Investigating Iranians’ Attitude, Practices, and Perceived Self-Ecacy towards Coronavirus Preventive Behaviors

Background and aim: Currently, one of the new health crises that has affected the world is the emergence of the novel coronavirus disease (n cov-2019). Today, most health challenges and problems are mainly due to behavioral factors and identifying these factors can play an important role in promoting public health. Therefore, this study was designed and conducted to determine Iranians’ attitude, practice, and perceived self-ecacy towards coronavirus preventive behaviors. Methods: This descriptive-analytical study was conducted online among 387 social media users (Telegram-WhatsApp). A researcher-made questionnaire was sent to the participants after conrmation of validity and reliability by the convenience sampling method. Kolmogorov-Smirnov, Mann-Whitney, analysis of variance, Pearson correlation and linear regression tests were used to analyze the collected data Results: The results of the Pearson test showed that there was a direct and signicant correlation between the subjects’ attitude with practice (r = 0.23, p <0.001) and perceived self-ecacy (r = 0.21, p <0.001) regarding coronavirus preventive behaviors. There was also a direct and signicant relationship between self-ecacy and practice (r = 0.46, p <0.001). The results of univariate regression test also showed that occupation (p=0.002, β=-0.16), marital status (p = 0.003, β=-0.15), attitude (p <0.001, b=0.23), and self-ecacy (p <0.001, β = 0.45) are predictive and inuential variables on the subjects' practice towards coronavirus preventive behaviors. Conclusion: Given the importance of positive attitude and promoting self-ecacy in improving people's practice regarding coronavirus preventive behaviors, it is suggested that various educational interventions be designed and implemented to reduce the incidence and mortality of this disease.


Introduction
Currently, one of the new global health crises is the emergence of the novel coronavirus disease (n cov-2019) or acute respiratory syndrome. It is an infectious disease caused by a new, genetically modi ed virus of the coronavirus family (1). It is an emerging respiratory disease identi ed in Wuhan, China, in late 2019 and spread rapidly to most countries in the world and was considered a pandemic disease by the World Health Organization (WHO) (2)(3)(4). Due to the pathogenicity of the virus as well as its rate of spread and mortality, people's physical and mental health status is at risk (5,6). The disease symptoms include pneumonia, fever, and muscle aches, and so far no vaccine or antiviral drug has been con rmed to treat it. The only way to prevent and control the infection is to follow hygiene principles by the public.
The number of Covid-19 patients worldwide was 19,266,069 people on August 7, 717,787 of whom died from the disease. Iran ranks 10th in the world in terms of cases with 320,117 patients and the number of deaths from this disease was 17,976 (7). Iran ranks 10th in the world in terms of Covid-19 patients (320,117 cases) and the number of deaths from this disease was reported 17,976 (7).
Due to the lack of vaccines to promote people's safety, the most effective way to prevent the transmission of the disease is preventive behaviors (8). The most important preventive measures to break the disease transmission chain include isolating cases, identifying and following up patients, disinfecting the environment, and using personal protective equipment (9).
Health problems and dangers are mainly due to behavioral factors and the identi cation of these factors can play an important role in promoting community health and helping educational interventions to change behavior (10). Attitude is de ned as a behavior degree of desirability or undesirability from an individual's point of view and is an individual's positive and negative impact re ection of the behavior.
Usually, the more favorable the attitude towards the behavior, the stronger his/her intention to perform the behavior (11). Improper attitude and practice increase the risk of people getting diseases(11); therefore, identifying and modifying individuals' attitudes is an important step in preventing diseases. Self-e cacy is also considered as the most effective motivational factor and the strongest predictor of behavioral intention so that an individual who does not believe in himself or his ability to perform the behavior will fail to adopt, initiate, and maintain that behavior. People with higher self-e cacy are more likely to perceive success, anticipate potential outcomes from a variety of strategies, and are more likely to initiate new behaviors.
Due to the rapid spread of coronavirus disease and the increasing and signi cant number of patients in Iran, it is required to conduct various studies to identify the factors affecting preventive behaviors of the disease to design and perform interventions to change behavior. Therefore, this study aimed to determine Iranians' attitude, practice, and perceived self-e cacy towards coronavirus preventive behaviors.

Study design, participants, and settings
This cross-sectional study was conducted from April to June 2020. The participants were selected through convenience sampling (n = 387). Due to the widespread prevalence of coronavirus disease and its epidemic nature, the study population included cyberspace users sampled by convenience methods and invited through social media (Telegram, WhatsApp). Before beginning the study the consent for approved by the ethics committee of Sabzevar University of Medical Sciences (code : IR.MEDSAB.REC.1399.007) was signed by are participants.

Study instrument
The study tool was a researcher-made questionnaire (Supplementary File-Questionnaire) designed based on a review of texts in three parts. Part 1: The participants' demographic information, which included eight questions (age, gender, education, marital status, place of residence, occupation, history of being infected with coronavirus or a family member). Part 2: To determine the individuals' attitudes towards coronavirus preventive behaviors, 11 questions with a 5-point Likert scale (score zero: Strongly disagree to score 4: Strongly agree) with a score range of 0-44 were designed. Examples of these questions include "A person who once was infected with coronavirus, no longer needs to follow preventive measures" and "Addicted people are protected against coronavirus (Strongly disagree = 4 and Strongly agree = 0)". Part 3: To measure the individuals' practice towards coronavirus preventive behaviors, nine questions were designed with a scale of Always = 3 to Never = 0 with a score range of 0-27. Examples of these questions include, "How much have you recently worn masks when going out?" and "How much have you recently shaken your friends and relatives' hands?" Part 4: To measure the Iranians' perceived self-e cacy towards coronavirus preventive behaviors, eight questions with a 5-point Likert scale (score zero: Strongly disagree to score 4: Strongly agree) with a score range of 0-32 were designed. Examples of these questions include "I can avoid crowded places" and "I can prepare and use masks and protective equipment." Validity and reliability of the questionnaire: In order to determine the content validity ratio (CVR) and content validity index (CVI), the opinions of 5 health education and promotion experts and one educational psychologist were used and the questions were approved after applying the experts' opinions (2 questions were deleted and ve questions were modi ed). Cronbach's alpha method was used to determine the reliability, con rmed by a coe cient of α = 0.892.

Data analysis
The collected data were analyzed using SPSS 17 statistical software package (SPSS Inc., Chicago, IL, USA). and descriptive statistics and Kolmogorov-Smirnov, Mann-Whitney, analysis of variance, Pearson correlation and linear regression tests. The signi cant level was considered less than 0.05 for all analyses.

Results
This online study aimed to identify attitude, practice, and perceived self-e cacy towards coronavirus preventive behaviors and was conducted on 385 subjects at the beginning of the corona epidemic in Iran. The mean age of the participants was 28.62 ± 9.67. Most participants were female (68.2%). Most of them had university education (75.5%) and lived in the city (84.9%), and also had no history of corona disease (88.8%) and in their relatives (78.1%).
The mean score of the subjects' attitudes towards coronavirus preventive behaviors was 27.85 ± 4.33, the mean score of practice was 22.86 ± 3.98, and the mean score of perceived self-e cacy was 24.45 ± 4.53, which is at a good level.
In response to attitude questions, 64.5% of the research units completely agreed that everyone should wear a mask when leaving the house. Moreover, 50.7% disagreed that people who once were infected with coronavirus, no longer need to follow preventive measures. The frequency of the participants' responses to the attitude questions is given in Table 1. The results of studying the subjects' perceived self-e cacy showed that 46.2% of the subjects agreed that they could stay at home. Also, 49.9% of the subjects agreed that they could prevent corona disease by taking preventive measures and 51.4% agreed that they could avoid crowded places ( Table 2). The results of studying the subjects' practice showed that 46.5% of the subjects wore a mask outside. Moreover, 67.4% of the subjects never shook their relatives or friends' hands, 60.6% always disinfected their daily purchases, and 58% washed their hands regularly for about 30 seconds (Table 3).

(1.3)
The results of the Pearson test showed that there was a statistically signi cant and direct relationship between the subjects' age and practice regarding coronavirus preventive behaviors (r = 0.12, p = 0.02), so that older subjects performed better towards coronavirus preventive behaviors. The results of the analysis of variance indicated that there was a statistically signi cant relationship between occupation and perceived self-e cacy score regarding coronavirus preventive behaviors (p < 0.001), so that employees had higher perceived self-e cacy than self-employed subjects (p = 0.003). There was no statistically signi cant difference between the self-e cacy scores of employed subjects and housewives. There was also a statistically signi cant relationship between occupation and practice towards coronavirus preventive behaviors (p < 0.001), so that employees performed better than self-employed subjects (p < 0.001). There was a direct and signi cant relationship between gender and self-e cacy and practice, so that females had higher self-e cacy and practice compared to males (p < 0.001). There was a statistically signi cant relationship between attitude score (p = 0.04), practice (p = 0.003), and perceived self-e cacy (p = 0.02) towards coronavirus preventive behaviors and marital status. So that married subjects had higher attitude, practice, and perceived self-e cacy than single subjects (Table 4).

Discussion
This online study aimed to investigate the attitude, practice, and perceived self-e cacy towards coronavirus preventive behaviors. The results indicated the subjects' positive attitude and self-e cacy and proper practice towards coronavirus preventive behaviors, which is consistent with the results of Shahnazi's (2020) study (12). Having a positive attitude and self-e cacy and proper practice towards this disease can probably play an important role in controlling, preventing its spread and reducing its prevalence. A study in Indonesia was conducted to examine individuals' knowledge, attitude, and practice towards social distance as a solution to prevent coronavirus, the results of which showed that most people had a positive attitude and proper practice towards coronavirus preventive behaviors (13). The results of Khasawneh's (2020) study in Jordan showed that medical students had an appropriate level of knowledge, attitude, and practice towards coronavirus prevention (14). The results of a study in Ethiopia also showed that most of the subjects had high knowledge and self-e cacy regarding coronavirus prevention (15), which is consistent with the present study. Goni et al. (2019) in their study in Malaysia entitled "Assessing the knowledge, attitude, and practice of Hajj pilgrims towards prevention of respiratory infections", reported that although the subjects had high knowledge about respiratory infections, their attitude and practice was not appropriate, which is not in line with the results of the present study (16). The difference between this study and the present study can be due to different study population and tools. Moreover, they measured the pilgrims' knowledge, attitude, and practice about all respiratory infections and was performed prior to COVIID-19 outbreak.
In the present study, a direct and signi cant relationship was observed between gender with perceived self-e cacy and practice, so that females had better self-e cacy and practice in coronavirus preventive behaviors than males. This result is consistent with the results of Goni (2019) and Kebede (2020) (15,16).
The results of a study conducted in Iran to evaluate COVID-19 preventive behaviors based on the Health Belief Model showed that the mean score of COVID-19 preventive behaviors in females was higher than males (12). In another study by Love et al. on the H1N1 pandemic in men and women in Hong Kong, women performed better than men in preventing the disease (17), which is consistent with the results of the above study. A study in Sudan also reported that women took more preventive measures than men in protecting themselves and others against coronavirus (18). This result may be due to women's role in the family as a wife or mother, who are more motivated to protect themselves than men; therefore, they showed better self-e cacy and practice in preventing coronavirus than men.
The results of the present study showed that occupation is one of the predictors and in uential variables on the individuals' practice towards coronavirus preventive behaviors. The results also showed that employees had higher perceived self-e cacy regarding coronavirus preventive behaviors than selfemployed subjects. Yanti (2020) reported that government employees had a better attitude and behavior towards coronavirus prevention than other occupations (13). Kebede's (2020) study also reported that employees had more preventive behaviors against coronavirus than self-employed subjects and occupation was a positive predictor of coronavirus preventive behaviors, which is consistent with the results of the present study (15).
In the current study, there was no signi cant relationship between the individuals' education level with attitudes, practice, and perceived self-e cacy, which is not in line with the results of Yanti's (2020) study (13). In this study, people with higher education showed a positive attitude and appropriate behavior towards social distance for corona prevention. In Kebede's (2020) study, people with higher education had better self-e cacy and practice regarding coronavirus prevention (15). A study in the US conducted on the evaluation of COVID-19-related knowledge, attitude, and practice among chronically ill adults reported that people with limited health literacy had poorer attitudes towards corona disease (19). Another study in Peru showed that people with higher education reported a better understanding of COVID-19 control measures and preventive strategies (20). The difference between the ndings of the above studies and the present study is due to the type of education level division in the present study. In terms of education, the subjects were divided into two categories: academic and non-academic, and due to the type of sampling in the present study, which was online, 75% of the research units included people with academic literacy.
The results indicated that self-e cacy and attitude are the most important predictors of the individuals' practice towards coronavirus preventive behaviors. In Goni's (2019) study, a signi cant and positive relationship was reported between the attitude and practice of pilgrims in preventing respiratory infections (16). The results of Carico's (2020) study in the US showed that perceived self-e cacy is an important factor in reinforcing COVID-19-preventive behaviors, such as social distance and staying at home(21). Shahnazi's (2020) study in Golestan also showed that perceived self-e cacy is a predictor of practice in preventing coronavirus (12), which is consistent with the results of the present study.
An individual's attitude predicts his/her behavior. Considering whether something is good or bad will affect an individual's practice, and the type of attitude can determine his/her practice. Health behaviors are affected by external factors and internal factors, such as knowledge and awareness, perception, attitude, emotions, motivation. Discovering a new infectious disease may increase motivational pressures and cause behavioral change (13). Self-e cacy is also a mediator between knowledge and behavior and an important prerequisite for behavior change and is in fact, the con dence that an individual has in his/her ability to perform a behavior (22). Self-e cacy is increasingly associated with health behaviors changes and is a strong predictor of health-promoting behaviors. Regarding coronavirus, increased selfe cacy has been associated with a decrease in the virus prevalence (18).
One of the limitations was performing the study online due to the limitations caused by the virus. As a result, random sampling was not possible and people with lower literacy, lower economic status or older people may not have access to smartphones and, therefore, they not be studied.

Conclusion
The results showed a positive attitude, self-e cacy, and proper practice of the subjects towards coronavirus preventive behaviors. Self-e cacy, attitude, occupation, and marital status were the most important predictors of the subjects' practice. Due to the males' poorer self-e cacy and practice than females, it is suggested that interventions be taken to improve the practice of males regarding coronavirus prevention.