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Health behavior is influenced by culture and social context. However, there are limited data evaluating the scope of these influences on COVID-19 response.
This study aimed to compare handwashing and social distancing practices in different countries and evaluate practice predictors using the health belief model (HBM).
From April 11 to May 1, 2020, we conducted an online, cross-sectional survey disseminated internationally via social media. Participants were adults aged 18 years or older from four different countries: the United States, Mexico, Hong Kong (China), and Taiwan. Primary outcomes were self-reported handwashing and social distancing practices during COVID-19. Predictors included constructs of the HBM: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, self-efficacy, and cues to action. Associations of these constructs with behavioral outcomes were assessed by multivariable logistic regression.
We analyzed a total of 71,851 participants, with 3070 from the United States, 3946 from Mexico, 1201 from Hong Kong (China), and 63,634 from Taiwan. Of these countries, respondents from the United States adhered to the most social distancing practices (χ23=2169.7,
Social media recruitment strategies can be used to reach a large audience during a pandemic. Self-efficacy was the strongest predictor for handwashing and social distancing. Policies that address relevant health beliefs can facilitate adoption of necessary actions for preventing COVID-19. Our findings may be explained by the timing of government policies, the number of cases reported in each country, individual beliefs, and cultural context.
The severity and rapid transmission of COVID-19 has forced most regions to implement community mitigation strategies. These strategies have ranged from government guidelines on personal protective measures and social distancing to strict lockdown orders that closed schools and businesses [
Although these interventions reduce the stress on health care systems, they also incur high economic and societal costs, making adherence more difficult for those under financial strain [
From April 11 to May 1, 2020, we conducted a confidential, cross-sectional, international open survey through the following social media platforms: Facebook, Instagram, Line, and Twitter. The survey was announced and advertised through Stanford Health Policy’s social media accounts. Facebook boosted posts were used to target social media users who were 18 years of age or older. We focused our analysis on countries and regions with at least 1000 survey responses: the United States, Mexico, Hong Kong (China), and Taiwan. Facebook is the most popular social media platform among adults in all four countries, whereas Instagram, Twitter, and Line have relatively high penetration in specific groups and countries [
The survey was developed on Qualtrics (Qualtrics Inc), an online survey distribution tool, and administered in English, Spanish, and Mandarin. Translations were provided by native speakers fluent in the respective languages, who tested the survey before it was fielded. Prior to survey completion, participants were provided with information about the study and were asked to acknowledge consent to the study. All items were optional except for country of residence. Through Qualtrics, cookies were used to assign a unique user identifier to each client computer to prevent participants from completing the survey more than once. Only completed surveys were analyzed. Given that no incentives were offered to participants and that the survey was voluntary, we did not assess whether surveys were completed in an atypical amount of time. The study was reviewed and approved by Stanford University’s Institutional Review Board.
We used the HBM, a widely used framework for explaining health behaviors and guiding related interventions, to create survey items to assess health beliefs among respondents in the four countries [
Conceptual framework of the study adapted from the health belief model to assess individual health beliefs, modifying factors, and the effects of public policy on social distancing and handwashing behaviors during the COVID-19 pandemic. CDC: Centers for Disease Control and Prevention; WHO: World Health Organization.
Survey items (see
Perceived susceptibility. What do you think your risk is of getting infected with COVID-19?
Perceived severity. How afraid are you of the COVID-19 pandemic?
Perceived benefits. How do you feel about the government measures of COVID-19 in your area?
Perceived barriers. Have any barriers prevented you from adhering to measures in your area?
Self-efficacy. How confident are you that you are able to and willing to carry out these measures?
Cues to action. What are your sources of information regarding COVID-19?
Perceived susceptibility, perceived severity, and self-efficacy items were assessed using a 5-point Likert scale. During analysis, response scales were eventually collapsed into three categories, such as
To account for modifying factors that influenced individual beliefs, we assessed for age (ie, 18-24, 25-34, 35-44, 45-59, and 60+ years), gender (ie, male, female, and other), highest educational attainment (ie, high school or less and college and above), country of residence (ie, United States, Mexico, Hong Kong, and Taiwan), race or ethnicity (eg, Asian, Hispanic/Latino, and White or European), change in income due to COVID-19 (ie, yes or no), and awareness of government measures or guidelines (ie, some/not aware and most/all).
Handwashing behaviors were assessed by asking respondents whether they washed their hands or used hand sanitizer in the following seven situations: (1) after coming home from being outside; (2) after grocery shopping; (3) after interacting with nonhousehold members; (4) while being in public; (5) before or after using their vehicle; (6) after blowing their nose, coughing, or sneezing into their hand; and (7) before eating. Responses for all situations were summed up to a score of 7. Social distancing behaviors were evaluated by assessing whether respondents did the following: (1) avoided nonessential gatherings, (2) kept at least the recommended distance from nonhousehold members (eg, 6 feet, 1.5 meters, 2 meters, etc), or (3) avoided close contact with individuals at higher risk for severe illness from COVID-19. Responses were summed up to a score of 3. Total adherence to either handwashing or social distancing responses was assessed by a binary variable, with individuals performing all of the practices as one group (yes = 1) and those who performed fewer than all practices as the other group (no = 0); this was done for each of the two behaviors.
We conducted poststratification weighting for each country by age and gender—and race or ethnicity for the United States—using each country’s most recent census data [
Countries were also analyzed separately with multivariable logistic regressions to examine the association of HBM constructs with two main outcomes: handwashing and social distancing practices. HBM covariates included perceived susceptibility, severity, benefits, and barriers; self-efficacy; and cues to action. All models were adjusted for gender, age, education, and reduced income. To ensure our handwashing variable appropriately captured COVID-19-related handwashing behaviors, we also ran a sensitivity analysis that assessed the association between handwashing time (ie, >20 seconds vs ≤20 seconds) and HBM constructs, because this handwashing duration was a specific COVID-19 recommendation in all four countries [
A total of 71,851 individuals were included in our analysis: 3070 from the United States (4.3%), 3946 from Mexico (5.5%), 1201 from Hong Kong (1.7%), and 63,634 from Taiwan (88.6%). Of these, 71,728 (99.8%) completed at least 80% of the survey (14 of 17 questions). Missing data for each item were less than 5% and, thus, were not imputed. After weighting, the gender and age distributions were representative of each country according to their most recent census data (see
Weighted demographic characteristics of survey respondents by country.
Characteristic | Value (N=71,851), n (%)a | ||||||||||
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United States (n=3070) | Mexico (n=3946) | Hong Kong (n=1201) | Taiwan (n=63,634) | |||||||
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<.001 | ||||||
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18-24 | 110 (3.6) | 507 (12.9) | 83 (7.0) | 4969 (7.8) | —c | |||||
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25-34 | 519 (17.0) | 953 (24.2) | 198 (16.6) | 10,509 (16.6) | — | |||||
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35-44 | 451 (14.7) | 820 (20.8) | 226 (18.9) | 12,865 (20.3) | — | |||||
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45-59 | 963 (31.4) | 977 (24.8) | 310 (25.9) | 17,836 (28.1) | — | |||||
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60+ | 1019 (33.3) | 684 (17.3) | 377 (31.6) | 17,294 (27.2) | — | |||||
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<.001 | ||||||
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Female | 1683 (55.0) | 2031 (51.6) | 602 (50.4) | 31,407 (49.6) | — | |||||
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Male | 1351 (44.2) | 1867 (47.4) | 562 (47.1) | 30,034 (47.4) | — | |||||
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Otherd | 25 (0.8) | 40 (1.0) | 30 (2.5) | 1894 (3.0) | — | |||||
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<.001 | ||||||
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Asian | 158 (5.2) | 15 (0.4) | 1180 (98.9) | 62,924 (99.3) | — | |||||
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Hispanic/Latino or othere | 1520 (49.7) | 3319 (84.7) | 11 (0.9) | 228 (0.4) | — | |||||
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White or European | 1379 (45.1) | 586 (15.0) | 2 (0.2) | 207 (0.3) | — | |||||
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<.001 | ||||||
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Below college | 286 (9.4) | 726 (18.4) | 263 (22.2) | 7889 (12.4) | — | |||||
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College and above | 2768 (90.6) | 3215 (81.6) | 923 (77.8) | 55,547 (87.6) | — | |||||
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<.001 | ||||||
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No | 2283 (74.6) | 1832 (46.6) | 852 (71.7) | 52,674 (83.1) | — | |||||
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Yes | 779 (25.4) | 2099 (53.4) | 337 (28.3) | 10,725 (16.9) | — | |||||
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<.001 | ||||||
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Some/not aware | 20 (0.7) | 123 (3.1) | 26 (2.2) | 2850 (4.5) | — | |||||
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All/most | 3034 (99.3) | 3818 (96.9) | 1167 (97.8) | 60,595 (95.5) | — |
aWeighted values were calculated by dividing the actual proportion of the country’s population by the proportion from the study’s sample, then renormalized for each country to ensure weighted and unweighted sample sizes were equal. Due to rounding and missing data (<5% for each item), the sum of frequencies and percentages for the sample weighted columns may not equal the country’s total sample size.
b
cNot available.
dResponses of
eResponses of
Bivariate chi-square analyses showed that respondents from Taiwan practiced the most handwashing behaviors (χ23=309.8,
Distribution of handwashing practices by country. Respondents were asked whether they washed their hands or used hand sanitizer in any of the following seven situations: (1) after coming home from being outside; (2) after grocery shopping; (3) after interacting with nonhousehold members; (4) while being in public; (5) before or after using their vehicle; (6) after blowing their nose, coughing, or sneezing into their hand; and (7) before eating.
Distribution of social distancing practices by country. Respondents were asked whether they did the following: (1) avoided nonessential gatherings, (2) kept at least the recommended healthy distance from nonhousehold members (eg, 6 feet, 1.5 meters, and 2 meters), or (3) avoided close contact with individuals at higher risk for severe illness from COVID-19.
Regarding perceived barriers to social distancing, Mexico (2547/3946, 64.5%) had the highest proportion of individuals who perceived difficulty in obtaining face masks, followed by 60.5% (1856/3070) of individuals in the United States, 52.7% (633/1201) in Hong Kong, and 12.2% (7736/63,634) in Taiwan. Having an essential job (eg, grocery store worker), as perceived by the individual or determined by local governments, was a common perceived barrier in all countries. Other common barriers included family obligations in Mexico as well as transportation needs in Hong Kong and Taiwan. For handwashing barriers, respondents from the United States (1536/3070, 50.0%) and Mexico (2056/3946, 52.1%) perceived more difficulty in obtaining hand sanitizer compared to those in Taiwan (2708/63,634, 4.3%) and Hong Kong (104/1201, 8.7%). Only a small proportion of individuals in all countries (<5% each) reported having difficulty obtaining hand soap.
For cues to action, respondents selected up to three sources of information for COVID-19. News (eg, TV news, newspaper, and radio) and social media were the most frequently reported sources of information in every country, with Hong Kong reporting the highest percentage (news: 1002/1201, 83.4%; social media: 846/1201, 70.4%) and Mexico the lowest (news: 1965/3946, 49.8%; social media: 1337/3946, 33.9%). More respondents selected federal, or central, government rather than regional government as a top information source in Taiwan (14,730/63,634, 23.1% vs 1387/63,634, 2.2%) and Mexico (1155/3946, 29.3% vs 567/3946, 14.4%), while more respondents selected regional rather than federal government in the United States (1129/3070, 36.8% vs 312/3070, 10.2%). Both choices were comparably low in Hong Kong (<5% each).
Weighted responses to health belief model (HBM) constructs by country.
HBM construct, survey question, and responses | Value (N=71,851), n (%)a | ||||||
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United States (n=3070) | Mexico (n=3946) | Hong Kong (n=1201) | Taiwan (n=63,634) | |||
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<.001 | ||
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Not likely/slightly likely | 1385 (45.1) | 1253 (31.8) | 635 (53.3) | 44,345 (69.9) | —c | |
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Moderately likely | 1024 (33.4) | 1523 (38.6) | 331 (27.7) | 10,038 (15.8) | — | |
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Likely/very likely | 659 (21.5) | 1165 (29.6) | 226 (19.0) | 9042 (14.3) | — | |
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<.001 | ||
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Not afraid/slightly afraid | 876 (28.6) | 1154 (29.3) | 289 (24.2) | 28,082 (44.2) | — | |
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Moderately afraid | 1022 (33.3) | 1135 (28.8) | 374 (31.3) | 15,216 (24.0) | — | |
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Afraid/very afraid | 1166 (38.1) | 1651 (41.9) | 532 (44.5) | 20,172 (31.8) | — | |
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<.001 | ||
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Appropriate/essential | 2062 (68.4) | 1343 (34.7) | 288 (24.5) | 53,573 (85.5) | — | |
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Unnecessarily restrictive/moderately restrictive | 297 (9.9) | 272 (7.0) | 139 (11.9) | 3227 (5.2) | — | |
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Not enough | 657 (21.8) | 2256 (58.3) | 745 (63.6) | 5825 (9.3) | — | |
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<.001 | ||
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Not confident/slightly confident | 138 (4.5) | 93 (2.3) | 52 (4.4) | 3867 (6.1) | — | |
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Moderately confident | 216 (7.0) | 248 (6.3) | 195 (16.3) | 11,470 (18.1) | — | |
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Confident/very confident | 2712 (88.5) | 3599 (91.4) | 946 (79.3) | 48,144 (75.8) | — | |
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Masks | 1856 (60.5) | 2547 (64.5) | 633 (52.7) | 7736 (12.2) | <.001 | |
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Essential job | 381 (12.4) | 630 (16.0) | 333 (27.8) | 16,141 (25.4) | <.001 | |
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Family obligations | 201 (6.6) | 636 (16.1) | 92 (7.7) | 5188 (8.2) | <.001 | |
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Transportation needs | 49 (1.6) | 193 (4.9) | 595 (49.6) | 15,158 (23.8) | <.001 | |
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Hand soap | 142 (4.6) | 167 (4.2) | 13 (1.1) | 384 (0.6) | <.001 | |
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Hand sanitizer | 1536 (50.0) | 2056 (52.1) | 104 (8.7) | 2708 (4.3) | <.001 | |
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News source | 2119 (69.0) | 1965 (49.8) | 1002 (83.4) | 50,443 (79.3) | <.001 | |
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Social media | 1234 (40.2) | 1337 (33.9) | 846 (70.4) | 39,251 (61.7) | <.001 | |
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Central administration officials | 312 (10.2) | 1155 (29.3) | 25 (2.1) | 14,730 (23.1) | <.001 | |
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Regional administration officials | 1129 (36.8) | 567 (14.4) | 60 (5.0) | 1387 (2.2) | <.001 |
aWeighted values were calculated by dividing the actual proportion of the country’s population by the proportion from the study’s sample, then renormalized for each country to ensure weighted and unweighted sample sizes were equal. Due to rounding and missing data (<5% for each item), the sum of frequencies and percentages for the sample weighted columns may not equal the country’s total sample size.
b
cNot available.
dThe top four media resources selected by respondents, when asked to pick their top three from the list, are shown.
In multivariable analyses, individuals with higher self-efficacy were more likely to perform more handwashing practices compared to those with lower self-efficacy (ORUnited States 1.58, 95% CI 1.21-2.07; ORMexico 1.54, 95% CI 1.21-1.96; ORHong Kong 2.48, 95% CI 1.80-3.44; ORTaiwan 2.30, 95% CI 2.21-2.39) (see
Similar to handwashing, individuals with higher self-efficacy were also more likely to practice social distancing compared to those with lower self-efficacy (ORUnited States 1.77, 95% CI 1.24-2.49; ORMexico 1.77, 95% CI 1.40-2.25; ORHong Kong 3.25, 95% CI 2.32-4.62; ORTaiwan 2.58, 95% CI 2.47-2.68) (see
Multivariable model of health beliefs and handwashing practices by country.
Characteristic or construct and responses | United States, ORa (95% CI) | Mexico, OR (95% CI) | Hong Kong, OR (95% CI) | Taiwan, OR (95% CI) | |||||||||||||
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18-24 | Reference |
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Reference |
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Reference |
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Reference |
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25-34 | 1.14 (0.65-2.03) | .70 | 1.15 (0.91-1.46) | .20 | 2.00 (1.14-3.55) | .02 | 1.44 (1.34-1.55) | <.001 | ||||||||
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35-44 | 1.24 (0.72-2.20) | .40 | 1.60 (1.25-2.04) | <.001 | 2.15 (1.24-3.80) | .007 | 2.24 (2.09-2.41) | <.001 | ||||||||
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45-59 | 1.91 (1.11-3.34) | .02 | 1.86 (1.47-2.35) | <.001 | 2.20 (1.29-3.82) | .004 | 2.66 (2.48-2.85) | <.001 | ||||||||
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60+ | 1.10 (0.63-1.95) | .70 | 1.76 (1.37-2.26) | <.001 | 1.16 (0.67-2.03) | .60 | 2.96 (2.76-3.18) | <.001 | ||||||||
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Female | Reference |
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Reference |
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Reference |
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Reference |
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Male | 0.84 (0.71-1.00) | .05 | 1.00 (0.87-1.14) | .90 | 1.09 (0.85-1.40) | .50 | 0.69 (0.66-0.71) | <.001 | ||||||||
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Otherb | 1.52 (0.62-3.93) | .40 | 1.09 (0.56-2.11) | .80 | 1.73 (0.80-3.84) | .20 | 1.06 (0.96-1.17) | .02 | ||||||||
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White or European | Reference |
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N/Ac |
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N/A |
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N/A |
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Hispanic/Latino or otherd | 3.22 (2.69-3.86) | <.001 | N/A | N/A | N/A | N/A | N/A | N/A | ||||||||
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Asian | 2.76 (1.89-4.04) | <.001 | N/A | N/A | N/A | N/A | N/A | N/A | ||||||||
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Below college | Reference |
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Reference |
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Reference |
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Reference |
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College and above | 0.99 (0.71-1.40) | .90 | 1.14 (0.95-1.36) | .20 | 1.13 (0.84-1.53) | .40 | 0.84 (0.80-0.88) | <.001 | ||||||||
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Not likely/slightly likely | Reference |
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Reference |
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Reference |
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Reference |
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Moderately to very likely | 1.12 (0.95-1.33) | .20 | 1.23 (1.06-1.42) | .006 | 1.44 (1.11-1.87) | .007 | 1.08 (1.04-1.12) | <.001 | ||||||||
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Not afraid/slightly afraid | Reference |
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Reference |
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Reference |
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Reference |
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Moderately to very afraid | 1.33 (1.09-1.61) | .005 | 1.06 (0.91-1.22) | .50 | 1.22 (0.90-1.65) | .20 | 1.24 (1.20-1.29) | <.001 | ||||||||
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Unnecessarily restrictive/moderately restrictive | 0.41 (0.30-0.55) | <.001 | 0.65 (0.50-0.86) | .002 | 0.65 (0.41-1.02) | .06 | 0.82 (0.76-0.89) | <.001 | ||||||||
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Appropriate/essential | Reference |
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Reference |
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Reference |
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Reference |
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Not enough | 1.49 (1.23-1.82) | <.001 | 0.97 (0.84-1.12) | .70 | 0.77 (0.56-1.07) | .12 | 0.91 (0.86-0.96) | .001 | ||||||||
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Not confident/moderately confident | Reference |
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Reference |
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Reference |
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Reference |
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Confident/very confident | 1.58 (1.21-2.07) | <.001 | 1.54 (1.21-1.96) | <.001 | 2.48 (1.80-3.44) | <.001 | 2.30 (2.21-2.39) | <.001 | ||||||||
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Hand soap | 0.73 (0.49-1.07) | .11 | 1.35 (0.98-1.87) | .07 | 7.59 (1.88-53.9) | .01 | 1.01 (0.81-1.27) | .90 | ||||||||
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Hand sanitizer | 0.88 (0.74-1.03) | .11 | 1.01 (0.88-1.15) | .90 | 1.14 (0.74-1.77) | .50 | 0.86 (0.79-0.94) | <.001 | ||||||||
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News source | 0.77 (0.64-0.92) | .003 | 0.80 (0.70-0.92) | .001 | 0.97 (0.69-1.35) | .80 | 0.95 (0.91-0.99) | .02 | ||||||||
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Social media | 0.60 (0.50-0.71) | <.001 | 0.77 (0.67-0.89) | <.001 | 0.79 (0.60-1.05) | .10 | 0.86 (0.83-0.89) | <.001 | ||||||||
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Central administration officials | 1.32 (1.01-1.74) | .05 | 0.84 (0.73-0.98) | .02 | 1.27 (0.55-3.02) | .60 | 0.99 (0.95-1.03) | .70 | ||||||||
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Regional administration officials | 0.63 (0.52-0.75) | <.001 | 0.83 (0.69-1.00) | .05 | 0.42 (0.22-0.77) | .007 | 1.08 (0.96-1.21) | .20 |
aOR: odds ratio; models were run using weighted data, which were calculated by dividing the actual proportion of the country’s population by the proportion from the study’s sample, then renormalized for each country to ensure weighted and unweighted sample sizes were equal.
bResponses of
cN/A: not applicable; race or ethnicity was not adjusted for these countries as the majority identified as the same race or ethnicity.
dResponses of
eThe top four media resources selected by respondents, when asked to pick their top three from the list, are shown.
Multivariable model of health beliefs and social distancing practices by country.
Characteristic or construct and responses | United States, OR (95% CI)a | Mexico, OR (95% CI) | Hong Kong, OR (95% CI) | Taiwan, OR (95% CI) | |||||
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18-24 | Reference |
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Reference |
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Reference |
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Reference |
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25-34 | 1.21 (0.52-2.66) | .60 | 0.70 (0.54-0.90) | .006 | 1.19 (0.68-2.08) | .50 | 1.39 (1.29-1.50) | <.001 |
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35-44 | 1.61 (0.71-3.53) | .20 | 0.69 (0.53-0.89) | .005 | 1.09 (0.63-1.89) | .80 | 1.82 (1.69-1.96) | <.001 |
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45-59 | 1.67 (0.72-3.65) | .20 | 0.67 (0.52-0.86) | .002 | 1.17 (0.69-1.99) | .60 | 1.93 (1.80-2.07) | <.001 |
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60+ | 3.30 (1.42-7.31) | .004 | 0.52 (0.40-0.68) | <.001 | 0.56 (0.32-0.97) | .04 | 1.89 (1.76-2.03) | <.001 |
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Female | Reference |
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Reference |
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Reference |
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Reference |
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Male | 1.36 (1.05-1.75) | .02 | 1.14 (0.99-1.31) | .07 | 1.04 (0.81-1.34) | .80 | 1.03 (1.00-1.07) | .07 |
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Otherb | 1.68 (0.47-8.23) | .50 | 1.02 (0.52-2.06) | .90 | 0.38 (0.15-0.87) | .03 | 0.92 (0.83-1.01) | .10 |
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White or European | Reference |
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N/Ac |
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N/A |
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N/A |
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Hispanic/Latino or otherd | 0.46 (0.35-0.61) | <.001 | N/A | N/A | N/A | N/A | N/A | N/A |
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Asian | 0.78 (0.44-1.42) | .40 | N/A | N/A | N/A | N/A | N/A | N/A |
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Below college | Reference |
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Reference |
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College and above | 0.60 (0.36-0.96) | .04 | 1.32 (1.10-1.60) | .003 | 1.13 (0.83-1.54) | .40 | 1.17 (1.12-1.24) | <.001 |
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No | Reference |
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Reference |
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Reference |
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Yes | 0.60 (0.46-0.78) | <.001 | 0.95 (0.83-1.10) | .50 | 0.98 (0.74-1.30) | .90 | 1.07 (1.03-1.12) | .002 |
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Not likely/slightly likely | Reference |
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Reference |
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Reference |
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Reference |
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Moderately to very likely | 1.11 (0.86-1.44) | .40 | 1.02 (0.88-1.19) | .80 | 0.76 (0.58-0.99) | .05 | 0.94 (0.90-0.97) | <.001 |
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Not afraid/slightly afraid | Reference |
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Reference |
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Reference |
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Reference |
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Moderately to very afraid | 1.62 (1.24-2.12) | <.001 | 1.29 (1.11-1.50) | .001 | 1.34 (0.99-1.84) | .06 | 1.17 (1.13-1.21) | <.001 |
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Unnecessarily restrictive/moderately restrictive | 0.52 (0.36-0.76) | <.001 | 0.65 (0.49-0.85) | .002 | 1.24 (0.79-1.96) | .40 | 0.82 (0.76-0.88) | <.001 |
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Appropriate/essential | Reference |
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Reference |
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Reference |
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Reference |
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Not enough | 1.72 (1.24-2.42) | .001 | 1.22 (1.05-1.41) | .01 | 1.04 (0.74-1.46) | .80 | 1.05 (0.99-1.11) | .13 |
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Not confident/moderately confident | Reference |
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Reference |
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Reference |
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Reference |
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Confident/very confident | 1.77 (1.24-2.49) | .001 | 1.77 (1.40-2.25) | <.001 | 3.25 (2.32-4.62) | <.001 | 2.58 (2.47-2.68) | <.001 |
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Masks | 0.95 (0.73-1.23) | .70 | 1.11 (0.96-1.28) | .20 | 1.61 (1.23-2.10) | <.001 | 0.92 (0.88-0.97) | .002 |
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Essential job | 0.86 (0.61-1.23) | .40 | 0.85 (0.71-1.03) | .09 | 0.66 (0.48-0.89) | .007 | 0.71 (0.68-0.74) | <.001 |
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Family obligations | 0.25 (0.17-0.36) | <.001 | 0.84 (0.70-1.01) | .06 | 0.80 (0.50-1.29) | .40 | 0.97 (0.92-1.04) | .40 |
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Transportation needs | 0.25 (0.11-0.57) | <.001 | 0.78 (0.57-1.06) | .11 | 0.67 (0.52-0.87) | .002 | 0.85 (0.82-0.89) | <.001 |
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News source | 1.58 (1.22-2.04) | <.001 | 0.96 (0.84-1.10) | .60 | 0.94 (0.66-1.33) | .70 | 0.93 (0.89-0.97) | <.001 |
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Social media | 0.53 (0.41-0.68) | <.001 | 0.92 (0.80-1.07) | .30 | 0.85 (0.64-1.13) | .30 | 0.91 (0.88-0.95) | <.001 |
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Central administration officials | 1.15 (0.78-1.75) | .50 | 1.04 (0.89-1.22) | .60 | 1.33 (0.56-3.13) | .50 | 1.15 (1.11-1.20) | <.001 |
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Regional administration officials | 0.70 (0.53-0.92) | .01 | 1.20 (0.98-1.46) | .08 | 1.59 (0.90-2.83) | .11 | 1.07 (0.96-1.20) | .20 |
aOR: odds ratio; models were run using weighted data, which were calculated by dividing the actual proportion of the country’s population by the proportion from the study’s sample, then renormalized for each country to ensure weighted and unweighted sample sizes were equal.
bResponses of
cN/A: not applicable; race or ethnicity was not adjusted for these countries as the majority identified as the same race or ethnicity.
dResponses of
eThe top four media resources selected by respondents, when asked to pick their top three from the list, are shown.
In this international study to examine COVID-19-related health behaviors using the HBM, we showed that respondents from the United States practiced the most social distancing, while those from Taiwan practiced the most handwashing. Despite these differences in health behaviors, self-efficacy was a significant predictor in all four countries. Our findings may be explained by the strictness and timing of government policies, the number of confirmed infection cases in each country, individual beliefs, and cultural context.
In the context of government interventions, Taiwan’s early border control, case identification, isolation of suspected cases, and resource allocation led to recommendations for social distancing, though not strictly enforced [
Furthermore, at the start of our study period on April 11, 2020, the World Health Organization Situation Report recorded 1.6 million confirmed COVID-19 cases, with more than 99,000 deaths in over 200 countries and territories [
Among the HBM constructs, our study found that self-efficacy was the strongest positive predictor for both handwashing and social distancing in all countries. These findings were largely consistent with previous studies that examined preventative behaviors for cancers using the HBM [
Previous studies have also suggested perceived susceptibility to be a good predictor for preventative behaviors [
Modifiable factors that influence individual beliefs, such as culture and prior knowledge, are important to consider. In Hong Kong and Taiwan, wide adoption of preventative behaviors after the 2003 SARS outbreak may have better prepared residents for COVID-19, which may explain their greater sense of self-efficacy in handwashing and social distancing compared to other countries. Many residents were already taking regular individual actions, practicing good hand hygiene for infection control or wearing masks to counter air pollution when the pandemic hit. In fact, the study team received several emails from respondents in Taiwan and Hong Kong, noting that they had practiced handwashing prior to the pandemic because they were taught to do so as children. For this study, we were unable to statistically account for social factors and prior knowledge in our analyses, but future studies should consider including them into models to assess the influence of social and cultural factors on preventative health behaviors.
Our study may also provide insight into the effect of using social media recruitment strategies to reach a large audience. Given the rapidly evolving information, beliefs, and policies surrounding COVID-19, internet sampling allowed us to (1) capture real-time data simultaneously in different countries in a short time span, (2) reach a large number of participants in lockdown, and (3) overcome financial limitations [
There are limitations to this study. Firstly, we used convenience sampling to recruit participants, which could have introduced potential sample selection bias. For example, we found an underrepresentation of populations with lower educational levels. This may have resulted in an overestimation of adherence rates and underestimation of perceived barriers. However, in multivariate analysis, education was not statistically associated with handwashing or social distancing practices. To best address the imbalances in our sample, we conducted poststratification weighting by age and gender, as well as race or ethnicity for the United States, to improve the generalizability of our results, although we understand that this does not make up for all of the differences [
Overall, our findings revealed that certain health belief constructs were independently associated with social distancing and handwashing behaviors. In the context of controlling the continued spread of COVID-19, self-efficacy is a significant predictor that can be easily targeted and modified by public health officials and educators. Policies and communications that address relevant health beliefs can facilitate adoption of necessary actions for preventing COVID-19.
Survey items.
Comparison of unweighted and weighted sample characteristics in the United States and Mexico relative to country population estimates.
Comparison of unweighted and weighted sample characteristics in Hong Kong and Taiwan relative to country population estimates.
Multivariable models assessing handwashing and social distancing practices by country.
Multivariable models of health beliefs and handwashing time (>20 seconds) by country.
health belief model
odds ratio
social cognitive theory
We would like to thank Beth Duff-Brown for disseminating the survey via social media and Judy Sun for helping with the Mandarin translation of study-related materials.
None declared.