Predicting the endorsement of preventive behaviors in the context of the Corona virus pandemic ------------------------------------------------------------------------ **Urte Scholz**, University of Zurich, Department of Psychology, Applied Social and Health Psychology **Alexandra M. Freund**, University of Zurich, Department of Psychology, Developmental Psychology: Adulthood ---------- **1 Project Summary** The current situation of the ongoing new Corona virus pandemic offers a rare chance to investigate the dynamics of the relation between perceived risks for oneself and one’s social environment, known health-behavior related factors (i.e., self-efficacy, perceived efficacy of different preventive behaviors, perceived social norms), and the self-reported intention and adoption of protective behaviors over time. We will investigate the associations between risk perception, health-behavior related factors, and self-reported preventive behaviors in a representative sample of the Swiss population (cross-sectional study). Depending on requested funding, we will also examine the changes in these associations over time (longitudinal study). As the prevention of a further spreading of the virus crucially depends on measures of “social distancing,” we maintain that it is essential to investigate the role of the perceived risk to oneself and others as one of the key predictors of the intention to adopt social distancing behaviors. We hypothesize that younger adults are less likely than older adults to perceive the risk they pose to transmitting the new Corona virus and the resulting potential harm to others. The lower perceived other-related risk, in turn, is hypothesized to lower the likelihood of adopting social distancing behaviors. Given that the level and importance of determinants are bound to change across the development of the pandemic, we propose the study as an 8 months longitudinal study with a sample representative of the general adult population of Switzerland. Given the urgency to start data collection, the University of Zurich has agreed to fund a first measurement point taking place during the last week of March 2020 (cross-sectional study). The remaining seven measurements depend on the funding of currently submitted proposals (longitudinal study). The full study will cover in total a period of 8 months with monthly assessments. Such a longitudinal, multi-measurement, representative study on the dynamic interplay of risk perception, and other evidence-based factors contributing to health behavior, and the currently only available measures to curb the further spread of the pandemic, namely the adoption of preventive behaviors by individuals, has never been conducted before. A unique and novel study like this during an ongoing pandemic is of key importance for informing future theory- and evidence-based effective interventions in the case of epidemics or pandemics. ---------- **2 Project plan** *2.1 State of the research* Several preventive measures are recommended for slowing the spread of epidemics and pandemics. The most important ones recommended for slowing the spread of the new Corona virus are hand hygiene, coughing or sneezing in flexed elbow or tissue, and disposing the tissue in a closed bin, avoiding close contact (i.e., social distancing) , and compliance with quarantine restrictions (e.g., Hatchett et al., 2007; Maharaj & Kleczkowski, 2012; Nicolaides et al., 2019). Given that there are currently no pharmaceutical means available to prevent the transmission of the virus or to heal Covid-19, non-pharmaceutical, behavioral preventive measures are even more central for infection control. However, changing behaviors such as not shaking hands when meeting colleagues or hugging close friends, washing hands more rigorously and diligently, or self-isolating is a major challenge for individuals (e.g., Davidson & Scholz, 2020; Inauen et al., 2016; Rubin et al., 2010; Scholz et al., 2009). Thus, the aim of the proposed research is to further our understanding of the central determinants driving the decision to adopt preventive behaviors in the adult Swiss population in the midst of the ongoing Corona crisis. *Predicting the uptake of preventive behaviors* For effectively identifying the key determinants for health behavior change, applying a theory-based approach is essential. Failure to do so may result in counterproductive interventions that might do more harm than good, as has been demonstrated impressively by the negative example of fear appeal interventions failing at reducing risk behaviors, such as smoking (Kok et al., 2018). One promising theory to identify the key factors contributing to the adoption of preventive behaviors is the protection motivation theory (Bui et al., 2013; Floyd et al., 2000; Maddux & Rogers, 1983). Core assumptions of the basic version of this theory are that a high perceived risk, specified as the severity of a disease and own vulnerability, will only translate into an intention to engage in a protective behavior (called here protection motivation) when combined with (a) high response efficacy, i.e. the expectation that a protective behavior will effectively reduce the risk, and (b) high self-efficacy, i.e., the optimistic belief that a person is capable of implementing the protective behavior. Although intentions are by no means equivalent to actual behaviors, there is a substantial positive association such that high levels of protection motivation predict the adoption of protective behaviors. Protective behaviors during a pandemic can be classified as preventive behaviors (e.g., hand washing, using tissues when coughing or sneezing), avoidance behaviors (e.g., social distancing, compliance to quarantine recommendations and regulations), and management behaviors (e.g., seeking professional medical advice) (Bish & Michie, 2010; Moran et al., 2016). We aim at assessing the core variables of the theory with regard to these different behavioral categories with a special focus on social distancing (see below). In addition, we will assess whether alternative means are taken that are based on subjective beliefs and have been mentioned in the media / social media in Switzerland (such as eating garlic or praying). Risk perceptions have been demonstrated to be related to the different kinds of the protective behaviors across a wide range of studies (Bish & Michie, 2010). We will deepen our understanding of the different risk perceptions, by assessing severity and vulnerability with regard to oneself and to others. This has only rarely been done (e.g., with assessing risk for family members or close social partners in addition to risk for oneself, Lau et al., 2007; Rolison, Hanoch, & Freund, 2019). Given that the objective risk for developing severe symptoms and mortality is linked to higher age and chronic conditions , we will assess the vulnerability (i.e., contracting the virus) and severity (i.e., developing severe symptoms) of the disease for oneself and for others. We will further assess the perceived risk of oneself and of others for transmitting the virus to others. One aim of this research is to investigate whether people are generally more inclined to adopt preventive measures aimed at protecting themselves or protecting others. In particular, we hypothesize that in people with low objective risk (i.e., < 65 years, no chronic conditions), protection motivation and protective behaviors will be mainly driven by risk perceptions related to others than to oneself. In addition, trust in authorities has been demonstrated to positively relate to all three kinds of protective behaviors during pandemics (Bish & Michie, 2010). *Health-related risk perception: The role of age* Reflecting the actual increase in health-related risks, older adults generally perceive a higher risk to develop health-risks such as cardiovascular disease (Renner, Knoll, & Schwarzer, 2000). Moreover, the perceived risks seem to be more closely related to the motivation and the actual adoption of health-protective behaviors (e.g., adhering to a healthy diet) in older compared to younger adults (Schwarzer & Renner, 2000). Concerning the perceived benefits and risks of medical interventions, Hanoch, Rolison, and Freund (2019) showed that adults of all ages held optimistic views of the likelihood to experience benefits and underestimated potential risks of medical interventions. This effect was not moderated by age. Similarly, a different study by Hanoch, Rolison, and Freund (2018) found no age-related differences in medical risk perception or expected benefits of risk-related actions (e.g., vaccination) using a general risk-scale (DROSPERT-M, Blais & Weber, 2006). Using a variety of health scenarios, older adults were more likely to adopt health-related measures for others, but less likely to do so for themselves. This result is in line with the finding that self-reported risk taking in the health domain decreases with age (Rolison, Hanoch, Wood, & Liu, 2013). Taken together, we expect that reflecting the higher risk of older adults to develop severe, life-threatening symptoms when contracting the Covid-19 virus, older adults perceive their risk as higher compared to younger adults. Moreover, given the results by Hanoch et al., (2018), we hypothesize that older adults are more likely to adopt preventive measures that are also oriented towards the protection of others and not mainly of oneself. One avoidance behavior, social distancing, is especially interesting with regard to potential age differences. Social distancing is one of the preventive measures that is currently hailed as effectively keeping all interaction partners as save as possible and it is assumed to be particularly effective if followed rigorously (Maharaj & Kleczkowski, 2012). However, in stressful times like these with the global spread of the pandemic and the direct consequences of restrictions in public life, doing the opposite of social distancing, that is turning to one’s social network for support is a common coping response (Berkman et al., 2000). On top of that, social distancing comes with a potential social cost: Trust between interaction partners is higher when they have physical contact (e.g, Gueguen, 2004), and being physically close to others might signal belonging to an ingroup (e.g., Xiao, Wohl, & Van Bavel, 2016). These social costs might be even higher in social groups with strong social norms of physical closeness and physical contact. Based on the literature on the role of social identity for other health behaviors (Haslam, Jette, Postmes, & Haslam, 2009; see also for., substance use: Mawson, Best, Beckwith, Dingle, & Lubman, 2015; for smoking: Moran & Sussman, 2014), and developmental theories, we hypothesize that “emerging adults” (18 to 29 years) are highly motivated to affiliate with their peers and to protect their social identity as belonging to a certain social group. Consequently, social norms, particularly for engaging in social distancing, might be relatively lower in younger adults. In contrast, with increasing age and particularly in older adulthood, generativity and altruism increases (Freund & Blanchard-Fields, 2014; Mayr & Freund, in press). This should lead to systematic age-related differences in adopting social distancing as a preventive measure. This is backed up by evidence from some, but not all studies demonstrating that older people are more likely to engage in social distancing behaviors during outbreaks of SARS, or an avian flu (for an overview see Bish & Michie, 2010). Taken together, we hypothesize and test in the proposed research that emerging compared to older adults are less likely to adopt social distancing as a preventive measure to the spread of the new Corona virus. ---------- *2.2 Methods and timeline* This study is representative of the general adult population of Switzerland. In a first step, a cross-sectional survey on the associations between perceived risks for oneself and one’s social environment, known health-behavior related factors (i.e., self-efficacy, perceived efficacy of different preventive behaviors, perceived social norms), and the self-reported intention and adoption of protective behaviors will be run during end of March (cross-sectional study). Depending on requested funding, we will expand this cross-sectional study to cover a period of 8 months (longitudinal study) for capturing the dynamic interrelation between these factors over time. Given how fast the crisis develops, the first measurement point is taking place in the last week of March 2020 and is funded by the University of Zurich (cross-sectional study), and proposals for funding of the remaining monthly measurements until January 2021 have been submitted (longitudinal study). These eight monthly surveys of the longitudinal study will allow to better capture the dynamic development of the relationship between risk perception, other known health-behavior related factors, and the endorsement of protective behaviors over time. In fact, the current situation provides a unique chance to shed light on the temporal dynamics of these constructs during a rapidly changing health crisis. The reason for the chosen time frame is mainly grounded in practical and financial considerations: To track the dynamic changes, data has to be collected relatively frequently without overburdening the participants that could lead to a substantial number of drop-outs. Moreover, although results of this study should be made available as soon as possible, it should also include a time period that covers a potential second wave of the novel Corona virus outbreak in the fall 2020. Depending on the development of the infection rate of the virus, a longer time frame might be desirable, but it is currently not possible to gauge how long the crisis will continue into 2021. Given that the financial costs of the representative sampling are relatively high owing to the high price level in Switzerland, we have decided on a time frame that likely covers the main period of the current crisis. For data collection, we collaborate with gfs Zürich (https://gfs-zh.ch/), sampling 1000 cohabitants of Switzerland: 200 people living in the Italian speaking part, 300 people living in the French speaking part, and 500 adults living in the German speaking part of Switzerland. The survey will be run by telephone in order to have the highest likelihood of unbiased coverage of the general population. Moreover, random digit dialing (RDD) will be implemented to allow inclusion of households not listed in the telephone book and of mobile phone numbers and thus avoid selection bias particularly in younger people who oftentimes do not have landline networks anymore. All participants included in the first survey (funded by the University of Zurich, taking place in last week of March) of the cross-sectional study, will be asked to continue their participation in the following surveys (longitudinal study, depending on the funding). For these participants only, we will offer to complete the following surveys online in order to let participants choose what is most comfortable to them and thereby decrease attrition rates. This will allow not only a representative longitudinal survey on the population level, but also analyzing individual change over time. In order to keep up power and representativeness, new participants will be recruited in every wave for compensating dropouts. Table 1 summarizes the main constructs in this study. ---------- **Table 1**. Constructs assessed in this study (unless indicated otherwise, all items will use a Likert response scale ranging from 0 to 10) | Constructs | Subdimensions | | --------- | ----------- | |Risk of contracting Covid-19 (vulnerability)|<ul><li>For oneself</li><li>For others</li></ul>| |Risk of developing severe symptoms (severity)|<ul><li>For oneself</li><li> For others</li></ul>| |Risk of spreading the virus|<ul><li>For oneself</li><li> For others</li></ul>| |Response efficacy| <ul><li>For preventive behaviors</li><li> For avoidance behaviors</li><li>For management behaviors</li><li>For alternative behaviors that are ineffective or even harmful</li></ul>| |Self-efficacy |<ul><li>For preventive behaviors</li><li> For avoidance behaviors</li><li>For management behaviors</li></ul>| |Social norms|<ul><li>For preventive behaviors</li><li> For avoidance behaviors</li><li>For management behaviors</li><li>For alternative behaviors that are ineffective or even harmful</li></ul>| |Prosocial attitude|<ul><li>For adhering to recommendations </li></ul>| |Intentions to adopt behaviors|<ul><li>For preventive behaviors</li><li> For avoidance behaviors</li><li>For management behaviors</li><li>For alternative behaviors that are ineffective or even harmful</li></ul>| |Self-reported frequency of behavioral measures|<ul><li>For preventive behaviors</li><li> For avoidance behaviors</li><li>For management behaviors</li><li>For alternative behaviors that are ineffective or even harmful</li></ul>| |Information seeking|<ul><li>Seeking information about the virus and the crisis situation </li></ul>| |Trust in authorities during the pandemic|<ul><li> Politics</li><li> Health system</li><li> Media </li></ul>| |Health, well-being, worries|<ul><li> Status of infection (having been positively tested for the virus (yes/no); being healed; (yes/no); belief of having had or currently having the virus without being tested (yes/no))</li><li> Belonging to the high risk group due to chronic conditions (yes / no)</li><li> Positive and negative affect</li><li> Loneliness</li><li> Worries for contracting the virus oneself</li><li> Worries for others contracting the virus</li></ul>| |Sociodemographic variables| Age, Gender, Marital status, Total number of people in household, Number of children in household, Education, Employment status, Nationality, Household income, Regular contact to people with high risk profile| ---------- *Timeline, data analyses, and milestones* The cross-sectional study, i.e. the first point of measurement takes place in the last week of March. Depending on the funding, the longitudinal study might continue on a monthly basis until January 2021. In the longitudinal study, the data of the subsequent measurement occasions will be continuously merged so as to allow their analyses as soon as data collection will be concluded. The data will be analyzed using latent growth models that allow to track intraindividual change in constructs included in the study, their correlation over time, and possible age-related (inter-individual) differences in this change. We will summarize the results for the individual measurement occasion and the trajectories after each wave of data collection. We expect to have the results of the cross-sectional study ready for the scientific community as soon as possible after end of March 2020, and for the longitudinal study in August 2021. We will compile a booklet on the main descriptive results and a summary of the trajectories that will be made openly available by November 2021. ---------- *2.3 Potential impact* On March 11, the World Health Organisation classified the current new Corona virus outbreak as a pandemic , that is a disease that spreads across wide geographic areas while affecting a large proportion of the population . Given that there is no vaccine available at the moment, the only preventive measure that can be taken to successfully slowing the spread of this pandemic, is the effective adoption or change of several behaviors (e.g., hand hygiene, social distancing). It is thus of crucial importance to examine the key factors for promoting the uptake of the recommended preventive measures by as many individuals as possible within a community, even by those who might not be at great risk to suffer severe consequences if they contract the virus as they might nevertheless transmit it. The proposed study will provide unique and novel insights into the determinants driving the decision to adopt preventive behaviors in the Swiss Population in midst of the ongoing crisis (cross-sectional study). Depending on the funding, the longitudinal study will further shed light on the dynamics of these determinants and outcomes across the trajectory of the pandemic on an individual basis. Given that the cross-sectional study with the first measurement point will take place end of March. This will enable early publication to the scientific community as well as to political stakeholders and the general public in Switzerland. This knowledge is of key importance for informing future theory- and evidence-based effective interventions in the case of epidemics or pandemics. ---------- **References** Berkman, L. F., Glass, T., Brissette, I., & Seeman, T. E. (2000). 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