Determining of the effective factors related to health-protective behaviors is important in prevent of diseases, especially infectious diseases. So, this study was applied to determine the role of health literacy and cognitive factors on COVID-19 protective behaviors among adults.
Gender was recognized as one of the demographic characteristics affecting health-protective behaviors. This was consistent with the results showed by Shahnazi in Iran and Sánchez-Arenas in Mexico [33, 34]. In general, in the prevention of the disease, women perform better than men [35].
Also, higher education level led to COVID-19 protective behaviors among adults in this study. In Iran, COVID‑19 preventive behaviors was greater in urban area than rural [33]. According to this finding, better understanding and performing protective behaviors requires education level and health literacy. Therefore, among the demographic factors gender and education level should be addressing in educational programs.
The most COVID-19 preventive behaviors distributions, among Iranian adults were wearing mask (66.3%) and covering mouth and nose while sneezing or coughing (44.2%) questions as “Always”. Results of the other study in Iran demonstrated rate of adherence to preventive behaviors from COVID-19 among adult were good health performance and 61.2% of participants reported placing a tissue paper or bending elbow in front of my mouth and nose when coughing or sneezing questions as “Always” [33]. This founding indicates providing masks and training in terms of covering mouth and nose while sneezing or coughing has been effective two of the selected and successful preventive behaviors in during the COVID-19 pandemic.
The results of this study showed protective COVID-19 behaviors relationships with all cognitive factors and HL. These results were consistent with the other study in Norway that reported an association between health literacy and adoption of protective behaviors among adolescents in COVID-19 pandemic [36]. It means that people’s health literacy can impact COVID-19 protective behaviors. The finding of Shaukat et al. indicated the health literacy of university students was predictor health protective in these groups [37]. Despite the spread of rumors and misconceptions during the COVID-19 pandemic, the promotion of health literacy and appropriate health behaviors by health centers and national media is a necessity.
Cognitive factors of this study have included risk perception, perceived benefits, perceived barriers, cues to action and self-efficacy. Among these factors perceived benefits and cues to action were strongest association with COVID-19 protective behaviors. In contrast, self-efficacy had the least association with them. The more adult perceived benefits of COVID-19 protective behaviors, the more cues to action and the less ones perceived barriers to perform the behavior, the more probably to adopt the COVID-19 protective behaviors. This result was also supported by the findings of Shahnazi etal., in 2021 [33].
Risk perception was the other construct that associated with protective behaviors. Kwok et al., reported individuals had higher risk perception of COVID-19, mild anxiety, and adoption of health behavior, travel-avoidance and social distancing [38]. Risk perception can help promote health behavior in outbreak, but it should not be overemphasized, because it may affect inverse on people. Indeed, people perform more to health behaviors, when they believe they are at risk [39]. It is normal that people have some risk perception of COVID-19 disease, but it should modify to a positive factor in the performing protective behaviors such as wearing mask, keeping a social distance, staying home, not touching face and, etc. This finding appeared to be in line with that of Shmueli in 2021 who indicated that people who intended to be vaccinated had higher risk perception of suffering and complications of COVID-19 [40].
In this study, higher perceived benefits were predictor of COVID-19 protective behaviors. Health care providers and national media should can balance among perceived benefits and perceived barriers an individual. People probably hesitate in performing protective behaviors when they are more inform of the complications and mortality of COVID-19 disease against perceived benefits of protective behaviors, because they believe protective behaviors are futile. This finding confirms the results of Grinberg and Sela (2021) [41].
Regarding perceived barriers, performing to preventive behaviors increased by decreasing perceived barriers. One of the effective constructs of HBM is perceived barriers because people need to overcome barriers to health behavior in contrast internal tendency to adopt protective behavior [33]. Perceived barriers in this study was the lower the other constructs, except self-efficacy. It seems individuals tend to protective behavior adherence despite external and environmental barriers. This finding is related to the result of the Grinberg and Sela that reported the lower perceived barriers led to the more willing to administer the measles vaccine in mothers [41]. In this research, environmental barriers included lack of masks, disinfectants, etc. that were unavoidable.
Cues to action determined the second most important factor in COVID-19 protective behaviors. this result is in contraction to a study was conducted by Shahnazi that there are n’t relationship between cues to action and COVID-19 protective behaviors [33]. This may be because which in that research, cues to action was measured only two questions (TV and radio). There are several information resources in term of cues to action including Ministry of Health, national media or mass media (TV and radio), cyberspace, a doctor, health care providers and staff medical in Iran. This is where that health policy makers and health care providers, etc. can make the greatest roles. Result of our study was similar to finding of Kohpeima Jahromi and et al, (2021) [42]. In study of Shmueli showed cues to action was significant predictors of intention to vaccinate against COVID-19 in adults [40] .
Self-efficacy was the last predictor of COVID-19 protective behaviors from HBM constructs. This result was supported by the findings of the previous studies [33, 34, 42]. This result showed people with the high self-efficacy can better perform protective behavior and take care of their own against COVID-19 disease. Self-efficacy is the situation-specific confidence that people can cope with high-risk situations without relapsing to their former behaviors [25]. In HBM, individuals should have an acceptable level of self-efficacy to overcome barriers to behavior [25]. that it is a modifiable factor that can promote health behavior. Then, it is necessary to address this factor during outbreak of the disease.
Health literacy was the other determinant of COVID-19 protective behaviors in this research. This result was comparable with previous studies conducted in Pakistan [37] and Mexico City [34]. In situation of Covid-19 outbreak, have emphasized increasing the health literacy to prevent the spread of infection, because health literacy is important for the prevention of communicable diseases [43]. Results of a study in Australia appeared low health literacy in individuals led to held misinformation beliefs about COVID-19 and vaccinations than people who had appropriate health literacy [44]. The present study, 66.3% of participants never wear mask to protect the corona outdoors, 45% seldom keeping their social distance, just 0.8% of people staying in home, 44.2% of them never use their handkerchief or cover when cough or sneeze and 1.1% of ones not touching mouth, eyes, nose and other part of their face. These results were in contradict with a study in Mexico that reported 85.4% of participants worn mask, 80.8% covered their mouth with a sleeve when coughing, 72.7% kept at least 1.5 meters distance, 68.5% avoided face touching, 62.1% stayed home [34]. The rate of COVID-19 protective behaviors was low in Iran during the COVID-19 pandemic. The need for improving of COVID-19 protective behaviors is a crucial factor to address in Iran. The low understanding of COVID-19 symptoms, less recognizing COVID-19 protective behaviors, the more problem in term of research information and understanding policy maker massages about COVID-19 disease result from lower health literacy in people [44].
This present study has shown that the HBM was successful to predict COVID-19 preventive behaviors among adults in Iran. 45% of the variation in protective behaviors was explained by cognitive factors of HBM as predictor variables, demographic features and health literacy factors. In the study of Shmueli, 74% of the variance in intention to get COVID-19 vaccine explained by HBM constructs, demographic and health-related factors [40]. Then, using of this model is suggested to be applied in the other communicable diseases and also, designing intervention programs.