The Role of Illness Perceptions, Coping, and Self-Efficacy on Adherence to Precautionary Measures for COVID-19

As the novel coronavirus disease 2019 (COVID-19) pandemic continues, engaging the public in adherence to precautionary measures for preventing COVID-19 spread or infection becomes difficult. The present study aims to extend our understanding of how illness perceptions, coping, and self-efficacy affect adherence to precautionary measures among the public. An online survey was administered between April and June 2020 to a sample of 514 Hong Kong citizens. Variables considered were illness perceptions toward COVID-19, problem-solving, avoidance-based coping, self-efficacy, as well as adherence to precautionary measures including physical distancing, limiting unnecessary travelling, and washing hands regularly with soap and water. Adjusted structural equation model showed that illness perceptions toward COVID-19 had significant direct effect on their adherence to precautionary measures (unstandardized β = 0.50, [95% CI, 0.28, 0.80], p = 0.001), and indirect effects through avoidance-based coping (β = −0.10 [95% CI, −0.26, −0.01], p = 0.016) and self-efficacy (β = −0.10, [95% CI, −0.18, −0.01], p = 0.025). These results imply that apart from emphasizing the health hazards of a novel infectious disease, an effective public health intervention and crisis communication should address avoidance-based coping and self-efficacy of the public in adherence to precautionary measures for COVID-19.


Introduction
The novel coronavirus disease 2019 (COVID-19) outbreak began in China on December 2019, with more than 20 million confirmed cases and 735,000 deaths worldwide as of 11 August 2020. In view of the absence of vaccines or effective treatments, current global efforts are largely focused on containing the virus spread by implementing different precautionary measures, including improved hygiene, physical distancing, wearing facemasks, comprehensive contact tracing, and quarantining, as well as border controls. Recent epidemiological studies have found the aforementioned measures can reduce the daily effective production number (R 1 ) for COVID-19 to less than one and the mean positively rate of COVID-19 to 0.49% per day [1,2]. 78 countries/regions worldwide exploring the behavioral and psychological impacts of COVID-19. This study recruited a convenience sample of Hong Kong citizens through online social media (e.g., Facebook, Instagram, Twitter, and WeChat), university mass emails and psychological associations between April and June 2020 (i.e., one month after the second wave of the COVID-19 pandemic in Hong Kong). Hong Kong Chinese residents aged 18 years or above with access to the Internet were eligible to participate in the study. An online, 20-min cross-sectional survey using a secured Google platform was used to collect data. Participants were informed of the study aims, risks, and benefits. Those who chose to participate provided informed consent. The survey was programmed as a forced response, such that all items on one page had to be completed in order to move to the next page, thereby avoiding missing data. Ethics approvals were obtained from the Cyprus National Bioethics Committee (EEBK EΠ 2020.01.60) and a University in Hong Kong (SBRE-19-593).

Measures
Adherence to Precautionary Measures for COVID-19 Infection. Three items (11-point Likert scale) were used to capture whether the participants adhered to precautionary measures in preventing COVID-19 transmission over the past, covering the following areas: physical distancing, limiting unnecessary travelling, and washing hands regularly with soap and water. A higher total score indicated better adherence. These items had adequate content validity (item content validity index, CVI = 0.95-0.98; scale CVI = 0.96) and internal consistency (Cronbach's alpha, α = 0.85) in our sample.
Illness Perceptions toward COVID-19. Three subscales, including the Brief Illness Perception Questionnaire items assessing the perceived consequences, timeline, concern, and emotional responses toward COVID-19 (4 items, 10-point Likert scale) [14], the items assessing the perceived susceptibility (3 items, 6-point Likert scale) and severity of COVID-19 (3 items, 6-point Likert scale) according to the Health Belief Model were used to assess the participants' overall illness perceptions toward COVID-19 [15]. For each subscale, a higher score indicated a stronger illness perception. For example, one question was "How do you think COVID-19 will continue?" The items had adequate content validity (item CVI = 0.92-0.99, scale CVI= 0.95) and internal consistency (α = 0.85-0.89) in our sample.
Coping. The Brief Coping Orientation to Problems Experienced (Brief COPE) inventory was adopted to measure situational and dispositional coping responses toward COVID-19 (4-point Likert Scale) [16]. In this study, three coping dimensions were assessed: seeking social support (use of emotional support, use of instrumental support, venting, and religion, 4 items), problem-solving (active coping and planning, 2 items) and avoidance (self-distraction, denial, substance use, behavioral disengagement, and self-blaming, 5 items). A higher score indicated a higher tendency to implement the corresponding coping strategy. The Brief COPE demonstrated adequate convergent validity [16], and the subscale items showed adequate internal consistencies in our sample (α = 0.79-0.84).
Self-Efficacy. Five items (7-point Likert scale) were used to assess the participant's self-appraisal of his/her own competencies to plan and execute actions successfully in order to follow the precautionary measures of COVID-19. One example item was "When facing difficulties in following the recommendations, I am certain that I will overcome them." A higher score indicates better self-efficacy. These items had adequate content validity (item CVI = 0.88-0.93, scale CVI = 0.96) and internal consistency (α = 0.84) in our sample.
Participants were also asked to report their age, gender, educational level, employment, family status, impacts of social isolation measures on daily activities and finance, and whether they and their family members were infected by COVID-19.

Statistical Analyses
The SPSS software (Version 23.0; IBM Corp., Armonk, NY, USA, 2014) was used to perform descriptive statistics and correlational analysis, and the SPSS Analysis of Moments Structure software (Version 23.0; IBM Corp., Chicago, IL, USA, 2014) was used for structural equation modelling (SEM). We first examined the correlations between all the observed variables in the model. To interpret the correlation coefficients (r) (absolute r), we referred to Cohen's criteria as follows: >0.10, small; >0.30, medium; >0.50, large [17]. Next, we performed the SEM analysis following the two-step approach as recommended by Anderson and Gerbing [18]. First, we conducted confirmatory factor analyses (CFA) for the following constructs, including illness perceptions toward COVID-19, seeking social support, problem solving, avoidance-based coping, and self-efficacy, to examine whether they were measured by the indicators with significant factor loadings. Second, based on the hypothesized path model, we examined an initial structural path model with adjustment for the socio-demographic and lifestyle characteristics as listed in Table 1. This model was then trimmed subsequently to obtain the final model ( Figure 1) by dropping insignificant socio-demographics. The SEM parameters were estimated by the maximum likelihood method. Since chi-square test is sensitive to sample size, the following model fit indices were assessed, with values in parentheses indicating an acceptable fit: (1) the root mean square error of approximation (RMSEA ≤ 0.08), (2) the comparative fit index (CFI ≥ 0.90) and (3) the standardized root mean square residual (SRMR ≤ 0.1) [19]. All statistical tests were two-sided with level of significance set at 0.05.  [11.52] years) completed the survey. Owing to the convenience sampling method, information regarding the response rate was unavailable. In general, the sample consisted of mainly females (74.1%), holding an undergraduate degree or higher (81.9%) and working as non-health care professionals (88.3%). Around one-third of the sample reported that they had been staying at home and that their finances became worse since the imposed social isolation measures, and only one participant reported that he/she was infected by COVID-19.  Table 2 presents the means (SDs) and bivariate correlations among study variables. Adherence to precautionary measures for COVID-19 was significantly correlated with all items assessing self-efficacy of adhering to the precautionary measures (rs = 0.30-0.54, all ps < 0.01), problem-solving (rs = 0.15, all ps < 0.01), and avoidance-based coping (rs = −0.20-0.15, all ps < 0.01), respectively. The results of the CFA indicated that the measuring items corresponding to the latent constructs were all adequately fit (χ 2 = 431.55, df = 139, CFI = 0.9, SRMR = 0.07, RMSEA = 0.06).

Results
Illness perceptions toward COVID-19 Illness perceptions in terms of consequences, timeline, concern, and emotional responses (2) 26.84 (5.66) When facing difficulties in following the recommendations, I am certain that I will overcome them. (7) 5.91 (1.00) Compared to other people, I can follow these recommendations pretty well. (8) Even when things get tough, I can follow these recommendations quite well.

Discussion
This study examined the role of illness perceptions, coping, and self-efficacy on adherence to precautionary measures for COVID-19 among Hong Kong citizens one month after the second wave of the COVID-19 pandemic. Our SEM model provides useful insight into the psychological pathways of behaviors in controlling or preventing the spread of the COVID-19 infection, which can be important in informing risk management and public health strategies to address promotion and maintenance of desired protective behaviors for infection control. We found that illness perceptions toward COVID-19 significantly predicted adherence behaviors to precautionary measures. This finding implies that providing accurate, concise, and up-to-date information regarding the transmission, mechanism, symptom severity, and plausible treatment of COVID-19 can help increase public awareness of the hazards and risks of harm from COVID-19. Illness perception, which refers to the cognitive appraisal and personal understanding by people of a novel infectious disease [14], can largely influence not only their psychological and behavioral responses to the illness condition, but also their health outcomes [20].
When encountering the COVID-19 pandemic, unfamiliarity and uncertainty about the infectious disease and its catastrophic potential could lead to high anxiety and emotional reactions of the public [21], which might shape their acceptance of and adherence to risk mitigation. This phenomenon is reflected in our results, showing that avoidance-based coping partially and significantly accounted for the influence of Hong Kong people's illness perceptions toward COVID-19 on their adherence to the precautionary measures. It is interesting to note that avoidance, but not problem-solving-based coping, has demonstrated a mediating role on adherence behaviors. This indicates that after the first and second waves of the COVID-19 pandemic, the Hong Kong people's emotional reaction to the pandemic likely interfered with their capacity to formulate or engage in problem-solving-based coping strategies to manage barriers to their adherence to the precautionary measures. With high levels of uncertainty and emotional strain, the Hong Kong people might unwittingly choose and adopt avoidance-based coping (i.e., denial, self-blame, rumination, and hypervigilance by over-doing precautions to become desensitized over time) to manage the anxiety and distress concerning the infection risk and impact of the COVID-19 outbreak, thus negatively impacting their adherence behaviors. Such avoidance-based coping identified in this study is consistent with another survey conducted in Hong Kong in the initial stage of H1N1 pandemic, in which around 77% of Hong Kong citizens showed avoidance behavior (e.g., avoiding going out or touching potentially contaminated objects), which was not the advice or restriction policy of the government, and was likely attributed to their intense emotional reactions [22]. These findings are also consistent with another study reporting that affective processes consistently predicted the uptake of protective behaviors across several waves of H1N1 epidemics in Hong Kong [23].
Self-efficacy in executing and following the precautionary measures for COVID-19 was found to be another mediating factor in adherence to the measures in our SEM model. This is important, but already evidenced in social science literature showing that an individual's perception of his/her competency to successfully perform the expected precautionary measures for COVID-19 affects his/her willingness and actual behavior to adhere to the measures [24]. More importantly, the simultaneous mediating effects co-produced by avoidance-based coping and self-efficacy might indicate an interactive relationship or effect of these two psychological constructs on affecting one's perceived capability of adhering to precautionary measures for COVID-19. Hence, apart from improving the public's self-efficacy in following the precautionary measures for COVID-19 through health education [25], an important but often neglected strategy is to address avoidance-based coping through effective interventions or resilience programs that are built from the framework of acceptance and commitment therapy, which is an empirically-based psychotherapy focusing on helping people to recognize their own avoidance and increasing their capacity to engage in values-based behavioral changes [21,26]. In addition, as suggested by the World Health Organization, public officials and health care providers should address the plausible emotional responses arising from the pandemic by using appropriate risk communication strategies at both individual and community levels. Such strategies include being responsive, honest, empathic, transparent, and consistent when delivering messages through trusted channels of communication, and monitoring infodemic and responding to rumors and misinformation with scientific evidence [27]. For any new regulatory measures that need to be imposed to address the COVID-19 pandemic, government officials should consider whether the public has adequate competency in adhering to the new measures, as well as their possible maladaptive psychological responses (e.g., avoidance) that may hinder the effect of these measures.
Our study findings should be interpreted with caution in view of the following study limitations. First, our data were cross-sectional and thus causal or temporal interpretations could not be made. Second, since the participants were self-selected into the study via social media platforms and university mass emails, the findings might be prone to selection bias. The respondents were primarily female (74.1%) and educated (81.9% graduated from universities), which might also limit the generalizability of our findings to the general populations. However, our findings were consistent with previous studies exploring the role of psychological factors in behavioral responses to the H1N1 pandemic [22,23], indicating its potential to apply in pandemics of different respiratory infectious diseases. Third, all data were self-reported and thus the participants' responses might be subject to recall, response and/or social desirability biases.
Notably, the international COVID-IMPACT study commenced in April 2020. During that time, wearing surgical masks or face coverings was controversial, as there was no evidence or policy supporting the conclusion that wearing masks could reduce the spread of infection in the community. Therefore, with the recent increasing evidence on different effective precautionary measures, the questionnaire used for assessing adherence to these measures should include more items than those used in this study (i.e., with physical distancing, limiting unnecessary travelling, and washing hands regularly with soap and water only). Hence, the adequacy of the latent construct representing the adherence to precautionary measures for COVID-19 can be further improved with significant factor loadings. Further research to develop and validate an instrument serving to comprehensively assess the public's adherence to precautionary measures of a novel infectious disease is also warranted. Finally, the percentage of the explained variance in adherence to precautionary measures of COVID-19 contributed by resilience and coping factors, together with the covariate (working as health care professionals), was only 28%. Further research should be conducted to test the model by including other contextual factors that affect individual's adherence, such as social norms of perceiving illness threat, social inequality in accessing resources for adhering to precautionary measures, and the practicalities of exercising precautionary measures [5,28]. It has been recently suggested that the tendency of adhering to COVID-19 precautionary measures may imply the involvement of prosocialness in containing the spread of COVID-19, because such adherence behavior can bring societal and communal benefits (e.g., by helping protect your neighborhood) rather than benefiting oneself only [29,30]. The role of prosocialness in facilitating collective behavior, thereby encouraging better adherence to COVID-19 precautionary measures, or even the effectiveness of public health interventions that leverage prosocial messages to improve adherence, deserves future research. As political ideology and trust in government have often been found to affect vaccine attitudes and uptake among the public [31], future studies could explore whether individual political affiliation or the phenomenon of political polarization affects how the public perceives and responds to COVID-19 or other infectious disease outbreaks [32].

Conclusions
Understanding specific cognitive factors and coping affecting public adherence to precautionary measures for COVID-19 is paramount to mitigating the adversity and progress of the COVID-19 pandemic. As shown in our findings, illness perceptions toward COVID-19 contribute to adherence to COVID-19 precautionary measures, as well as through less avoidance-based coping and better self-efficacy in following the precautionary measures. Our findings suggest that only emphasizing the health hazards of a novel infectious disease is unlikely to adequately motivate and engage the public to make desired behavioral changes. An individual's psychological capacity, in terms of avoidance-based coping and self-efficacy, should also be addressed.