COVID-19 precautionary behavior:  The Israeli case in the initial stage of the outbreak

Abstract

Background: The lay public's behavioral responses during a virus spread, such as the coronavirus disease 2019 (COVID-19), play an important role in bringing the outbreak under control, and provide insights into development of risk communication messages to the public. Therefore, this study aimed to explore the association between knowledge about COVID-19, perceived susceptibility, emotional reactions and precautionary behavior among the Israeli lay public at the beginning of the COVID-19 outbreak.

Method: A cross-sectional study was conducted among 1,407 participants, aged 18+. Participants completed measures of knowledge about COVID-19, perceived susceptibility, emotional reactions, precautionary behavior , and socio-demographic questionnaires. A multiple hierarchical regression was calculated with precautionary behavior as the dependent variable.

Results: Findings indicated that precautionary behavior was higher for females, older participants, participants with higher levels of knowledge about COVID-19, and participants with greater negative emotional reactions. A negative curvilinear relationship was found between perceived susceptibility and precautionary behavior, so that the latter was highest for participants with moderate perceived susceptibility. All interaction terms were non-significant.

Conclusions: Findings suggest that in order to enhance precautionary behavior in the initial stage of a virus outbreak, it is recommended to pay attention to the public’s knowledge about the virus, perceived susceptibility and emotional reactions. Although negative feelings about the virus may motivate preventive behavior, it is important to address these feelings.

Introduction

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2)¹. The incubation period of COVID-19 is 1 to 14 days; the mean has been estimated at 5.2 days². The most common presenting clinical symptoms are fever and cough, in addition to other non-specific symptomatology, such as fatigue, dyspnea, headache and muscle soreness³. Most people infected with COVID-19 will experience mild to moderate respiratory illness and recover without requiring special treatment^4,5. However, older adults, and those with underlying medical problems - such as cardiovascular disease, diabetes, chronic respiratory disease, and cancer - are more likely to develop a serious illness^4,6.

First appearing in December 2019 in China, this virus has rapidly spread around the world⁷, including Israel. The first Israeli person with COVID-19 was diagnosed on February 21, 2020. Since then, in Israel, thousands have been isolated in their homes, hundreds have been diagnosed and 16 individuals have died from this virus (at the time of writing this paper). The Israeli Ministry of Health⁸ continues to release and update guidelines, instructions and restrictions for the lay public regarding how to behave in the new daily routine. These guidelines include precautionary behavior such as washing hands often with soap and water or an alcohol-based hand sanitizer; avoiding close contact with people with symptoms such as coughing or sneezing; avoiding shaking hands; and covering one’s mouth and nose when coughing or sneezing⁸. However, as Israeli citizens receive information about COVID-19 from various sources, they may have incorrect knowledge regarding the disease. In addition, the numbers of suspicious and diagnosed cases continue to increase, which may affect the public’s estimation about the severity and controllability of the virus^1,9.

Among the factors that may influence willingness and motivation to adopt precautionary behaviors are perceived susceptibility¹⁰ and emotional reactions such as worry, fear and stress¹¹. Perceived susceptibility has been used to measure one’s perception of the likelihood of experiencing a disease or a virus¹². Worry is assumed to involve an emotional process and is closely related to anxiety¹³. Fear is defined as an unpleasant emotional state that occurs in response to a real threat or danger¹⁴. Regarding stress, studies on Severe Acute Respiratory Syndrome (SARS) indicated that the outbreak of an unprecedented virus can cause immense stress to the lay public and influence the public’s precautionary behaviors^11,15.

Knowledge about COVID-19, perceived susceptibility, emotional reactions and precautionary behaviors among the lay public are significant in the control of epidemics, as was learned after SARS¹⁶. Both cognitive (e.g., knowledge about COVID-19, perceived susceptibility) and emotional matters (e.g., worry, fear and stress) have an important bearing on coping with health threats¹⁷. However, research literature regarding these concepts in the area of COVID-19 is only now beginning to emerge⁹. Therefore, the aim of the current study was to examine the association between knowledge about COVID-19, perceived susceptibility, emotional reactions and precautionary behavior. This aim is especially important, given that the behavior of the general population can play an important role in both the spread and control of infectious diseases¹⁸.

Methods

Procedure and participants

Prior to commencing the study, authorization was obtained from Bar-Ilan University’s Ethics Committee (approval No. 032003). To minimize personal contact during the outbreak, the questionnaires were administered through the Qualtrics online platform (www.qualtrics.com). A total of 1,435 Israelis visited the online survey between March 12, 2020 and March 21, 2020. Inclusion criteria for the study were: (1) individuals aged 18+; and (2) Hebrew speakers. Exclusion criteria were: (1) minors (under the age of 18), who require parental consent (n=14); and (2) responses to the items in a similar pattern (e.g., choosing the same answer across multiple consecutive items or within the whole questionnaire) or not completing the questionnaire in its entirety (n=14).

As can be seen in Table 1, the study included 1,407 participants. The majority of the respondents were female (80%), with a mean age of about 41 years (range 18–97) and an average education of approximately 16.5 years (range 9–30). Most were married (63%) with a mean of two children. About 85% did not have health problems and about 80% reported good health status. Only 5% were isolated in their homes since the outbreak of COVID-19 and the most favorable resource that participants reported which could ease their coping with COVID-19 was working from home.

Table 1 about here

Measures

Precautionary behavior was measured using a 4-item scale created by the authors following the precautionary guidelines issued by the Israeli Ministry of Health⁸. The scale’s validity was reached by expert validity, a form of content validity. In this validity process, the scale was reviewed by a panel of four expert physicians in order to eliminate totally irrelevant items from the instrument¹⁹ and to re-phrase or supply new wording for items related to the measured construct where necessary²⁰. Participants were asked to indicate how often they perform various precautionary behavior on a 5-point scale (from 1 = not at all to 5 = very often). A composite index of the average of all items was created, a higher score indicating that participants display more precautionary behavior. Sample items include washing hands with soap and water or alcohol-based hand sanitizer, and avoiding close contact with people with symptoms such as coughing or sneezing. The internal consistency of the index was moderate (Cronbach’s α = 0.75).

Knowledge about COVID-19 was measured using a 6-item COVID-19 knowledge test assessing the symptoms, diagnosis, risk factors, ways of transmitting the infection, ways to protect oneself from COVID-19 and knowledge regarding where to refer a person who is suspected to have COVID-19. The scale’s validity was reached by expert validity (as detailed in the Precautionary behavior measure). Answers were rated on a 5-point Likert-type scale, ranging from 1 = don’t know at all to 5 = know very much. A composite index of the average of all items was created, with a higher score indicating higher levels of knowledge about COVID-19. The internal consistency of the index was very good (Cronbach’s α = 0.82).

Perceived susceptibility was assessed based on previous studies conducted among the general public (e.g.,¹³), with a one- item measure examining the extent to which the participant thinks he will contract the virus. “How likely do you think it is that you will contract COVID-19?” Answers were rated on a 5-point Likert-type scale, ranging from 1 = not at all likely to 5 = very likely.

Emotional reactions towards COVID-19 were assessed based on previous studies conducted among the general public (e.g.,¹³), with 3 questions concerning worry, fear and stress as a result of COVID-19 (e.g., “How much do you worry about COVID-19?”). Answers were rated on a 5-point Likert-type scale, ranging from 1 = not at all to 5 = very much. A composite index of the average of all items was created, with a higher score indicating higher levels of negative emotional reactions towards COVID-19. The internal consistency of the index was excellent (Cronbach’s α = 0.94).

Socio-demographic variables included gender, age, years of education, marital status (married/divorced/widow/single/other), number of children, medical problems (yes/no), health status (bad/reasonable/good), home insulation since the outbreak of COVID-19 (yes/no), resources that can make it easier to cope with COVID-19 (more information regarding COVID-19/professional support/non-professional support/working from home/other).

Statistical analyses

Data were analyzed using SPSS ver. 25. Descriptive statistics were used to describe the participants’ demographic characteristics and the research variables. Pearson correlations were calculated to assess the associations between the research variables. Strength of correlation was as follows: 0-0.20, weak; 0.21-0.50, moderate; 0.51-0.80, good; and 0.81-1-00, excellent. A multiple hierarchical regression was calculated with precautionary behavior as the dependent variable. Gender (1-males, 0-females) and age were entered in the first step, knowledge about COVID-19 in the second, perceived susceptibility in the third, and negative emotions in the fourth. As perceived susceptibility had a curvilinear relationship with precautionary behavior, all variables were standardized.

Results

Table 2 summarizes the means, SDs, ranges and correlates of the study's variables. As can be seen, the mean for the precautionary behavior score was 3.71 (SD=0.85), in a range of 1-5, meaning the precautionary behavior score was relatively high. The mean score of knowledge about COVID-19 was also relatively high, while the means for emotional reactions and perceived susceptibility were moderate. In other words, participants in the current study had relatively high knowledge about COVID-19, believed there is a moderate probability that they would become ill from COVID-19, and had moderate negative feelings as a result of the virus. Figure 1 summarizes the means and SDs of the study's variables.

According to Table 2, positive associations were found between knowledge about COVID-19, emotional reactions and precautionary behavior, meaning the more knowledge participants had about COVID-19, and the more negative emotions they had towards COVID-19, the more precautionary behavior they exhibited. In addition, higher perceived susceptibility was associated with higher levels of negative emotions towards COVID-19.

Table 2 about here

Precautionary behavior was higher among females (M = 3.74, SD = 0.84) than males (M = 3.57, SD = 0.88) (t(1399) = -3.02, p = .003), and higher among married participants (M = 3.78, SD = 0.79) than non-married ones (M = 3.58, SD = 0.92) (t(964.38) = 4.15 , p < .001). The correlation between age and precautionary behavior was significant (r = .24, p < .001), as was the correlation between number of children and precautionary behavior (r = .12, p < .001). In addition, the correlation between years of education and precautionary behavior was also found to be significant (r = .19; p < .001). Finally, precautionary behavior was higher among participants with health problems (M = 3.91, SD = 0.83) than participants with no health problems (M = 3.67, SD = 0.85) (t(1398) = 3.82 , p < .001). Thus, analyses were calculated while controlling for gender and age (age was highly interrelated with marital status r = .35, p < .001, number of children r = .52, p < .001, and years of education r = .42, p < .001).

Regression analysis for identifying precautionary behavior correlates

A multiple hierarchical regression was calculated for precautionary behavior, with gender, age, knowledge about COVID-19, perceived susceptibility, and emotional reactions as predictors. A preliminary analysis of  precautionary behavior by  perceived susceptibility revealed that, for very low and low susceptibility, the means for precautionary behavior increased from 3.49 (SD = 0.98) to 3.65 (SD = 0.83); for moderate susceptibility, the mean for precautionary behavior was even higher- 3.81 (SD = 0.79); and for high and very high susceptibility the means decreased to 3.69 (SD = 0.82) and 3.62 (SD = 1.15), respectively. Indeed, the relationship was found to be curvilinear-quadratic (contrast estimate = -0.20, SE = 0.09, p = .033, 95%CI = -0.38, -0.02). Thus, the regression model was defined to test the curvilinear-quadratic effect of perceived susceptibility on precautionary behavior. The results in Table 3 reveal significant models, with 27% of the variance in precautionary behavior being explained in the final model. Precautionary behavior was higher for females, older participants, participants with higher levels of knowledge about COVID-19, and participants with greater negative emotional reactions. A negative curvilinear relationship was found between perceived susceptibility and precautionary behavior, so that the latter was highest for participants with moderate perceived susceptibility. All interaction terms were non-significant.

Table 3 about here

Discussion

The lay public's behavioral responses during a virus outbreak play an important role in bringing the outbreak under control, and provide insights into the development of risk communication messages to the public^21,22. Therefore, this study aimed to explore the association between knowledge about COVID-19, perceived susceptibility, emotional reactions and precautionary behavior among the Israeli lay public at the beginning of the COVID-19 outbreak.

Overall, our findings indicate that the precautionary behavior score was relatively high among participants. This is an encouraging finding, given that the spread of this virus depends on everyday human behaviour, i.e., hygiene behaviours and social contact. The current study was conducted in the fourth week of the epidemic in Israel, meaning that the Israeli public began to address the basic requirements for precautionary behavior in a relatively short time period. It should be noted that during the outbreak of COVID-19, all types of Israeli media were used in order to provide current and comprehensive information about world infection trends and Israel’s situation. These various channels of access to information are relatively easy to follow and may have served as significant sources of preventive actions. This strategy of spreading information regarding the virus and its risk factors may also explain the association we found between knowledge about COVID-19 and precautionary behaviour.

Our results indicate that moderate perceived susceptibility predicted precautionary behavior. It seems that, at least during the initial phase of the outbreak, perceived susceptibility of contracting the virus is associated with the potential risk attributed to one’s own individual behaviors. However, perhaps the reason we found that only moderate levels of perceived susceptibility predicted precautionary behavior was because, in this initial stage of the virus spread, it is difficult to think about the possibility of becoming infected by the virus. Furthermore, there might be an attempt to keep the virus away with wishful thinking, such as "it won’t happen to me."

In our sample, negative emotional reactions appeared to motivate precautionary behavior. In other words, in the early stages of a crisis, the public may develop a protective response because of worry, fear and stress. This finding indicates that in an acute threat situation, like COVID-19, the emotional aspects need to be perceived ; their significance must be recognized; and an adequate response should be provided (Is this what you meant?)²¹. In Israel, with the understanding that the virus is spreading, various organizations have begun to provide reactive and proactive emotional support to people in isolation, older people, and those seeking mental support on their own initiative.

This study has several limitations. First, as the survey was conducted during the fourth week of the virus outbreak, it presents an immediate and initial picture of the lay public’s reactions towards COVID-19. However, with the spread of the virus, the behavioral guidelines are constantly changing; therefore, it is advisable to continue to explore preventive behaviors among the lay public across time. Second, we used a correlational design, which limits our capacity to demonstrate causal relationships. Third, we lack information regarding those who refused to participate in the study. Finally, female participants with higher education were over-represented in the sample, which makes the findings not entirely generalizable to other populations.

Conclusions

In order to enhance precautionary behavior in the initial stage of a virus outbreak, it is recommended to pay attention to the public’s knowledge about the virus, perceived susceptibility and emotional reactions. Although negative feelings about COVID-19 may well motivate preventive behavior, it is important to address and legitimize these feelings. Therefore, ongoing scrutiny and monitoring of the psychological outcomes resulting from epidemic outbreaks, and providing prompt targeted mental health interventions should become standard procedure in preparedness efforts worldwide.

Declarations

Ethics approval and consent to participate - Ethics approval was received from the Ethics Committee of Bar-Ilan University (approval No. 032003). Our survey's introductory page stated explicitly that proceeding to the questionnaire would signify consent to participate.

Consent for publication - Not applicable.

Availability of data and materials - The data that support the findings of this study are available from the authors upon reasonable request.

Competing interests - The authors declare no competing interest concerning this paper.

Funding - The authors received no funding for this study.

Contributions - Both authors recruited the participants and collected the data. Dr. Shinan-Altman extracted and analyzed the data and wrote the paper. Dr. Inbar Levkovich revised the manuscript. Both authors read and approved the final manuscript.

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Tables

Table 2. Correlates, Means, SDs, and ranges of study variables (n=1,407)

***p<0.001

Table 3: Regression analysis for precautionary behavior (N = 1181)

*p<.05, **p<.01, ***p<.001   F(6, 1174) = 74.39, p<.001