Role of Threat and Coping Appraisal in Protection Motivation for Adoption of Preventive Behavior During COVID-19 Pandemic

Exploring the determinants of online health service usage intentions under the threat of air pollution

Introduction

The rapid evolution of online health services (OHS) has significantly improved healthcare accessibility. However, the impact of air pollution on individuals' willingness to engage with OHS remains underexplored in the existing literature. This study addresses this gap by investigating how air pollution threats influence the intention to use OHS, grounded in Protection Motivation Theory (PMT) and Rational Choice Theory (RCT).

Methods

Using cross-sectional survey data, a theoretical model was developed and tested to examine the relationships between threat appraisal, coping appraisal, perceived benefits, perceived costs, and OHS usage intentions.

Results

The findings indicate that threat appraisal, coping appraisal, and perceived benefits positively affect the intention to use OHS, while perceived costs negatively impact usage intention. Additionally, age significantly moderates the relationship between coping appraisal and the intention to use OHS.

Discussion

This study extends the application of PMT and RCT in the context of OHS. It provides valuable insights into the factors influencing users' intentions to utilize these services, with implications for improving OHS adoption in environments affected by air pollution.

Effects of health-related dispositions on citizens' appraisals toward the COVID-19 pandemic and protective behavior

In this study, health risk attitude and health locus of control were included as dispositional factors in the Protection Motivation Theory (PMT) to explain people's protective behavior in the context of COVID-19 pandemic. Empirical data involved two waves of data with a sample of 526 adults with full-time jobs from Beijing, China, and structural equation model results confirmed a partial successful extension of the PMT. Specifically, health risk attitude had a direct effect on citizens' protective behavior, but without an indirect effect mediated by threat appraisal toward the COVID-19 pandemic; health locus of control did not directly associate with citizens' protective behavior, but had an indirect effect on it fully via coping appraisal toward the COVID-19 pandemic. Thus, the PMT has been extended by adding a distal dispositional factor on the impact of coping appraisal on protective behavior. Implications for advancing the government's anti-epidemic strategy are discussed.

Longitudinal relationship between pre-exposure prophylaxis motivation and change in adherence among men who have sex with men in Western China

INTRODUCTION

The efficacy of pre-exposure prophylaxis (PrEP) is highly dependent on adherence, and adherence behavior is influenced by motivation. The aim of this study was to explore the longitudinal relationship between PrEP motivation and change in adherence among men who have sex with men (MSM) in Western China.

METHODS

From November 2019 to June 2021, we conducted a PrEP prospective cohort study. Motivation to take medicine was measured by the PrEP Motivation Scale at baseline, and was grouped into different levels of latent categories by Latent Profile Analysis (LPA). A multinomial logistic regression model was used to explore the longitudinal relationship between change in adherence (improvement, decline, no change) and different levels of PrEP motivation.

RESULTS

MSM were divided into two categories of PrEP motivation, a "high motivation group" (n = 506, 69.89%) and a "low motivation group" (n = 218, 30.11%). High PrEP motivation had no significant effect on the change in short-term adherence, however, it contributed to the improvement in long-term adherence [odds ratio (OR) = 3.028 (1.100-8.332), p = 0.031]. The predictive power of the adherence model was significantly enhanced with the addition of the PrEP motivation factor.

CONCLUSIONS

There was a positive correlation between high PrEP motivation at baseline and an improvement in long-term adherence. Surveillance and intervention of PrEP motivation in MSM can increase their adherence, and then promote PrEP efficacy.

Psychological and psychosocial determinants of COVID-related handwashing behaviours: A systematic review

Background

The COVID-19 pandemic, caused by the SARS-CoV-2 virus, has resulted in illness, deaths and societal disruption on a global scale. Societies have implemented various control measures to reduce transmission of the virus and mitigate its impact. Individual behavioural changes are crucial to the successful implementation of these measures. One commonly recommended measure to limit risk of infection is frequent handwashing. It is important to identify those factors that can predict the uptake and maintenance of handwashing.

Objectives

We aimed to identify and synthesise the evidence on malleable psychological and psychosocial factors that determine uptake and adherence to handwashing aimed at reducing the risk of infection or transmission of COVID-19.

Search Methods

We searched various literature sources including electronic databases (Medline ALL, Child Development & Adolescent Studies, ERIC, PsycInfo, CINAHL and Web of Science), web searches, conference proceedings, government reports, other repositories of literature and grey literature. The search strategy was built around three concepts of interest including (1) context (terms relating to COVID-19), (2) behaviour of interest and (3) terms related to psychological and psychosocial determinants of COVID Health-Related Behaviours and adherence or compliance with handwashing, to capture malleable determines. Searches capture studies up until October 2021.

Selection Criteria

Eligibility criteria included observational studies (both retrospective and prospective) and experimental studies that measure and report malleable psychological and psychosocial determinants and handwashing at an individual level, amongst the general public. Screening was supported by the Cochrane Crowd. Titles and abstracts were screened against the eligibility criteria by three independent screeners. Following this, all potentially relevant studies were screened at full-text level by the research team. All conflicts between screeners were resolved by discussion between the core research team.

Data Collection and Analysis

All data extraction was managed in EPPI-Reviewer software. All eligible studies, identified through full-text screening were extracted by one author. We extracted data on study information, population, determinant, behaviour and effects. A second author checked data extraction on 20% of all included papers. All conflicts were discussed by the two authors until consensus was reached.We assessed methodological quality of all included studies using an adapted version of the Joanna Briggs Institute Quality appraisal tool for cross-sectional studies.

Main Results

Our initial searches yielded 23,587 results, of which 56 studies were included in this review. The included studies were cross sectional in design, came from 22 countries and had a combined sample of 199,376 participants. The vast majority of studies had samples from the general public, with eight of the studies focusing on specific samples. All included studies considered people over the age of 18. The quality of the majority of the studies was good (n = 30 rated low risk of bias), with 8 rated high risk of bias, predominately due to lack of reporting of recruitment, sample characteristics and methodology. Thirty-four studies were included in the narrative synthesis and 28 in the meta-analysis.Findings indicated that emotions about COVID-19 (worry [0.381, confidence interval [CI] = 0.270-0.482, I 2 = 92%) and anxiety (0.308, CI = 0.154-0.448, I 2 = 91%]), knowledge of COVID-19 (0.323, CI = 0.223-0.417, I 2 = 94%), and perceived social norms (0.303, CI = 0.184-0.413, I 2 = 92%) were among the malleable determinants most associated with handwashing. Perceived severity (0.006, CI = -0.011-0.023) and susceptibility of COVID-19 (0.041, CI = -0.034 to 0.115) had little to no effect on handwashing behaviour.

Authors' Conclusions

Understanding the effects of various malleable determinants on COVID-related handwashing can aid in the development and implementation of interventions and public health campaigns to promote handwashing behaviour in potential new waves of COVID-19 or other respiratory infections. Emotions about COVID, knowledge of COVID and perceived social norms warrant further consideration in future research and policy.

Home-Isolation Care in Newly COVID-19-Positive Elderly Patients: A Caregiver-Centric Explanatory Framework

Objectives: This community-based study aimed to identify the effect of different behavioral factors of family caregivers on the decision for home-isolation-based treatment of a new COVID-19-diagnosed elderly individual. It also explored the facilitators and barriers contributing to the decision-making process. Methods: A mixed-methods design was adopted to study the role of behavioral constructs such as risk tolerance, risk aversion, regret aversion, loss aversion, self-efficacy, and risk perception in healthcare-seeking decisions. By integrating the findings from the quantitative and qualitative parts, a framework was developed. Results: Self-efficacy, risk perception, and risk tolerance related to different issues were crucial factors behind the healthcare decision. However, regarding the various issues under consideration, risk perception followed by risk tolerance were the significant predictors for decision-making. Conclusion: To enhance appropriateness and equity in emergency healthcare-seeking, interventions should target risk tolerance and risk perception, taking into account the awareness levels of caregivers and the target population's risk and regret aversion. Such integrated approaches can improve the quality of care for elderly patients in home-based settings.

Anxiety, Stress Perception, and Coping Strategies among Students with COVID-19 Exposure

Background: Studying anxiety, stress, and coping strategies during the COVID-19 pandemic is crucial to mitigate the negative effects associated with infection risk and disease consequences. Objective: This study aimed to investigate anxiety levels, stress perception, and coping strategies in relation to the presence of illness. Material and Methods: A cross-sectional online survey was conducted anonymously among 3950 university students from Poland (1822), Lithuania (232), and the Russian exclave of Kaliningrad (1896). Due to the nearly identical application of anti-epidemic measures, the respondents were treated as a unified group. The State-trait Anxiety Inventory (STAI), Perceived Stress Scale 10 (PSS-10), and mini-COPE scale questionnaires were used. Statistical analysis included the Shapiro-Wilk test to check normality, the Mann-Whitney U test for comparative analysis between groups, the Pearson χ² test for categorical data, and Spearman coefficients for correlations between variables. Results: A significant proportion of young adults in the community exhibited symptoms of anxiety and stress during the COVID-19 pandemic. Among the 1212 men and 2738 women surveyed, 348 (28.7%) and 1020 (37.3%) individuals, respectively, were diagnosed with COVID-19 according to clinical protocols. Prolonged disease duration and more severe residual symptoms correlated with higher self-reported anxiety levels. Conclusions: The level of anxiety and stress varied depending on the duration of the disease, significantly impacting the choice of coping strategies. Overall, students displayed a proactive approach to coping activities but tended to postpone important decisions. Seeking social support was a prevalent coping mechanism, although respondents who had COVID-19 showed higher levels of concern for their own emotions, a tendency to discharge emotions through alcohol or other substances (male), and a greater reliance on religion (female). The study provides data that may be useful in developing educational and health policies focused on the mental well-being of university students and potentially other social groups.

Cognitive and Emotional Motivation to Explain Infection-Prevention Behaviors with Social Support as a Mediator During the COVID-19 Pandemic: A Nationwide Cross-Sectional Study in Korea

Purpose

To predict the performance of infection-prevention behaviors among adults in Korea based on the health belief model, using social support as a mediator.

Patients and Methods

A nationwide cross-sectional survey of 700 participants from the local community was conducted using both online and offline methods from 8 metropolitan cities and 9 provinces in Korea from November 2021 to March 2022. The questionnaire was composed of 4 sections: demographic information, motivational factors for behavior change, social support, and infection-prevention behaviors. Data were analyzed using structural equation modeling with the AMOS program. The general least-squares method was applied to assess the fit of the model and the bootstrapping method was tested for indirect effect and the total effect.

Results

Motivation factors that directly affected infection-prevention behaviors were self-efficacy (γ=0.58, p<0.001), perceived barriers (γ=-.08, p=0.004), perceived benefits (γ=0.10, p=0.002), perceived threats (γ=0.08, p=0.009), and social support (γ=0.13, p<0.001), after controlling for related demographic variables. Cognitive and emotional motivation factors together explained 59% of the variance in infection-prevention behaviors. Social support exerted significant mediating effects between each cognitive and emotional motivation variable and infection-prevention behaviors, along with a significant direct effect on infection-prevention behaviors (γ=0.12, p<0.001).

Conclusion

The engagement of prevention behaviors among community-dwelling adults was influenced by their self-efficacy, perceived barriers, perceived benefits, and perceived threats with social support as a mediator. Prevention policy approaches could include providing specific information to improve self-efficacy and build awareness of the severity of the disease while establishing a supportive social environment for promoting health behaviors during the COVID-19 pandemic.

Effects of Cognitive Appraisals on Perceived Self-Efficacy and Distress during the COVID-19 Lockdown: An Empirical Analysis Based on Structural Equation Modeling

During the COVID-19 lockdown, individuals and households had to responsibly manage the difficulties and problems caused by the restrictions on their mobility, such as the interruptions to work schedules, insecure food supplies, and the procurement of services and health care. The perceptions of risk as well as the fear of disease were strongly linked to worry, defined as a sequence of thoughts that evoke negative emotions and elevated levels of anxiety and distress. This study evaluated how different cognitive appraisals of an individual's sources of worry could influence their perceived self-efficacy and directly or indirectly moderate their perceived general distress. A sample of 544 participants completed a survey that included questions based on the generalized self-efficacy scale, the sources of concern during the epidemic, the cognitive appraisal scale in emergency, and perceived discomfort. Subsequently, a structural-equation-modeling (SEM) analysis was performed to test the moderating role of cognitive appraisals and perceived self-efficacy on participants' overall distress during a lockdown. Overall, the model reported acceptable fit values and confirmed the hypotheses of the study. An individual's worries activated either a dysfunctional threat appraisal, which prompted a fear-and-closure response that then increased their overall state of distress; or two other functional appraisals (i.e., adaptive or supportive) that contributed to significantly improving the individual's self-efficacy. Higher self-efficacy was shown to be associated with lower levels of perceived distress. For the purposes of prevention and distress containment, it would be appropriate to promote psycho-educational interventions that promote the adoption of appraisal strategies that are functional and beneficial for perceived self-efficacy.

Perceived COVID-19 Severity, Risk of Infection, and Prevention Self-Efficacy in Saudi Arabia During Lockdown: A Population-Based National Study

Evidence shows that the risk perception of humans can significantly affect their response to a threat. This population-based, cross-sectional study explored the determinants of perceived disease seriousness, perceived disease infectiveness, and perceived prevention self-efficacy of coronavirus disease (COVID-19), during the lockdown period, using the health belief model for preventive behavior (HBMPB) among 4423 adults in Saudi Arabia from 13 provinces. Multivariate binary regression was used to analyze the independent factors of three risk perception variables and to measure their effect on adherence to preventive measures. Overall, COVID-19 seriousness was perceived to be higher than that of diabetes and lower than that of a heart attack, while its infectiousness was perceived to be high by 75.3% of the participants. Furthermore, 66.6% had a low perception of their prevention self-efficacy. The HBMPB showed independent effects of all three risk perception parameters on adherence to the preventive measures, including perceived seriousness (Odd's ratio [OR] = 1.26; 95% confidence interval [95% CI] = 1.01-1.56), infectiousness (OR = 1.90; 95% CI = 1.52-2.38), and prevention self-efficacy (OR = 1.51; 95% CI = 1.20-1.91). Authorities should maintain an optimal level of communication on the COVID-19 risk, communicate more about the virus' cycle and the disease to demystify the rationale of the preventive measures, and enhance confidence in their efficiency.

Threat Appraisal, Resilience, and Health Behaviors in Recovered COVID-19 Patients: The Serial Mediation of Coping and Meaning-Making

Research indicates that both cognitive appraisal and personal resources can noticeably influence health behaviors, as individuals modify their health convictions and practices on the basis of threat appraisal, personality, and meaning. The aim of the current study was to investigate whether coping strategies and meaning-making can serially mediate the relationship of threat appraisal and resilience with health behaviors in recovered COVID-19 patients. Self-report measures of threat appraisal, resilience, coping, meaning-making, and health behaviors were completed by 266 participants (aged 17 to 78, 51.5% female) who had recovered from COVID-19. The serial mediation analysis showed that the relationship of threat appraisal and resilience with health behaviors was mediated by problem-focused coping, meaning-focused coping, and meaning-making, but not by emotion-focused coping. These results suggest that associations among threat perception, resilience, and health behavior depend to some extent on the interplay of coping and meaning-making, which reveals their unique role in the process of recovery from COVID-19, with potential implications for health interventions.

Education level modifies parental hesitancy about COVID-19 vaccinations for their children

It is important to encourage parental acceptance of children's vaccination against COVID-19 to ensure population immunity and mitigate morbidity and mortality. This study drew upon protection motivation theory (PMT) to explore the factors of parental hesitancy about vaccinating their children. A national online survey was performed in China. A total of 2054 Chinese parents of children aged 6-12 years were included in this study. They reported on measures that assessed hesitancy about children's vaccination against COVID-19, PMT constructs (susceptibility, severity, response efficacy, self-efficacy, and response costs) and sociodemographic characteristics. Chinese parents reported a hesitancy rate of 29.4% for children's vaccination. Parents with higher level education were more likely to hesitate to vaccinate their children against COVID-19. After controlling for parents' and children's demographic variables, logistic regression showed that parents' hesitancy about their children's vaccination increased if parents had lower levels of susceptibility, response efficacy or self-efficacy, as well as higher levels of response costs. In addition, a high educational level can significantly increase the promotive effect of response cost and the protective effect of response efficacy on vaccine hesitancy. In conclusion, our findings suggested that PMT can explain parents' vaccine hesitancy and that education level can modify the effect of copying appraisal, but not threat appraisal, on parental hesitancy. This study will help public health officials send targeted messages to parents to improve the rate of COVID-19 vaccination in children aged 6-12 years and thus reach a higher level of immunity in the population.

Application of protection motivation theory and cultural tightness-looseness for predicting individuals' compliance with the government's recommended preventive measures during regular prevention and control of the COVID-19 pandemic in China

Introduction

In the period of regular prevention and control of the COVID-19 pandemic, the public must continue to comply with the government's recommended preventive measures to further curb the pandemic. Based on the theories of protection motivation and cultural tightness-looseness, this study investigates individuals' compliance with the government's recommended preventive measures during this period in China. It also establishes a moderated mediation model to explore the underlying mechanisms.

Methods

We used structural equation modeling and latent model structural equations to analyze data from an online survey of 443 participants.

Results

The analysis showed that media exposure significantly predicted perceived severity, maladaptive rewards, self-efficacy, response efficacy, and response cost. Perceived severity, self-efficacy, and response efficacy were positively associated with protection motivation, which, in turn, was positively associated with individuals' compliance. Additionally, protection motivation positively affected individuals' compliance via implementation intention, and perceived cultural tightness-looseness significantly moderated the association between protection motivation and implementation intention.

Discussion

This study helps to better understand individuals' compliance from a theoretical perspective and provide practical advice on promoting individuals' compliance with the government's precautionary measures.

Follow or not? Descriptive norms and public health compliance: Mediating role of risk perception and moderating effect of behavioral visibility

In a pandemic context, public health events are receiving unprecedented attention, and identifying ways to enhance individual public health compliance behaviors has become an urgent practical problem. Considering that individual decisions are susceptible to group members' behaviors and that descriptive norms provide social information about the typical behaviors of others, we focused on the effects of the properties and reference groups of descriptive norms on public health compliance behaviors. We also investigated the mechanism with risk perception as a mediator and the applicable condition with behavioral visibility as a moderator. Through a 2 × 2 × 2 between-subject survey experiment with 529 subjects, we demonstrated that (1) compared with the negative norm, the positive norm was more effective in promoting public health compliance behaviors; (2) compared with the distal group norm, the proximal group norm more significantly promoted public health compliance behaviors; (3) the effect of the property of descriptive norms on public health compliance behaviors was weakened in the treatment of the proximal group norm; (4) risk perception partially mediated the association between the property of descriptive norms and public health compliance behaviors and fully mediated the effect of the interaction of the property and the reference group of descriptive norms on public health compliance behaviors; in the treatment of the negative-proximal group norm, individuals perceived more risk, thus effectively nudging their public health compliance behaviors; (5) compared with low-visibility behaviors, public health compliance behaviors were significantly stronger for high-visibility behaviors; (6) the property of descriptive norms had a weaker effect on public health compliance behaviors for low-visibility behaviors. In terms of theoretical significance, we refined the study of descriptive norms to promote the application of behavioral public policy. Moreover, the new model of public health compliance behaviors constructed in this study explains the mechanism and applicable conditions of public health compliance behaviors. In practical terms, this study has implications for designing intervention programs to nudge public health compliance behaviors.

Effect of Digital-Based Self-Learned Educational Intervention about COVID-19 Using Protection Motivation Theory on Non-Health Students' Knowledge and Self-Protective Behaviors at Saudi Electronic University

BACKGROUND

The COVID-19 pandemic has disastrous impacts that impose the cultivation of knowledge and motivation of self-protection to foster disease containment.

AIM

Evaluate the effect of digital self-learned educational intervention about COVID-19 using the protection motivation theory (PMT) on non-health students' knowledge and self-protective behaviors at Saudi Electronic University (SEU).

METHODS

A quasi-experimental study was accomplished at three randomly chosen branches of SEU (Riyadh, Dammam, Jeddah) using a multistage sampling technique to conveniently select 219 students. An electronic self-administered questionnaire was used, which included three scales for assessing the students' knowledge, self-protective behaviors, and the constructs of the PMT. The educational intervention was designed using four stages: need assessment, planning, implementation, and evaluation. A peer-reviewed digital educational content was developed after assessing the participants' educational needs using the pretest. Then, distributed through their university emails. A weekly synchronous Zoom cloud meeting and daily key health messages were shared with them. Finally, the post-test was conducted after two months.

RESULTS

The mean participants' age (SD) among the experimental group was 28.94 (6.719), and the control group was 27.80 (7.256), with a high female percentage (63.4%, 73.8%) and a previous history of direct contact with verified COVID-19 patients (78.6%, 69.2%), respectively. A significant positive mean change (p = 0.000) was detected in the total COVID-19 knowledge of the experimental group post-intervention, either when it was adjusted for the covariates effect of the control group (F₁ = 630.547) or the pretest (F₁ = 8.585) with a large effect size (η² = 0.745, η² = 0.268, respectively). The same was proved by the ANCOVA test for the total self-protective behaviors either when it adjusted for the covariates effect of the control group (F₁ = 66.671, p = 0.000) or the pretest (F₁ = 5.873, p = 0.020) with a large effect size (η² = 0.236, η² = 0.164, respectively). The ANCOVA test proved that post-intervention, all the PMT constructs (perceived threats, reward appraisal, efficacy appraisal, response cost, and protection intention) and the total PMT score were significantly improved (p = 0.000) among the experimental group either when adjusted for the covariates effect of the control group (F₁ = 83.835) or the pretest (F₁ = 11.658) with a large effect size (η² = 0.280, η² = 0.561, respectively).

CONCLUSIONS

The digital PMT-based self-learned educational intervention effectively boosts non-health university students' COVID-19 knowledge, protection motivation, and self-protective behaviors. Thus, PMT is highly praised as a basis for COVID-19-related educational intervention and, on similar occasions, future outbreaks.

Development and cross-national investigation of a model explaining participation in WHO-recommended and placebo behaviours to prevent COVID-19 infection

To protect themselves from COVID-19, people follow the recommendations of the authorities, but they also resort to placebos. To stop the virus, it is important to understand the factors underlying both types of preventive behaviour. This study examined whether our model (developed based on the Health Belief Model and the Transactional Model of Stress) can explain participation in WHO-recommended and placebo actions during the pandemic. Model was tested on a sample of 3346 participants from Italy, Japan, Poland, Korea, Sweden, and the US. It was broadly supported: objective risk and cues to action showed both direct and indirect (through perceived threat) associations with preventive behaviours. Moreover, locus of control, decision balance, health anxiety and preventive coping moderated these relationships. Numerous differences were also found between countries. We conclude that beliefs about control over health and perceived benefits of actions are critical to the development of interventions to improve adherence to recommendations.

Using Chatbot as an Alternative Approach for In-Person Tooth Brushing Training During the COVID-19 Pandemic

Background

It is recommended that caregivers receive oral health education and in-person training to improve toothbrushing for young children. To strengthen oral health education before COVID-19, the 21-Day FunDee chatbot with in-person toothbrushing training for caregivers was used. During the pandemic, practical experience was difficult to implement. Therefore, the 30-Day FunDee chatbot was created to extend the coverage of chatbots from 21 days to 30 days by incorporating more videos on toothbrushing demonstrations and dialogue. This was a secondary data comparison of 2 chatbots in similar rural areas of Pattani province: Maikan district (Study I) and Maelan district (Study II).

Objective

This study aimed to evaluate the effectiveness and usability of 2 chatbots, 21-Day FunDee (Study I) and 30-Day FunDee (Study II), based on the protection motivation theory (PMT). This study explored the feasibility of using the 30-Day FunDee chatbot to increase toothbrushing behaviors for caregivers in oral hygiene care for children aged 6 months to 36 months without in-person training during the COVID-19 pandemic.

Methods

A pre-post design was used in both studies. The effectiveness was evaluated among caregivers in terms of oral hygiene practices, knowledge, and oral health care perceptions based on PMT. In Study I, participants received in-person training and a 21-day chatbot course during October 2018 to February 2019. In Study II, participants received only daily chatbot programming for 30 days during December 2021 to February 2022. Data were gathered at baseline of each study and at 30 days and 60 days after the start of Study I and Study II, respectively. After completing their interventions, the chatbot's usability was assessed using open-ended questions. Study I evaluated the plaque score, whereas Study II included an in-depth interview. The 2 studies were compared to determine the feasibility of using the 30-Day FunDee chatbot as an alternative to in-person training.

Results

There were 71 pairs of participants: 37 in Study I and 34 in Study II. Both chatbots significantly improved overall knowledge (Study I: P<.001; Study II: P=.001), overall oral health care perceptions based on PMT (Study I: P<.001; Study II: P<.001), and toothbrushing for children by caregivers (Study I: P=.02; Study II: P=.04). Only Study I had statistically significant differences in toothbrushing at least twice a day (P=.002) and perceived vulnerability (P=.003). The highest overall chatbot satisfaction was 9.2 (SD 0.9) in Study I and 8.6 (SD 1.2) in Study II. In Study I, plaque levels differed significantly (P<.001).

Conclusions

This was the first study using a chatbot in oral health education. We established the effectiveness and usability of 2 chatbot programs for promoting oral hygiene care of young children by caregivers. The 30-Day FunDee chatbot showed the possibility of improving toothbrushing skills without requiring in-person training.

Trial Registration

Thai Clinical Trials Registry TCTR20191223005; http://www.thaiclinicaltrials.org/show/TCTR20191223005 and TCTR20210927004; https://www.thaiclinicaltrials.org/show/TCTR20210927004

The Global Impact of COVID-19 on Threat Appraisals

We planned an infodemiological analysis to estimate the global impact of coronavirus disease 2019 (COVID-19) on threat appraisals. We accessed Google Trends using the search terms “Anxiety”, “Distress”, “Fear”, “Rumination”, “Stress” and “Worry” within the “topic” domain, setting the geographical location to “worldwide”, between July 2017 and July 2022. The weekly Google Trends score for the six search terms, thus, mirroring Web popularity and probable prevalence, was compared between the two search periods, “pre-COVID” (between July 2017 and February 2020) and COVID (between March 2020 and July 2022), thus, reflecting the volume of searches before and during the ongoing COVID-19 pandemic. The median weekly Google Trends score of all these search terms significantly increased during the COVID-19 pandemic, i.e., anxiety by 22%, distress by 13%, fear by 9%, rumination by 18%, stress by 13% and worry by 20%. With variable strength, the weekly Google Trends scores of each search term were found to be significantly associated (all p < 0.001). We can, hence, conclude that the enhanced burden of threat appraisals observed after SARS-CoV-2 spread leads the way to establish preventive, diagnostic and therapeutic measures in order to limit the unfavorable mental health consequences caused by the ongoing COVID-19 pandemic.

Changes in residents' hygiene awareness and behaviors in public toilets before and during the COVID-19 pandemic in Hangzhou, China: a two-round cross-sectional study

Background

Hygiene behaviors in public toilets are important to prevent the transmission of infectious diseases, especially during the pandemic. All through the novel coronavirus (COVID-19) pandemic, governments in many countries published guidance on personal hygiene for the general population to prevent disease transmission. This study aimed to investigate improvements in residents’ hygiene awareness and behaviors in public toilets before and during the pandemic.

Methods

We recruited 316 residents between November and December 2018 before the pandemic, and 314 residents between December 2020 and January 2021 during the pandemic in the same study sites in Hangzhou, a well-developed city in China. Residents’ hygiene behaviors in public toilets, hygiene awareness, risk perception, and sociodemographic factors were collected. Bivariate analysis and multivariable logistic regressions were used to test the differences between the two rounds. We conducted an observational study to record the provision of hygiene amenities at toilets during the pandemic.

Results

After controlling for sociodemographic factors (gender, marital status, age, education level, and monthly household income), compared with respondents recruited before the pandemic, respondents recruited during the pandemic were more likely to perceive the risks of infection when using public toilets (aOR = 1.77, 95%CI [1.20, 2.60]), and were more likely to be aware of the risks of touching contaminated toilet facilities (aOR = 1.72, 95%CI [1.17, 2.54]) and the risks of not using soap to wash one’s hands after using the toilet (aOR = 1.93, 95%CI [1.38, 2.72]). They were more likely to always clean their toilet seat with alcohol (aOR = 1.88, 95%CI [1.01, 3.51]), wash hands with soap (aOR = 1.52, 95%CI [1.09, 2.10]) and dry their hands with a dryer (aOR = 1.78, 95%CI [1.16, 2.71]), but they were less likely to always wash their hands after using the toilets (aOR = 0.57, 95%CI [0.32, 1.00]). Among 70 public toilets observed, 9 provided alcohol for toilet seat disinfection, 52 provided soap, 33 provided paper towels, and 41 had working hand dryers.

Conclusions

Despite the overall improvement, residents’ hygiene behaviors in public toilets and the supply of hygiene amenities were still suboptimal during the pandemic. Further hygiene education and an adequate supply of hygiene amenities in public toilets are needed to promote residents’ hygiene behaviors.

Cruise traveling behavior post-COVID-19: An integrated model of health protection motivation, travel constraint and social learning

Travel restrictions have harmed the cruise industry as a result of the COVID-19 pandemic. The goal of this study, which is attributed to permanent changes in the regulatory and social landscape, is to identify and examine the factors influencing post-COVID-19 cruise travel intention. To explain cruise travel intention, we developed a theoretical model incorporating health protection motivation, social learning and travel constraint theories. An online survey was conducted with 400 valid responses collected from Singapore. The theoretical model was estimated using structural equation modeling and the survey data. The findings indicate that (1) observing societal behavior, (2) observing the COVID-19 situation, (3) threat appraisal, and (4) coping appraisal all have a direct influence on travel constraint negotiation. Furthermore, travel constraint negotiation and societal observation have a direct impact on intention. An intriguing finding is that observing the COVID-19 situation has no effect on threat assessment, which can be attributed to pandemic fatigue. The findings allow for a set of recommendations to cruise companies and policymakers for post-COVID-19 cruise industry management.

Typologies of stress appraisal and problem-focused coping: associations with compliance with public health recommendations during the COVID-19 pandemic

BACKGROUND

Given prior research finding that young adults are less likely to engage in recommended public health behaviors (PHBs) than older adults, understanding who is and is not likely to engage in PHBs among young adults is crucial to mitigating the effects of the COVID-19 pandemic. Drawing on the Transactional Theory of Stress and Coping, this study examined how typologies of stress appraisal (SA) and problem-focused coping (PFC) among young adults were associated with compliance with public health recommendations during the pandemic.

METHODS

An online sample of young adults in the United States, ages 18-35, was recruited during the early phase of the pandemic (April-May 2020). Participants reported their appraisals of how central, threatening, and uncontrollable the pandemic was, their tendencies to engage in instrumental, problem-focused coping strategies, and how frequently they engaged in three recommended PHBs (social distancing, mask wearing, and hand washing).

RESULTS

Using latent class analysis, we identified three classes of individuals: Low-SA/Low-PFC, Low-SA/High-PFC, and High-SA/High-PFC. Demographics did not efficiently distinguish membership in the three classes. The former two classes reported less compliance with public health recommendations than did the latter class. Tests of measurement invariance for gender indicated trivial differences in the composition of class membership and relations to compliance.

CONCLUSIONS

This research uncovered three qualitatively distinct classes of people who differed in their appraisal of the pandemic and their tendency to engage in PFC. Individuals who view the pandemic as central and threatening and engage in problem-focused coping were more likely than their peers to comply with guidelines recommending social distancing, mask wearing, and hand washing. These results contribute to our understanding of why people do and do not comply with public health guidelines and highlight the importance of attending to psychological variables in public health research. Understanding what drives poor compliance with public health recommendations can contribute to efforts promoting better compliance, and ultimately better health outcomes.

Using an extended protection motivation theory to explain vaccine hesitancy: a cross-sectional study among Chinese adults

Background

Vaccine hesitancy was listed as one of the top 10 issues threatening global health in 2019. The objectives of this study were to (a) use an extended protection motivation theory (PMT) with an added trust component to identify predictors of vaccine hesitancy and (b) explore the predictive ability of vaccine hesitancy on vaccination behavior.

Methods

We conducted an online questionnaire from February 9 to April 9, 2021, in China. The target population was Chinese residents aged 18 and over. A total of 14,236 responses were received. Structural equation modeling was used to test the extended PMT model hypotheses.

Results

A total of 10,379 participants were finally included in this study, of whom 52.0% showed hesitancy toward vaccination. 2854 (27.5%) participants reported that they got flu shots in the past year, and 2561 (24.7%) participants were vaccinated against COVID-19. 2857 (27.5%) participants engaged in healthcare occupation. The model explained 85.7% variance of vaccine hesitancy. Self-efficacy was the strongest predictor, negatively associated with vaccine hesitancy (β = −0.584; p < .001). Response efficacy had a negative effect on vaccine hesitancy (β = −0.372; p < .001), while threat appraisal showed a positive effect (β = 0.104; p < .001). Compared with non-health workers, health workers showed more vaccine hesitancy, and response efficacy was the strongest predictor (β = −0.560; p < .001). Vaccine hesitancy had a negative effect on vaccination behavior (β = −0.483; p < .001), and the model explained 23.4% variance of vaccination behavior.

Conclusions

This study demonstrates that the extended PMT model is efficient in explaining vaccine hesitancy. However, the predictive ability of vaccine hesitancy on vaccination behavior is limited.