key: cord-0814777-1l1sysmf authors: Mehanna, A. A.; Elhadi, Y. A. M.; Lucero-Prisno, D. E. title: Factors influencing intention to adhere to precautionary behavior in times of COVID- 19 pandemic in Sudan: an application of the Health Belief Model date: 2020-12-31 journal: nan DOI: 10.1101/2020.12.25.20248859 sha: 580f0cf8e87419c6634e19c00d7665417b3cdf4b doc_id: 814777 cord_uid: 1l1sysmf Background Corona virus disease (covid-19) is an emerging highly infectious disease caused by novel corona virus (SARS-CoV-2). Several public health and social protective measures that may prevent or slow down the transmission of the COVID-19 were introduced. However, these measures are unfortunately neglected or deliberately ignored by some individuals. Objective To identify the factors influencing intention to adhere to precautionary measures againstCOVID-19 in Sudan. Methods and Design Cross sectional online based survey using virtual convenience sampling technique. Variables Measured Perceived threat of corona virus (perceived severity and perceived susceptibility), perceived benefits, perceived barriers, self-efficacy and intention to adhere to precautionary behavior towards COVID-19 Results The significant predictors of intention to adhere to the precautionary behavior against COVID-19 were: gender ({beta} =3.34, P <0.001), self-efficacy ({beta}= 0.476, P<0.001), perceived benefits ({beta}= 0.349, P<0.001) and perceived severity ({beta}= 0.113, P=0.005). These factors explained 43% of the variance in participants intention to adhere to the protective measures. Participants who were female, confident in their ability to adhere to the protective measures when available, believing in the benefits of the protective measures against COVID-19 and perceiving that the disease could have serious consequences were more likely to be willing to adhere to the protective measures. Conclusion Health Belief model is a useful framework for addressing factors influencing intention to adhere to precautionary behavior during COVID pandemic. At this time, there is no approved vaccine preventing corona virus disease. The best prevention is to avoid exposure to the virus (6) . In response to this Pandemic, Almost all countries imposed lockdown policy to slow the spread of the virus and introduced measures that may reduce the risk of exposure these include: use of face masks; regular hand washing with soap or disinfection with hand sanitizer; avoidance of contact with infected people and complying with social distancing measures in crowded places; and avoid touching eyes, nose, and mouth with unwashed hands(7) (8) . However, these guidelines, which were introduced to slow the spread of COVID-19 and contribute to public well-being, are unfortunately neglected or deliberately ignored by some individuals (9) . Health Belief Model (10) was originally formulated to explain different preventive health behaviors. According to this model, the individual's health behavior depends on an individual's perception of being at risk to get the disease, perceived severity of the disease, perceived benefits and perceived costs of taking a particular health action (11) and feeling capable of implementing the desired behavior to achieve results (12) . This study aims to identify the possible factors influencing Sudanese people's intention to adhere to the protective measures (staying at home, wearing masks/gloves and following social distancing measures) using the Health Belief Model. A cross-sectional design was used to study participants' intention to adhere to protective measures against COVID-19. The study was conducted in Sudan in 2020.The study was conducted on 625 participants based on the assumption that intention to adhere to protective measures =50%, precision =5% and alpha = 0.05. Convenience internetbased sampling technique was used. Using Google forms, an online structured questionnaire was developed by the researchers based on review of previous literature. The questionnaire link was distributed to the participants through social media such as: Email, Facebook, What's App, Twitter .Etc. The questionnaire was used to collect socio-demographic data of study participants, their health beliefs and intention regarding adherence to . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted December 31, 2020. ; https://doi.org/10.1101/2020.12.25.20248859 doi: medRxiv preprint precautionary behavior against COVID-19. Precautionary behaviors are actions taken in advance to protect against possible exposure to COVID-19. The precautionary behaviors addressed in this study were: staying at home, wearing masks/gloves and practicing social distancing on going out. The scale measuring HBM constructs consists of 5 subscales measuring perceived susceptibility & severity of COVID-19, perceived benefits and barriers to adherence to precautionary behaviors and self-efficacy in adhering to precautionary behaviors. Responses to scale items were scored on a five-point Likert scale ranging from 0 (strongly disagree) to 4 (strongly agree). The score was reversed for some items, it was calculated for each subscale, converted to percentage and categorized into high (> 66.67%), moderate (33.33% to 66.67%) and low (< or equal to 33.33%). It was assessed using two statements: "In the coming period, I will try to stay at home and not go out unless necessary", and "In the coming period, I will try to adhere to the protective measures (wearing a mask, gloves and social distancing) when going out". Responses to scale items were scored on a five-point Likert scale ranging from 0 (strongly disagree) to 4 (strongly agree). The score was calculated and converted to percentage and categorized into high (> 66.67%), moderate (33.33% to 66.67%) and low (< or equal to 33.33%). . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted December 31, 2020. ; https://doi.org/10.1101/2020.12.25.20248859 doi: medRxiv preprint Data were fed to the computer and analyzed using IBM SPSS software package version 20.0(Armonk, NY: IBM Corp).Qualitative data were described using number and percent. Quantitative data were described using mean and standard deviation. Significance of the obtained results was judged at the 5% level. Pearson's coefficient was used to correlate between the different variables used in the study. Linear regression analysis was performed to detect the significant predictors of intention to adhere to precautionary behavior. A Total of 680 Sudanese has responded to the questionnaire. The mean age of participants was 26.7 (±7.95 years), 56.8% of participants were females, 83.7% were living in Khartoum (the capital of Sudan), 79% were single and77.6% were university undergraduates. The monthly income of about half the participants (49.6%) was just enough (Table 1) . . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted December 31, 2020. ; . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted December 31, 2020. ; https://doi.org/10.1101/2020.12.25.20248859 doi: medRxiv preprint The mean percent scores (MPS) of all the domains of the HBM -except for perceived barriers were pertinentlyhigh indicatingthat participants strongly believedin being suceptible to COVID-19(80.48%) and that the disease could have severe consequences(84.99%). Participants also perceived that adherence to the protective measures such as social distancing and wearing masks was important and beneficial (93.65%)and were confident in their ability to adhere to these protective measures(81.01%) if they were available.Nevertheless, the MPS of perceived barriers was moderately high (61.48%) denoting thatseveral barriers to the adherence to protective measures were reported by a significant proportion of participants.The MPS of intention was high (87.21%) reflecting participants' strong will to adhere to the protective measures against COVID-19 ( Figure 1 ). Most of the participants agreed/strongly agreed on being at risk of getting COVID-19 (71.3%) and on the possibility of getting infected when being in contact with a person not showing the symptoms of the disease (87.6%) meanwhile, they disagreed/strongly disagreed on the negative statement "Covid-19 disease is not transmitted through contact with surfaces or tools"(80.4%).However, more than one third (35.6%) of participants were not sure whetherthe hot climate in Sudan killed the virus and thus reduced the possibility of infection. More than 90% of the participants agreed/strongly agreed that COVID-19 is spreading rapidly and that it may lead to dealth. More than 90% agreed/srongly agreed that adherence to protective measures reduced the number of cases and decreased spread of the disease. A great majority of the participants believed that they were capable of staying at home for the entire period of time specified by the ministry of health, and only go out if necessary (78.7%) and were able to commit to wearing the mask (if available) whenever they went out . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted December 31, 2020. ; (91.6%).Regarding perceieved barriers, bring the needs of the family was the most frequently reported factor hindering participants from satying at home (85.1%) followed by work requirements (62.4%) then feeling bored (46.8%), while disagreements between family members at home was the least mentioned barrier to staying at home (17.6%). Concerning factors hindering adherence to protective measures outside home,the absenceof rules governing the distance between people in crowded places such as markets and means of public transportation was the barrier most agreed/strongly agreed upon(91.8%) followed by the unavailability and high prices of gloves/masks (76.3% and 72.6% respectively) ( Table 2) . ( . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted December 31, 2020. ; https://doi.org/10.1101/2020.12.25.20248859 doi: medRxiv preprint Table 3 shows the correlation between intention and the different parameters of the HBM. Intention was significantly correlated with all the parameters of the model. The five parameters of the model were significantly positively correlated except for perceived barriers which, expectedly, showed a significant negative correlation with intention and with all the other parameters of the HBM. Self-efficacy had the strongest positive correlation with intention to adhere to preventive measures (r =0.589) followed by perceived benefits (r =0.490). Intuitively, this means that the more confident the person is in his ability to perform the behavior (adhere to protective measures), the more likely he feels he would perform the behavior. However, intention is influenced by other factors as well including perceived benefits and perceived severity. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted December 31, 2020. ; https://doi.org/10.1101/2020.12.25.20248859 doi: medRxiv preprint ( were more likely to be willing to adhere to the protective measures. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted December 31, 2020. ; agreed that females were more compliant to health-related guidelines than males. Intuitively, health educators should invest more effort in educating females who would, in turn, act as change agents influencing their social networks. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted December 31, 2020. ; Regarding health beliefs, participants scored high on their health beliefs about adherence to the protective measures. It seems that the world wide awareness-raising campaigns played an important role in increasing peoples' knowledge of the virus and helped them acquire a more negative attitude towards the disease and a more positive attitude towards adopting the protective measures against the disease. Hence, most participants in the present study believed in being susceptible to the disease whether directly through their contact with infected people or indirectly through their contact with virus-contaminated surfaces or tools. However, a non-negligible proportion of participants neither agreed nor disagreed that the hot climate in Sudan killed the virus and believed that the Sudanese citizen had strong immunity and therefore was less likely to contract the disease. Such findings should draw the attention of the health authorities in Sudan to the need to provide credible information to correct the misunderstanding and clear the ambiguity people might have about the disease. Nonetheless, it seems that the role of perceived susceptibility was not very evident in enhancing participants' intention to adhere to the protective measures. An intriguing result was that among health beliefs, self-efficacy-and not perceived barriers-was the most significant predictor of intention. Feeling capable of adhering to protective measures against COVID-19 has strongly influenced participants' intention to do so. This finding highlights the importance of enhancing people's confidence in their ability to adhere to protective measures by disseminating credible information about these measures: what they are, where to be found, when and how to be used. Moreover, they should be affordable and accessible. Additionally, enforcing rules concerning social distancing and wearing masks would transform these precautionary measures into accepted social norms, thus, encouraging people and giving them the . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted December 31, 2020. ; https://doi.org/10.1101/2020. 12.25.20248859 doi: medRxiv preprint confidence to adhere to such measures. In his Social Cognitive theory, Albert Bandura described self-efficacy as the most important pre-requisite for behavior change (19) (20) . Indeed, a considerable amount of research revealed that self-efficacy was a significant predictor of health behavior (21) , (22) , (23) lending support to our findings. Examination of correlation analyses revealed that intention to adhere to the protective Several barriers to adherence were documented in the current study, most important of which were the high prices of masks/gloves, their unavailability in the market and the absence of rules governing the distance between citizens in public places and public transportation. As regards staying at home, the most important constraints were bringing family needs and work demands. Despite not being a significant predictor of intention, these barriers should not be overlooked. In fact, resolving these barriers would be an avenue to enhancing people's self-efficacy and perceived controllability of adherence behavior. Ultimately, emphasis on some HBM constructs does not mean that we should . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted December 31, 2020. ; ignore other constructs to achieve synergetic effect. In contradiction to our findings, several studies found perceived barriers to be a significant predictor of preventive health behaviors including immunization and screening behaviors (25)(28)(29)(30). This research could be an important guide in designing health education messages to enhance adherence to the protective measures againstCOVID-19. Educational messages should essentially focus on improving people's self-efficacy in adhering to the protective measures. Moreover, more efforts should be done in targeting females who would act as influential change agents among their social networks. This study has some limitations. Cues to action were not assessed in this study in order to avoid a long questionnaire, however, knowing the triggers instigating participants to adhere to the protective measures would have certainly added to this work. We used the convenience sampling technique; hence generalization of data would not be possible. Nonetheless, the present research was able to shed important light on some of the factors influencing participants' intention to adhere to the protective measures in Sudan. A subjective tool -self-report questionnaire -was used to collect data; therefore, participants' responses might be affected by social desirability. Female participants and participants having higher self-efficacy, higher perceived benefits and higher perceived severity were more likely to be willing to adhere to the protective measures against COVID-19 in Sudan. The Health Belief model was a useful . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. This study was approved by the Ethics Committee of the High Institute of Public Health, Alexandria University, Egypt in 8/9/2020. The questionnaire was preceded by a cover letter explaining the aim of the study followed by an invitation to participate. The anonymity and confidentiality of participants were guaranteed. Online submission of the questionnaire was considered as consent to participate in the study. Not applicable. The manuscript does not include any individual person's data in any form (including individual details, images or videos). Data and questionnaire are available from the corresponding author upon request. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted December 31, 2020. ; https://doi.org/10.1101/2020. 12.25.20248859 doi: medRxiv preprint The authors report no conflicts of interest in this work. The study was not funded by any agency or organization. Design of the study and collection, analysis and interpretation of data and writing the manuscript were financed by the researchers. The concept for this research was developed by YE and AM. YE and AM designed the Data collection tool, collected the data, developed the draft and prepared the manuscript with an important contribution from DL. All the authors have read and agreed to the final manuscripts. . 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