key: cord-1050588-8cvwt57r
authors: Commodari, Elena; La Rosa, Valentina Lucia; Coniglio, Maria Anna
title: Health risk perceptions in the era of the new coronavirus: Are the Italian people ready for a novel virus? A cross sectional study on perceived personal and comparative susceptibility for infectious diseases
date: 2020-08-03
journal: Public Health
DOI: 10.1016/j.puhe.2020.07.036
sha: 774d8753e0a839b39ed13139acd4f8b1a48dc174
doc_id: 1050588
cord_uid: 8cvwt57r

Abstract Objectives This study aims to evaluate the impact of psychological and socio-demographic variables on perceived personal and comparative susceptibility to diseases caused by a novel, unknown virus. Study design Cross sectional study. Methods A total of 438 adults (200 male and 238 female) were interviewed in the waiting rooms of three primary care medicine outpatient clinics. The participants completed three validated questionnaires: the Italian Adjustment of Risk Perception of Infectious Diseases questionnaire, the General Self-Efficacy scale (GSE), and the Italian Version of Personality Inventory (ITAPI). Results Only 5% of the respondents believed it likely that they would contract a disease caused by a novel virus in the following months, even though 5.9% considered this probability higher than that of other people of the same age and gender. Gender (p <.04), age (p=.002), and marital status (p=.002) significantly affected the perceived risk of getting a disease caused by a novel virus. Self-efficacy (p<.001), imagination (p<.001), and empathy (p<.001) were significant predictors of perceived personal susceptibility. Self-efficacy (p=.04) and imagination (p=.04) were predictive of perceived comparative susceptibility. Conclusions Adequate psycho-educational interventions are necessary to empower the population in adopting the necessary prevention and containment measures aimed at limiting the spread of novel diseases such as Covid-19 and avoiding disastrous consequences both at health and economic level.

Risk perception related to health is a subjective judgment that people make about dangers affecting their personal wellbeing 1, 2 . Such judgments dictate precautionary actions [3] [4] [5] and influence the probability of complying with health-related recommendations 6 . One main component of risk perception is the concept of 'susceptibility', which concerns how individuals rate their likelihood of contracting a specific disease 7 . Perceived susceptibility, also called perceived vulnerability, includes two dimensions: personal perceived susceptibility, which is the probability that one will be harmed by a hazard, and comparative perceived susceptibility, which is the perceived probability that one is more susceptible to a given danger compared with other people of the same age and gender 8 .

The successful adoption of preventive behaviors to control the spread of diseases largely depends on perceived susceptibility. Although people are often aware of the importance of adopting adequate behaviors to ensure good health for themselves and for others, several subjective variables, such as self-efficacy, personality, and socio-demographic variables, influence the perception and effective adoption of preventive measures 9 . The contribution of subjective variables in determining risk perception is of extreme importance when planning preventive campaigns or in situations that require adherence to specific behavioral models 10 .

'Self-efficacy' refers to the confidence that people have in their personal ability to adopt preventive behavioral measures 11 . It is influenced by culture 12 and affects clinical practice and behavioral change 13 , contributing to predicting practices in health behaviors 14 . 'Personality' traits 15, 16 refer to those elements which underlie our individual cognitive, emotional, and behavioral differences 16, 17 .

Personality traits can help predict individual responses to diseases, health behaviors, mortality risks, and perceived vulnerability to diseases compared to or in association with several sociodemographic variables, such as age and gender 18, 19 . Moreover, they are prospectively related to health status in adulthood and influence the adoption of preventive behaviors [20] [21] [22] . In this regard, Gaygisiz et al. found that personality traits heavily influenced behavioral responses to the flu during the 2009 pandemic 23 .

The spread of the novel coronavirus, which has caused many deaths in China and around the world, makes the investigation of perceived susceptibility a pertinent concern. Realistic perceptions of disease probability significantly influence the adoption of preventive measures and optimize the possibility of maintaining good health and avoiding the spread of infectious diseases. The novel coronavirus, now called SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), is the causative agent for COVID-19 outbreak, a new acute respiratory syndrome affecting mostly people in China with some outbreaks in other countries 24, 25 In light of these considerations and the current health and social emergency represented by the growing spread of the novel Coronavirus, the present study, conducted in the final months of 2019, aimed to investigate perceived susceptibility for a novel, non-defined hypothetical virus. The main goal was to evaluate the impact of psychological and socio-demographic variables on perceived personal and comparative susceptibility to diseases caused by a novel, unknown virus. These findings are particularly relevant in this emergency period related to the new Coronavirus, as they increase available information about how people perceive their susceptibility to infectious diseases and aid in the organization of effective preventive campaigns.

In this study, 438 adults (age ranges 19-69 years; 200 males; 238 females) who were in the waiting rooms of three primary care medicine outpatient clinics in [omissis for peer review] filled out a battery of standardized questionnaires under the supervision of three psychologists. All people who visited the clinics during a period of five days completed the questionnaire, except for three suffering from serious diseases. A total of 235 participants were in the ambulatory for medical consultation or health-status certification release; the remaining were companions. None of the participants suffered from severe pathologies. This modality of consecutive recruitment, which was used in previous studies 10, 30 , depended on interviewing people who did not have serious illnesses The GSE (Cronbach's alphas: from .76 to .90 in samples from 23 nations) evaluates self-efficacy. It is a four-point Likert-type scale and consists of 10 items. It supplies a global score from 10 to 40 32 .

It has been validated in Italian by Sibilia et al. 36 The ITAPI (short version) measures eight personality traits ("dynamicity," "susceptibility," "empathy," "conscientiousness," "imagination," "defensiveness," and "introversion") using 28 items. Several psychological characteristics describe each trait. Dynamicity" (reliability coefficient:

Cronbach's alpha: .86) concerns curiosity, the ease of taking initiatives, and liveliness. Dynamic people are resourceful and innovative. "Susceptibility" (reliability coefficient: Cronbach's alpha:

.86) concerns attitudes toward discouragement and fear. Susceptible people are often unhappy and change their moods easily. "Empathy" (reliability coefficient: Cronbach's alpha: .79) includes psychological characteristics related to sociability and sensitivity. This trait facilitates recognition of emotions and sensitivity toward other people. "Conscientiousness" (reliability coefficient:

Cronbach's alpha: .82) involves attitudes that are careful, perseverant, and rational. People with high scores in this trait are meticulous and precise. "Imagination" (reliability coefficient:

Cronbach's alpha: .82) concerns creativity and imagination. "Defensiveness" (reliability coefficient:

Cronbach's alpha: .79) is characterized by mental rigidity, materialism, and suspiciousness. Finally, "introversion" (reliability coefficient: Cronbach's alpha: .72) includes attitudes of introspection, self-isolation, and emotional control. For each trait, the score ranges were from one to five, where one was "very low" and five considered "very high" 33 .

Several statistical analyses using the Statistical Package for the Social Sciences (SPSS) version 25.0 (Armonk, NY: IBM Corp.) and Amos package for Structural Equation Modeling (SEM) were conducted. As a preliminary step, we calculated respondents' perceived probabilities of contracting certain infectious diseases (common cold, HIV, tuberculosis, A/H1N1 flu, avian flu in Italy, and a novel virus developed outside Italy). Descriptive statistics, t-test, and ANOVA analyses for perceived personal and comparative susceptibility by age and gender were also calculated.

Based on the primary goal of this study, and to better analyze the impact of socio-demographic and psychological variables on perceived susceptibility to a novel virus, we calculated multiple regression analyses. We also developed two structural equation models which described the relationships between psychological variables and perceived personal and comparative susceptibility. As a preliminary measure, the participants confirmed that they had heard of diseases that were investigated in the questionnaire and were aware that a 'new virus' is a virus that is not previously observed in humans.

The analysis of the responses on likelihood to contract infectious diseases which were investigated in the questionnaire showed that only 5% of the respondents believed it likely that they would contract a disease caused by a novel virus in the following months, even though 5.9% considered this probability higher than that of other people of the same age and gender (Table 1) .

Interestingly, participants considered the probability of getting a disease linked to a new virus higher than the possibility of contracting the infectious diseases that were taken into consideration in the questionnaire, except for a common cold. This result is worthy of attention. Although the perception of risk was low, the respondents considered it more dangerous to have an unknown disease than a pathology caused by known infectious diseases, such as the A/H1N1 flu, which was diffused during the 2019/2020 seasonal flu. In this regard, the European Regional Office of the WHO, in its Flu News Europe of February 2020, reported that A/H1N1 pdm (2009) ANOVA analyses showed significant differences by age in perceived personal and comparative susceptibility for all the investigated diseases, except HIV (Table 2) , which all respondents considered a highly unlikely disease. Older people had a higher perceived susceptibility for all diseases examined in the questionnaire except for a common cold. Oddly enough, younger people rated the likelihood of contracting the latter disease higher than older participants did. There were no differences by gender in the perceived susceptibility. 18 ). According to these data, being women, older and married is associated with a higher perceived risk of getting a disease caused by a novel virus while being men, younger in age and unmarried is associated with a lower perceived risk. Table 3 presents the significant results of the regression analyses and shows the contribution of each predictor to the dependent variables.

To better describe the relationships between the psychological variables that influence perceived susceptibility and their relationships, two structural equation models were developed. The models included the three variables that were found to be significant predictors in the regression analyses.

The non-significant Chi-square (Chi Square=.001; df=1; Chi-q/df:0.001) and the other FIT model values (RMSEA=. .06 ; SRMR=.07; CFI= .9) indicated a good fit. The results of the SEM analyses are presented in Figure 1 .

The results of the present study showed the impact of socio-demographic and psychological variables on perceived susceptibility. Interestingly, the influence of subjective factors on risk perception for health is relevant, even if the perceived risk concerns a non-specific pathology, such as a hypothetical disease related to an unknown virus. Our study clearly shows that interviewed people considered themselves at a lower risk of catching a familiar virus than a novel one, despite the fact that some of these common infectious diseases, such as the flu, are known throughout the population. These data are at the moment particularly useful for planning and implementing Public health control activities against COVID-19 outbreak, because people ought to strictly follow the recommended prevention strategies, such as avoiding exposure by adhering to recommended hygiene procedures (e.g., hand washing, mouth and nose covering when coughing and sneezing, daily cleaning and disinfecting touched surfaces, etc.), isolation of SARS-CoV-2 infected persons and social distancing.

The older respondents of our sample perceived themselves at higher risk of getting a disease related to a novel virus compared with the younger respondents. This data is particularly important for two main reasons, at least. First of all because, as already underlined, elderly people are at increased the risk of serious COVID-19. Therefore, a high-risk perception could mean that older people are most likely to adopt protective behaviors. On the other hand, children are less likely to become infected or their symptoms are so mild that their infection could escape detection, which has important epidemiological implications 40 . For this reason, the implementation of behavioral strategies appropriate for the young is necessary in order to protect the elderly. Self-control strategies for behavioral interventions could help young people in learning the skills necessary to practice and implement behavioral changes, adopt prevention measures or eventually correct mistakes. In particular, young people may require external support persons (e.g., parents, teachers or behavioral analysts) when learning the established prevention measures for reducing COVID19 or other communicable diseases transmission in the population through the correct application of personal protective measures. These measures refer to hand and respiratory hygiene, cough etiquette and use of face masks in the community, as recommended by the ECDC 41 . The external supports should provide modeling of skills for the young to watch, encouraging them to practice, and correcting mistakes. Obviously, adults will model the appropriate behaviors themselves in the same contexts where young people will be expected to exhibit those skills (schools, shopping centers, public parks, etc.). As young people learn how to perform skills and when and where to perform them, they should learn to self-monitor their own behavior in appropriate contexts 42 .

The multiple regression analyses and SEM contributed to better investigating the impact of sociodemographic and psychological variables on perceived risks of health. The findings showed that gender, age, and marital status influenced the perceived personal probability of getting a disease caused by a novel virus. Psychological variables also have a high impact on perceived risk for health. This result is worthy of attention, pending planning effective prevention campaigns that reach a large part of the population. People with different personality characteristics present a different level of risk perception for their health. The levels of empathy, self-efficacy, and imagination significantly influenced perceived susceptibility, presumably contributing to the adoption of preventive behaviors in situations of need. These issues clarify the results of previous studies that found that several personality aspects affect the perception of being at risk and the consequent engaging in health-protective behaviors [43] [44] [45] [46] . Interestingly, "self-efficacy" and "imagination" were found to be significant predictors of risk perception, as reported in previous studies about this topic 10 . To confirm this data, the recent literature on the topic showed that these psychological variables have a significant role in promoting effective prevention campaigns. More specifically, preventive self-efficacy, defined as the perception that an individual has of their own ability to adopt specific healthy behaviors, is an important variable in promoting adherence to preventive measures and healthy behaviors such as quitting smoking or exercising more 47 .

Furthermore, it has also been shown that empathic messages that stimulate self-efficacy are helpful in promoting disease prevention 47 This study has some limitations. First of all, it is based on data from a single center and it would be interesting to conduct similar studies in other geographic areas to evaluate any differences in risk perception related to social and cultural differences. Furthermore, we investigated the perceived risk for a hypothetical novel virus and it would be important to replicate this study in light of the recent outbreak of the Covid-19 epidemic in Italy to verify how much the impact with this new disease may have changed the risk perception of the subjects interviewed.

However, these results are of particular practical interest, given that the recent outbreak of Coronavirus in Italy requires that people engage in the proper behavioral measures to mitigate the disease's spread.

In conclusion, our study shows how subjective factors significantly affect the risk perception for health, even in case of non-specific pathology, such as a hypothetical disease related to an unknown virus. In this regard, our results suggest taking into account the role of psychological variables, especially empathy, self-efficacy and imagination, in promoting effective psycho-educational interventions aimed at empowering the population in adopting the necessary prevention and containment measures.

In light of the current Covid-19 outbreak worldwide, it is therefore important adopt specific programs to enhance personality characteristics that play an important role in adopting healthy and preventive behaviors in order to limit the spread of the virus and avoid disastrous consequences both at health and economic level. 

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