key: cord-0909044-8m6be4np
authors: Prasetyo, Yogi Tri; Castillo, Allysa Mae; Salonga, Louie John; Sia, John Allen; Seneta, Joshua Adam
title: Factors Affecting Perceived Effectiveness of COVID-19 Prevention Measures among Filipino during Enhanced Community Quarantine in Luzon, Philippines: Integrating Protection Motivation Theory and Extended Theory of Planned Behavior
date: 2020-08-06
journal: Int J Infect Dis
DOI: 10.1016/j.ijid.2020.07.074
sha: 08f9f89abc1305b15b34468a3b7ba9ba190cfa0b
doc_id: 909044
cord_uid: 8m6be4np

OBJECTIVE: The current study integrated Protection Motivation Theory (PMT) and extended Theory of Planned Behavior (TPB) to evaluate factors affecting the perceived effectiveness of COVID-19 prevention measures among Filipino during Enhanced Community Quarantine (ECQ) in Luzon, Philippines. METHODS: A total of 649 Filipino answered the online questionnaire which contained of 63 questions. Structural Equation Modeling (SEM) was utilized to derive the causal relationships of latent variables construct. RESULTS: SEM showed that understanding of COVID-19 had significant direct effects on perceived vulnerability and perceived severity. In addition, perceived vulnerability and perceived severity had significant indirect effects on intention to follow. Intention to follow had significant direct effects on actual behavior and adapted behavior which subsequently lead to perceived effectiveness. Interestingly, understanding of COVID-19 was found to have a significant indirect effect on perceived effectiveness. CONCLUSIONS: The current study is one of the first studies that analyzed factors affecting perceived effectiveness of COVID-19 prevention measures during the global pandemic. Finally, the integrated PMT and extended TPB of this study can be applied and extended to evaluate the perceived effectiveness of COVID-19 measures in other countries that currently dealing with COVID-19 pandemic.

Coronavirus (COVID-19), a highly transmittable disease that threatens the human population worldwide, is considered to be the third pandemic within the 21 st century (Perlman, 2020 The International Committee on Taxonomy of Viruses (ICTV) recently named the novel coronavirus into SARS coronavirus 2 (SARS-COV-2), which is now generally called coronavirus Due to the global pandemic of COVID-19, several prevention measures were taken. A massive lockdown has been implemented by governments in several countries. In addition, "#StayAtHome" was also promoted by media to prevent the spread of COVID-19. Moreover, researchers are currently in the process of developing a vaccine and there is no effective medicine that has invented for the medication of COVID-19 infections (Paital, 2020) . At the moment, the only possible remedial option is hospitalization and thorough care unit management. With these initial medications, predicting the duration and final size of the virus in every country become very critical for policymakers and public health authorities in preventing the spread of the outbreak.

Despite the availability of different studies about the preventive measures in other countries, there is a significant lack of academic research addressing the COVID-19 situation in the Philippines. On July 16 th 2020, Philippines was declared as the highest number of active cases in Southeast Asia (Table 1) Figure 2 represents the Theoretical Research Framework of the current study. Different from one previous study which only utilized PMT related to COVID-19 (Barati et al., 2020) , we integrated the PMT and extended TPB to determine the causal relationships between determined variables and latent assembles. The final goal was to evaluate factors affecting the perceived effectiveness of COVID-19 prevention measures among Filipino during ECQ in Luzon.

Based on PMT, when individuals encounter a threatening event, they are most motivated to engage in protective behavior (Janmaimool, 2017) . According to studies, individuals believe that performing preventive behavior can reduce the threat that comes with the lack of action (Hung et al. 2014) . During the global crisis, providing reliable and accurate information is very essential.

In 2009, the public believed that H1N1 virus was much more lethal than H5N1 human avian flu and SARS because various forms of new infectious diseases were merged together (Lau et al. 2009 ). Early knowledge of the outbreak can help to illustrate the public's risk behavior and how J o u r n a l P r e -p r o o f they perceived it (Balkhy et al. 2010) . Moreover, Johnson and Hariharan (2017) highlighted that during an outbreak, providing health education and creating awareness is an effective measure to prevent the spread of the disease. Thus, we hypothesized the following: H1. Understanding of COVID-19 had a significant direct effect on perceived vulnerability.

Understanding of COVID-19 had a significant direct effect on perceived severity.

Health understanding and perceived behavioral control have been identified frequently as predictors to an individuals' tendency to follow the prescribed prescription which subsequently conforms to treatment procedures (Davis et al. 2006) . Bandura (1977) stated that the essential predictor of various medical behaviors including medication constancy is the perceived behavioral control. However, Cameron et al. (2010) point out that taking medication as prescribed is the responsibility of the patient. It is not an unusual occurrence if, due to inadequate knowledge, a patient fails to understand how to administer the medication properly, misuse, or non-adherence (Cameron et al. 2010) . Moreover, this pivotal dispute of misconception and ignorance of directions for prescribed pharmaceutical products, particularly for people with poor health literacy (Cameron et al. 2010) , is associated with avoidance of preventive care and worse outcomes in many chronic medical conditions (Berkman et al. 2011 ). Thus, we hypothesized the following:

H3. Understanding of COVID-19 had a significant direct effect on perceived behavioral control of an individual.

Based on the Theory of Planned Behavior, the behavioral intent of a person is profoundly affected by the behavioral norms of its social community (Ajzen, 2011) . However, in a technology context, protective technologies are significantly influenced by the user's knowledge and the implications of technologies (Dinev & Hu, 2007) . Moreover, Biglan and Taylor (2000) stated the J o u r n a l P r e -p r o o f process of educating the public of issues was found to influence the growing collective organizational network which actively supports policy strategies to reduce the complications. A critical stage in this approach is a thorough exposition of the problem that was accomplished by intensive engagement with the various communities, leading to stronger cultural norms (Biglan & Taylor, 2000) . Thus, it is logical to conclude that the greater the group standards, the higher the level of understanding among the members of the social community. Hence, we proposed:

H4. Understanding of COVID-19 had a significant direct effect on subjective norms about the preventive measures implemented in the Philippines.

Some studies have observed that healthcare professionals exhibit a greater understanding, optimistic attitudes towards the pandemic, and frequently exhibit low rates of anxiety (Mishra et al. 2016 Tobago reported that a substantial proportion of the general population is still oblivious of the severity and the prevention measures of the epidemic (Johnson & Hariharan, 2017) . A related study was found that most respondents among secondary children in Nigeria had insufficient awareness and had a negative approach to Ebola virus (Ilesami et al. 2014) . Along with hypotheses 1 and 2, we also hypothesized the following: Most studies about health-related behaviors have utilized TPB (Gabriel et al. 2019; Hagger et al. 2016; Huang et al., 2020) or PMT separately (Barati et al., 2020) . It specifies that attitudes, J o u r n a l P r e -p r o o f subjective norms, and perceived behavioral control are the essential components of behavioral intent and actual health-related behavior (Kam et al. 2009 ). However, there is little to none have discussed a relationship between TPB and PMT. Hence, the current model attempts to correlate factors associated with PMT to the key determinants of TPB. Thus, we hypothesized the following: H6. Perceived vulnerability had a significant direct effect on perceived behavioral control.

Perceived severity had a significant direct effect on perceived behavioral control.

Perceived vulnerability had a significant direct effect on subjective norms.

Perceived severity had a significant direct effect on subjective norms.

Perceived vulnerability had a significant direct effect on an individual's attitude towards COVID-19.

Perceived severity had a significant direct effect on an individual's attitude towards COVID-19. Lau et al. (2010) mentioned that the variables of behavioral intention is directly correlated to the factors derived from the TPB. According to Ajzen (1991a) , self-efficacy is an element that is common to both TPB and PMT which has the same concept of perceived behavioral control. It highlights the skills and competencies of a person handling the task or decision making (Bandura, 1997; Bandura, 1978) . In fact, some studies (Workman et al. 2008) shows that self-efficacy has a significant effect on the capability of a person to perform task behavior. Hence, we hypothesize the following:

H12. Perceived behavioral control had a significant direct effect on intention to follow the preventive measures of COVID-19.

Subjective norm is defined as the normative rewards, values, and desires to adhere to a specific act which is primarily told by observation of others' behaviors (Ajzen, 1991a; Aronson et al. 2010) . Past studies (Chan et al. 2005) have reported that the behavior of an individual is affected by the norm in their community. In the context of the individual's compliance in organizations, Chan et al. (2005) stated that when supervisors and employees collogue cooperate and follow the guidelines, employees are most likely to comply with the organization's guidelines.

In addition, most studies have proven that there is a strong relationship between subjective norms and compliance in organizations (Ho et al. 2017; Schepers & Wetzels, 2007; Grimes & Marquardson, 2019) . However, some studies mentioned that subjective norms construct are usually a poor indicator of behavioral intention since it is possible that the behavior of a person are affected by societal influences and personal choices (Armitage & Conner, 2001) . Thus, we hypothesized the following: H13. Subjective norms had a significant direct effect on an individual's behavioral intention to follow the preventive measures of COVID-19.

Attitude towards behavior refers to the perception of the individual performing a particular behavior. Most studies have confirmed that people will comply with rules, requirements, and guidelines when they have a positive attitude (Mcmillan & Conner, 2003; Sasse et al. 2004; Ng et al. 2009; Herath & Rao, 2009; Bulgurcu et al. 2010 ). On the other hand, people who disregard certain desirable habits do not adhere readily to the implemented guidelines (Pahnila et al. 2007; Myyry et al. 2009 ). Hence, we hypothesized that:

H14. Attitude had a significant direct effect on an individual's behavioral intention to follow the preventive measures of COVID-19.

Behavioral intent is defined as the subjective probability that an individual will execute a particular behavior (Mahardika et al. 2020) . It is depicted as the best possible predictor of an individual's action despite the many factors that may affect the effectivity of the intention-behavior relationship (Bentler & Speckart, 1979) . Furthermore, when an actual behavior is deliberated upon an individual's behavioral intention judgment, the behavioral intention will be foresighted. Hence Bentler & Speckart et al., (1979) proposed a model that complements Hill et al., (1977) theory in predicting behavior. Thus, we hypothesized the following:

Behavioral intention had a significant direct effect on the actual behavior of individuals.

Previous studies emphasized that the feeling that individuals can only have a negligible impact on a larger scale as an essential barrier for socially responsible behavior (Ellen et al. 1991 ).

According to Owens (2000) , individuals may perceive their actions as irrelevant on a larger scale even if they have awareness regarding the situation and have a desire to have a contribution in society. Consequently, in addition to maintaining prosocial values, the perception that one's actions will make a difference is a necessary precursor to socially responsible behavior. For example, in a study of social activism, only those individuals who perceived their actions as effective acted on their beliefs (Hinkle at al. 1996) . Hence, we hypothesized the following: 

The current study utilized a cross-sectional design. An online questionnaire was distributed from May 7 th to May 11 th 2020 since it was not possible to do a community-based sampling during ECQ in Luzon, Philippines. A total of 649 Filipino aged between 15 to 75 years old (mean: 27.76; standard deviation: 10.64) answered the online questionnaire which contains of 63 questions. Table 2 represents the descriptive statistics of the respondents. Among the 649 respondents, 57% of them were female and 43% were male. Most respondents were between 15-24 years of age (60.9%). About 18.2% of the respondents were between the age of 25 and 34 years, 10.8% were between 35 and 44 years, 6.6% were between 45 and 54 years, 2.9% were between 55 and 64 years, and only 0.6% were over 64 years and above. Approximately, 1.2% of the respondents were elementary graduates, 18.2% were high school graduates, 8.9% were college graduates, 4.2% were master graduates, and only 0.6% were graduates of Ph.D. Most of the respondents have a monthly salary/allowance of less than PHP15,000 (40.8%). About 31.1% of the respondents have a monthly salary/allowance of PHP15,000 -PHP30,000, 7.6% of them have a monthly salary/allowance of PHP30,000 -PHP45,000, 4.9% have a salary/allowance of PHP45,000 -PHP60,000 monthly, 2.8% have a monthly salary/allowance of PHP60,000 -PHP75,000, and 12.8% of the respondents have a salary/allowance of more than PHP75,000 monthly. Most respondents answered that they are currently enrolled in health insurance (56.9%) while only 43.1% of them were not.

J o u r n a l P r e -p r o o f

Following our theoretical framework, a self-administered questionnaire was developed for this study to evaluate factors affecting perceived effectiveness of COVID-19 prevention measures during the ECQ in Luzon, Philippines (Table 3 ). The questionnaire consists of 11 sections: (1) demographic information (gender, age, educational attainment, monthly income/allowance, and health insurance), (2) Perceived Vulnerability, (3) Perceived Severity, (4) Understanding of COVID-19, (5) Attitude, (6) Subjective Norm, (7) Perceived Behavioral Control, (8) Intention to Follow, (9) Actual Behavior, (10) Adapted Behavior, and (11) Perceived Effectiveness. All latent constructs included in the SEM were measured by utilizing 5-point Likert scale.

Structural Equation Modeling (SEM) is an advanced statistical approach mainly designed to describe the causal relationships between the latent variables construct (Hair et al., 2006; Martinez et al., 2019; Torres et al., 2019) . AMOS 22 with Maximum Likelihood estimation approach was utilized to run the SEM. (Hair, 2010; Hu & Bentler, 1999) .

Similar to R 2 in the multiple linear regression (Lin et al., 2019a) , a value greater than 0.80 is the minimum indication of good model fit for GFI and GFI (Gefen et al., 2000) . Finally, a value smaller than 0.07 is also an indication of a good model fit for RMSEA (Steiger, 2007) . Attitude (Hypothesis 5). Therefore, a revised SEM was derived by removing this hypothesis.

Following some of our previous studies which utilized SEM approach (Lin et al., 2018; Lin et al., 2019b; Miraja et al., 2019) , some modification indices were applied in order to enhance the model fit.

J o u r n a l P r e -p r o o f Table 4 demonstrates the descriptive statistic results of each indicator. As presented in Table 5 , the IFI, TLI, and CFI values were greater than the suggested cutoff of 0.90, indicating that the hypothesized construct of the specified model was a very good representation of the observed data. In addition, the GFI and AGFI values were 0.842 and 0.820 respectively, indicating that the model was also good. The RMSEA value was 0.044 which also lower than the recommended value. Finally, the direct, indirect, and total effects are presented in Table 6 .

The current study integrated Protection Motivation Theory (PMT) and extended Theory of As discussed before, the current study integrated the extended TPB wherein it was classified into three elements such as perceived behavioral control (PB), subjective norm (SN), and attitude (AT). Based on the result, it proved that understanding of COVID-19 had significant direct effects on SN (β:0.366; p=0.001) and PBC (β:0.700; p=0.001). It could be interpreted that people can understand the virus if they are surrounded by people who are following the preventive protocols given by the government such as wearing face masks outside, staying and working from home, using hand sanitizer frequently, and practicing social distancing during the outbreak.

Moreover, people are more confident if they understand the symptoms of COVID-19. Apart from the significant direct effects, the current model surprisingly showed that understanding COVID-19 had no significant direct effect on attitude but it was found to have a significant indirect effect. Currently, some regions (e.g. Region II, Region III, Region IV, NCR) and provinces (e.g. Albay and Pangasinan) in Luzon are placed under GCQ in which it has more relaxed measures compared to MECQ (GOVPH, 2020). The difference of GCQ and MECQ is that during the GCQ, transportation excluding the jeepneys and buses is now allowed but not in full capacity in compliance with strict social distancing (Esguerra, 2020). All industries and businesses are allowed to operate up to 75% and must follow strict protocols. Although our study was conducted during ECQ, our results are still valid during MECQ and GCQ since the implemented preventive measures of the government are still in effect.

Despite the clear and substantial contributions, the authors would like to acknowledge several limitations of this study. First, the current study was mainly focused on the perceived effectiveness rather than measuring the effectiveness of prevention measures itself. A future study to correlate the perceived effectiveness and the number of cases would be a very promising topic.

Second, our sample was collected through an online questionnaire. Future research to collect more samples in the community after ECQ would lead to more comprehensive results. Last but not the least, we did not correlate the power of media to the understanding of COVID-19. Future studies should also incorporate the trust of people in information and outcome expectations as one of the essential predictors of behavioral intention to follow. 

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Y.T.P as the first and the corresponding author were responsible for the conceptualization of the paper as well as securing the funding from Mapúa University DRIVE, running SEM in AMOS, 

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