematic analysis. Four databases: PsychINFO, Embase, Global Health and MEDLINE were searched on March 7, 2020 as a part of the original scoping review. Our search strategy is available in a supplementary le.

Screening
A pair of researchers used Covidence to conduct title and abstract screening, and full-text screening. We were most interested in qualitative, quantitative, as well as mixed-methods studies analyzing how students in higher education institutions responded to Ebola, H1N1, and MERS. We included articles describing social media analyses. We excluded theses, dissertations, abstracts as well as published papers that did not have any empirical primary data.

Data Extraction
We extracted study and methodological characteristics using a data extraction form, including the following information: author, year of publication, title, research objectives, country, type of pandemic, epidemic or outbreak (Ebola, In uenza A/H1N1, or MERS), topic/setting (community knowledge and attitudes, risk perception, public trust, social media, and community interventions), methodology (crosssectional, qualitative or mixed-methods design), data collection method (semi-structured interviews, selfadministered questionnaire, or focus groups), and number and type of participants.

Data Analysis
We conducted qualitative analysis of ndings across the following stages: pilot coding, initial coding, and focused coding. In the pilot coding stage, we identi ed common themes in the abstracts and used them to develop a preliminary coding schema. We used the schema to create two coding templates: 1) knowledge and awareness and 2) health behaviours to code the results and discussion sections of included studies (Aronson, 1995). The coding process was completed with consideration for how the authors presented their ndings. We extracted relevant data from the included studies and used it to populate our templates in the focused coding stage. Using the constant comparative method, we then conducted a comparison of codes across various studies, contexts, topics and countries (Boejie, 2002).
Following the completion of coding, the lead author drafted narrative summaries for every theme, which they revised in light of feedback provided by other researchers. The lead author then integrated all narrative summaries in order to provide a clear and coherent interpretation of the results.

Quality Appraisal
We appraised observational studies using the STROBE checklist retrieved from the Equator Network (Von Elm et al., 2007). We used the cohort and cross-sectional versions of STROBE as appropriate. Each study was appraised as a yes, no, or not applicable in accordance with the quality criteria. The appraisal ndings are reported narratively in a supplemental le. Social media was the most widely used source of information amongst students. Three studies from Italy, Turkey, and the United States reported that students used social media as their primary source of information ( A study conducted in Australia found that although 60.4% of university students believed that the H1N1 pandemic was serious, 40.4% reported that they were "not anxious" ( Van et al., 2010). Students in this study believed they were not susceptible to H1N1, despite being the age group with the higher number of cases ( Van et al., 2010). In a separate study conducted in Australia, students believed they were capable of ghting off any illness because they were young and led a healthy lifestyle (Seale et al., 2012). Similar sentiments were also found in students residing in the United States (Mitchell et al., 2011;Wilson and Huttlinger, 2010). For example, a study conducted in the United States found that 60% of students did not perceive dormitory residences to be a source of infection despite there being evidence that shared bathrooms and sleeping quarters were high risk areas for disease spread (Wilson and Huttlinger, 2010).

In uence of Mass Media on Risk Perception
The in uence of mass media on student perception of the infection varied throughout the pandemic. For example, a study conducted in Australia found that the resurgence of H1N1 media coverage caused a signi cant increase in anxiety, perceived susceptibility, and seriousness of disease spread ( Van et al., 2010). However, media coverage of the infection declined in accordance with a decrease in laboratory con rmed cases of H1N1 in Australia ( Van et al., 2010). Similarly, another study conducted in Pakistan reported 32% of medical students believed themselves to be at a risk of contracting H1N1 (Hussain et al., 2012). This nding re ected the relationship between low-risk perception due to the low number of laboratory-con rmed outbreaks reported in the newspaper and media (Hussain et al., 2012). Furthermore, one study conducted in South Korea reported a positive correlation between trust in the media, risk perception and overreaction (Yang and Cho, 2017). The study supported the claim that the mass media may increase perceptions of disease risks due to the frequent reporting of community spread of disease (Yang and Cho, 2017).

Health Behaviors
Studies reported that a signi cant portion of students did not wear masks. Two studies found that the use of a face mask was met with the most resistance among undergraduate and graduate students . Furthermore, a study conducted in Italy found that 67% of the 'very worried' students adopted a number of health behaviors, which contrasts with only 18% of 'not worried' students who adopted at least one health behavior (Serino et al., 2011). Furthermore, 32% of 'very worried' students from Italy reported that they would cancel their travel plans to the United States to avoid the risk of infection compared to only 5% of students who did not express worry (Serino et al., 2011). Consequently, 59% of students reported not modifying their behavior to reduce their risk of infection (Serino et al., 2011). One study reported that risk perception was directly associated with overreaction to the behavior of oneself and others. However, risk perception was not correlated with compliance with self-quarantine (Yang and Cho, 2017). This study found that risk perception motivates self-protective behaviour rather than behaviors that protect others such as quarantining (Yang and Cho, 2017). Misconceptions regarding the transmission of disease were also prevalent. While 39% of medical and dental students thought that H1N1 can be contracted through contaminated food and water, 35.2% believed that eating cooked pork was a potential means of transmission (Hasan et al., 2018). The same study also reported that approximately a tenth of university students inaccurately identi ed sexual intercourse and mosquitoes as modes of transmission of the disease (Hasan et al., 2018). Similarly, 70.9% of students from Saudi Arabia were found to falsely believe that the consumption of raw or insu ciently cooked animal products, including dairy products and meat, was unsafe in the context of the MERS outbreak (Al-Mohaissen, 2016).

Misconceptions
Students across various studies also demonstrated confusion regarding the origin of infection, classi cation of pandemics, and their support for conspiracy theories. For example, in one study, some university students from Iran suggested that EVD had been produced in the West to be tested in Africa (Holakouie-Naieni et al., 2015). Moreover, some university students in a study conducted in Pakistan incorrectly indicated that H1N1 was caused by a bacterium or that it was a heritable condition ( The included studies cover three major pandemics and global outbreaks in the 21st century: Ebola, In uenza A/H1N1, and MERS. In the following section, we analyze the ndings from our systematic review and discuss potential interventions or strategies that can help to curb the spread of disease among students and increase compliance to appropriate health behaviors. We employ the Information-Motivation-Behavioral Skills (IMB) model to develop future policies that may help to reduce high-risk behavior among students.

Risk Perception, Unrealistic Optimism, and Preventive Behavior
Past literature has reported that risk perception contains an affective component which involves fear or worry about the health problem (Kiviniemi and Ellis 2013). The Protection Motivation Theory was developed to examine how individuals protect themselves against health threats (Rogers 1975).
According to the Protection Motivation Theory, individuals who perceive higher levels of risk are more likely to adopt preventive behaviors (Prentice-Dunn & Rogers, 1986). In this study, we found that the majority of students possessed low levels of concern in response to the pandemic which translated to lower adherence to preventive behaviors (Hasan 2018; Holakouie-Naienia 2015; Hussain 2012; Van 2010). Low levels of concern and worry were attributed to students' perception of their "invincible and immune" bodies, which were deemed to be incapable of contracting viruses (Seale 2012). Previous research has found that students are more likely to make inaccurate or unstable judgments about selfrisk and behavioral control compared to the general population (Notani 1998). For example, a study that explored possible roles for optimistic bias in the Integrative Model of Behavioral Prediction on a university campus during the 2009 H1N1 pandemic supported this idea (Kim and Niederdeppe 2012). This study found that unrealistic optimists (i.e., individuals who believed that their risk is lower or equal to others) had signi cantly lower intentions to execute hand hygiene practices compared with others who believed that their risk was higher than other groups (Kim and Niederdeppe 2012). Another study found that students were less likely to follow precautionary measures when they believed that information from the media related to the pandemic was not relevant to them (Lee 2016). A lack of concern related to pandemic in uenza may decrease risk perception and hence decrease adherence to preventive behaviors.

Minimizing High-Risk Behavior
A possible model that can be used as a framework to minimize pandemic high-risk behaviors and promote preventive behaviors among university students is the Information-Motivation-Behavioral skills (IMB) model (Fisher and Fisher, 1992). The IMB model conceptualizes that three fundamental determinants -health-related information, motivation to avoid the disease and health behavioral skillsare necessary to promote and reinforce prevention behavior (Fisher and Fisher, 1992). This model has been statistically validated and applicable in young adults in the United States The rst construct (health-related information) of the model claims that information levels about prevention behaviors is a vital but not su cient condition for behavior change, especially when the behavior is complex in nature (Robinson 2017). To understand the IMB framework, it is important to de ne the terms "incremental theorists" and "entity theorists." Incremental theorists believe that individuals are malleable and can evolve through action whereas entity theorists believe that people are xated and cannot change. Given the distinction between incremental and entity theorists an intervention that promotes preventive behaviors during pandemics may include the following: claims that certain hygiene behaviors and physical distancing guidelines prevent viral transmission, myths pertaining to vaccination, and the implicit theory that "incremental-theorists will perceive greater self-e cacy compared to entity theorists" (Zhang et al., 2020). These three pieces of information are based on the original IMB model which was found to produce a powerful effect in the adoption of HIV preventive behaviors in truck drivers in India (Cornman 2007). Similarly, a study conducted in Jordan during the COVID-19 pandemic found that high levels of symptom and vaccination knowledge was due to the effectiveness and reach of various awareness campaigns (Alzoubi 2020). A number of studies in this review indicated that higher levels of knowledge about modes of transmission, symptoms, and preventive methods led to a greater uptake of hygiene behaviors and compliance with self-quarantine guidelines (Yang 2017; Zottarelli 2012). However, one study in this review found that despite public health and university health education campaigns, approximately 25% of students were unaware of the virus (Wilson 2010). This nding reinforces the importance of utilizing personalized health education strategies that are consistent with the mechanisms that students use to gain health information (Wilson 2010).
Although social media was a prominent information source in a number of included studies, it often lacked the depth and organization to reliably implement an educational curriculum. Hence, personalized education based on clinical practice guidelines, reminders and social media support may effectively inform students about prevention behaviors. This may include the development of social media apps that can connect students to government COVID-tracking sites and other resources. In addition, teachers and administrators of education can also play a more active role in information dissemination.
Encouragement of verbal communication and discussion-based learning can help to facilitate a better understanding of the disease and aid students in becoming aware of the purpose behind recommended health measures. Moreover, having more of these discussions can create an environment where students can clarify any misconceptions and be led to use the right information sources.
The second construct (motivation to avoid the disease) of the model pertains to personal motivation (i.e., perceptions of intervention e cacy and health behavior attitudes) and social motivation (i.e., perceived social support or social norms surrounding behavior) (Fisher and Fisher 1992). The in uence of personal motivation on behavior change was demonstrated in a study conducted in the United States on the general population during the COVID-19 pandemic, which found that adherence to non-pharmaceutical interventions (NPI) was associated with both outcome expectations (i.e., NPIs are effective) and process expectations (i.e., NPIs are inconvenient) (Kantor and Kantor 2020). Another study conducted in Jordan during COVID-19 found that only 19.3% of medical students believed face masks to be preventive, which correlated with 61% of students who did not wear face masks during the pandemic (Khasawneh 2020). Low process expectations were also evident within this review where students were most resistant to comply to social avoidance interventions as they were deemed to be impractical due to the regularity of human interaction in society (Seale 2012). Furthermore, international university students considered maintaining distance from infected acquaintances or relatives to be impolite (Seale 2012). At the same time, due to low process expectations, the use of masks were considered uncomfortable, inconvenient, and in some cases, unnecessary (Seale 2012). Being aware of reasons for NPI refusal among students may enable policymakers to tailor their messaging accordingly and induce behavioral change. Hence, understanding the relationship between intervention outcome beliefs and adherence to preventive behavior is essential as knowledge gaps of NPI e cacy can be addressed through outreach efforts. One study in this review claimed that perception of media in uence on self is the most important indicator of consequent attitudinal and behavioral changes (Lee 2016). In this sense, regardless of the severity of a news story, unless people perceived the story as personally relevant to them and were con dent in their ability to perform the suggested behaviors, the sensationalization of a news story may have no meaningful difference in behavior change. who endorse an incremental theory believe in their general abilities to evoke change more so than do entity-theorists, hence these individuals should exhibit higher levels of perceived self-e cacy (Zhang et al., 2020). This correlation is suggested but not directly tested in the health behavior literature.

Implications of this Research
In the face of public health crises, the IMB model can serve as a framework for the construction of effective interventions. Policymakers and government o cials should pay attention to publicity and guidance, strengthen positive interactions with the public and disclose relevant information in a timely manner to gain trust and to maintain the positive public perception of the interventions. Health education campaigns should target behavioral skills, strive to mitigate ineffective prevention information and raise awareness about the disease in order relieve stress and anxiety among university students. The ndings of this review may be used to construct better communication policies in order to manage future pandemics and outbreaks on university campuses. Taking into consideration the negative relationship between unrealistic optimism and intention to adhere to preventive behaviors, it is also vital to inform students of risk factors that lead to infection, so students are aware of the relationship between perceived and actual risk.

Strengths and Limitations
This systematic review has many strengths. This review explored a broad spectrum of university student campuses from various countries which allowed for a diverse extraction of behavior analysis from each group. This may lead to a greater degree of transferability of our ndings. Our ndings may be applicable when discussing, constructing and enforcing higher education health policies that are re ective of the behavior of students. Furthermore, this review may also be bene cial in gauging the knowledge levels of students. It may thus have implications for implementation of campaigns speci cally tailored to this group, allowing for a more e cient communication of pandemic-related information.
Despite the many strengths of this systematic review, we identify a number of limitations. This review was not able to examine all the possible pandemics, epidemics and outbreaks that occurred during the 21st century. Three major pandemics were selected based on their global impact, transmission method, and disease epidemiology. Moreover, pandemics and epidemics prior to the 21st century were not analyzed, which may have provided important insights into how knowledge, awareness, risk perceptions and health behaviors have changed with time.