The Ethics Committee of Tabriz University of Medical Sciences approved the study (No: IR.TBZMED.REC.1398.1307). We obtained informed consent from all participants.
Data collection and participants
Data were collected using an electronic questionnaire via Porsline. Participants were recruited using online applications and posts on several platforms such as Telegram, WhatsApp, and Instagram. We asked people for sharing the study announcements and to participate in the study. We also send several messages to significant others, virtual groups to share the study announcements. The posts asked people aged 15 years and over to take part in a study that investigates on the COVID-19. Those interested in participating were directed to complete the online questionnaire. This cross-sectional study was conducted online in Iran on March and April 2020.
Sample size estimation
The sample size for the study was estimated using the following formula :
n = Z2P(1-P)/d2
where Z for 95% confidence interval is 1.96, P = 0.5 (assuming that 50% of people would either be engaged in danger control or fear control processes), and d = 0.02 (precision = 2%). As such we estimated at least 2400 participants would be requiring for the study to have a power of 80% at 5% significant level. However, in practice 3727 individuals participated in the study.
The study questionnaire
The Risk-Percept COVID-19 was used to collect the data. This questionnaire was developed based on a literature review of the EPPM-based risk perception assessments of other infectious diseases. The questionnaire was subjected to psychometric evaluation before the data collection and found to be a valid and reliable measure. The Cronbach’s alpha coefficients for the dimensions ranged from 0.69 to 0.79, which indicated acceptable internal consistency for the questionnaire. In addition, the stability of the questionnaire as assessed by Intraclass Correlation Coefficient (ICC) showed satisfactory results (ICC ranged from 0.71 to 0.80) among (n=195) same. The questionnaire was pilot tested with a sample of 420 respondents. However, the final questionnaire consisted of 29 items tapping into three pre-defined dimensions:
1. Efficacy (perceived self-efficacy and perceived response efficacy): This dimension included 13 items.
1.1 The perceived self-efficacy included six items measuring participants’ beliefs about their ability to perform the recommended responses to the COVID-19. A sample item reads as follws: “I am able to use a mask in closed places with more than two people.”
1.2 The response efficacy included seven items measuring participants’ beliefs about the effectiveness of the recommended preventative responses to the COVID-19. A sample items reads as follows: “I believe that by disinfecting surfaces, I am less likely to get coronavirus.”
2. Defensive response (denial, reactance and avoidance): This dimension included eight items measuring people’s beliefs about their perception of the risk of COVID-19.
2.1 A sample item for denial: “I think sickness or death is in God’s hands and following the precautionary measures is not so important”.
2.2 A sample item for reactance: “I believe that health staffs significantly exaggerate about the disease”.
2.3 A sample item for avoidance: “When TV or radio talks about coronavirus, I flip the channel”.
3. Perceived threats (susceptibility and severity). This dimension included eight items measuring people’s beliefs about the magnitude of the COVID-19 and about their risk of experiencing the disease.
3.1 A sample item for susceptibility: “I am at risk for getting the coronavirus”.
3.2. A sample item for severity: “The coronavirus is a lethal threat”.
Each item was rated on a 5-point Likert scale (1=strongly disagree, 2=disagree, 3=neutral, 4=agree, 5=strongly agree) giving an overall row score ranging from 29 to 145. The rating for items belonging to defensive response were recoded so that to keep the direction of scoring as same as the other two dimensions. Additionally, the following demographic data were collected for all participants: age, gender, education, marital status, economic status, history of coronavirus, family history of coronavirus, having chronic diseases, and living condition (urban vs. rural).
- Risk perception: Using the following simple linear transformation [Row score – the lowest possible raw score / highest possible raw score – the lowest possible raw score] x 100, the row scores were converted into a score of 0 to 100 where lower scores indicated lower risk perception and the higher scores indicated higher risk perception.
- Danger control and fear control: Consistent with previous studies , we subtracted the perceived threat score from the perceived efficacy score (self- plus response-efficacy divided by two), resulting in a discriminating value. The discriminating value could be either positive or negative. A positive value meant that a person was engaging in danger control processes because their perceived efficacy was stronger than their threat perceptions. In other words, a person was likely to engage in some level of protective behaviors with regard to the specific health threat. A negative value meant that a person was engaging in fear control processes because their threat perceptions were stronger than their perceptions of efficacy. In these cases, a person was likely to engage in fear control processes and was probably not protecting himself or herself against the specific health threat.
Statistical analyses were performed using the Statistical Package for Social Science, Version 18, for Windows (SPSS Inc., Chicago, IL, USA). The normality of the data was analyzed using a Kolmogorov-Smirnov test and the normal distribution of data was confirmed. The characteristics of the participants were summarized as numbers, percentages, or means with standard deviations, where appropriate. Analysis of variance (ANOVA), t-tests, and chi-square were used to compare the study sub-groups. In all tests, a value of p < 0.05 was considered statistically significant.