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J Educ Health Promot
J Educ Health Promot
JEHP
J Edu Health Promot
Journal of Education and Health Promotion
2277-9531
2319-6440
Wolters Kluwer - Medknow India

JEHP-13-187
10.4103/jehp.jehp_679_23
Original Article
Predictors of performing preventive behaviors against affliction with COVID-19 based on vaccination: An application of the health belief model
Eftekhari Adel
Baghian Najmeh 1
Yoshany Nooshin 2
Dehghan Moori Abadi Fatemeh 3
Jambarsang Sara 4
Dehghani Mohammad Hossein 5
Askari Roohollah 6*
Department of Nursing, Meybod School of Nursing, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
1 Clinical Research Development Center, Shahid Rahnemoon Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
2 Department of Health Education and Promotion, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
3 School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
4 Departments of Biostatistics and Epidemiology, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
5 Department of Anesthesiology and Critical Care, Shahid Rahnemoun Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
6 Department of Health Management and Economics, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
Address for correspondence: Dr. Roohollah Askari, Department of Health Management and Economics, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran. E-mail: r.asqari@gmail.com
2024
05 7 2024
13 18717 5 2023
28 6 2023
Copyright: © 2024 Journal of Education and Health Promotion
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
BACKGROUND:

Nowadays, the COVID-19 pandemic has become one of the greatest global threats to human communities. Presently, the most important solution to deal with this pandemic is to fully comply with health protocols along with general vaccination. Given the increased vaccination rate in the community and the change in the thought of some people in the field of durable immunity and changing health behaviors, the present study determined the predictors of preventive behaviors against affliction with COVID-19 in two vaccinated and non-vaccinated groups based on the health belief model in the Iranian population aged 15–65 years.

MATERIALS AND METHODS:

This descriptive-analytical study was conducted cross-sectionally in 2022. A sample size of 500 Yazdi citizens was selected using the convenience non-random sampling method using the contact numbers received from the SIB system of the Iranian health deputy. They were examined online in two vaccinated and unvaccinated groups. The instrument used was Delshad Noghabi et al.’s questionnaire which was based on the health belief model. Due to the adjustment of the questionnaire according to the target group, its validity and reliability were re-checked and confirmed. Data were analyzed with SPSS22 using descriptive and analytical statistics, t-test, and linear regression.

RESULTS:

Based on the findings of the study, a significant difference was observed between the three variables of income level (P = 0.019), smoking (P <0.001), and employment status (P = 0.025) in two vaccinated and unvaccinated groups at the level of preventive behaviors. Besides, the constructs of perceived sensitivity (P <0.001), perceived benefits (P <0.001), action guide (P <0.001), and self-efficacy (P = 0.018) significantly predict preventive behaviors, so that the predictive value of perceived benefits (β =3.67) was more than other variables.

CONCLUSION:

To prevent diseases, it is very important to increase people’s awareness and information (self-efficacy) about the use of vaccination and pay attention to individual demographic characteristics in vaccination programs. Also, perceived sensitivity, perceived benefits, action guidelines, and perceived self-efficacy can be considered as important factors in determining people’s willingness to be vaccinated. Therefore, education and information programs should be focused on these factors to increase people’s willingness to be vaccinated.

COVID-19 vaccines
Health behavior
Health belief model
Prevention and control
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pmcIntroduction

The emergence of various types and mutations of the coronavirus since 2018 has affected the lives of billions of people[1] and created new challenges to control this epidemic disease.[2,3] This calamity has led to serious complications and mortality around the globe, so that by April 2023, more than 760 million people were affected worldwide by this disease, and more than 7 million of those affected were in Iran.[4] With the appearance of this disease, the only main solution recognized by the World Health Organization to contain and control this disease was preventive measures, so that education, improving awareness, attitude, and preventive action to protect against this disease, was stated as important prevention strategies. Preventive measures put forward against this disease included home quarantine, limiting gatherings and trips, physical and social distancing, preventing unnecessary trips, and observing personal hygienic tips (regular hand washing and wearing a mask).[4] With the passage of time and the widespread prevalence of this disease, vaccination was declared the safest way to achieve collective immunity and end morbidity and mortality. In less than 12 months after the outbreak, several research teams had developed different types of vaccines. According to the World Health Organization Statistics, until April 2023, more than 13 billion doses of vaccines were injected and more than 157 million of these statistics belong to Iran.[4] With the commencement of vaccination, many questions were raised in people’s minds regarding the necessity of continuing to follow health protocols and the time to return to normal activities and limit compliance with protocols. Based on the findings of the studies, there is no sufficient certainty in terms of not needing to use a fixed mask and other health protocols.[5] Since there is not enough information regarding the non-infection of vaccinated people, according to the recommendations of the Center for Disease Control and Prevention and the World Health Organization, health protocols should still be considered.[6,7] Moreover, to achieve acceptable immunity in society against the COVID-19 and its control, about two-thirds of the people in the community must be immune to the disease, and considering that the manufactured vaccines do not provide complete immunity (100%), more than two-thirds of people in a community must have been immunized either through vaccination or through a history of catching this disease.[7] In fact, the use of risk reduction methods such as social distancing, hand washing, and using a mask after vaccination is also fully and forcibly applied if people in the community understand what is expected of them and if they really understand the importance of observing them. In this regard, the health belief model is the most suitable behavioral framework for understanding why people do not participate in preventive measures.[8] The health belief model, as one of the appropriate and necessary models in teaching preventive behaviors against disease and following it, emphasizes that a person must first feel the risk (perceived sensitivity) of the problem, then understand the severity and seriousness of the complications (perceived severity) and with the positive signals that he perceives from the environment (guidelines for action), understand the applicability of the COVID-19 prevention program (perceived benefits), and finally, identify the factors that prevent action with less expenses than its benefits (perceived obstacles). In addition, positive judgment about one’s abilities to adopt preventive behaviors from COVID-19 (perceived self-efficacy) is also an accelerating force that causes a person’s need to adopt preventive behaviors against COVID-19.[9,10] The studies conducted so far have been about the observance of preventive behaviors during the COVID-19 epidemic, but in this study, based on the behavioral model, the determinants of vaccine injection or non-injection have been investigated. In conclusion, given the increased vaccinations in the community and the change of thought of some people in the domain of durable immunity and change of preventive behaviors, this study was conducted with the aim of investigating the predictors of performing preventive behaviors against affliction with COVID-19 in two vaccinated and non-vaccinated groups based on the health belief model in the Iranian population aged 15–65 years.

Materials and Methods

Study design and setting

This descriptive-analytical study was carried out cross-sectionally in 2022 in Yazd province.

Study participants and sampling

The sample size was calculated as 500 participants using the formula below by considering first type error of 5%, test power of 80%, assuming a 10% difference in the two groups in terms of compliance with preventive behavior in each group with a subject attrition rate of 25%.

The selection of samples was done in such a way that after coordinating with the health deputy, 500 citizens who have been vaccinated and 500 citizens who have not been vaccinated were divided into two virtual groups based on their vaccination status, and a link to the questionnaire was sent to them.

Inclusion criteria were willingness to participate in the study, being a resident of Yazd province, being in the age range of 15–65 years, having injected at least one dose of vaccine (in the vaccinated group), and having the file available in the SIB system. Exclusion criteria were poor response and incomplete completion of the questionnaire.

Data collection tool and technique

The data collection instrument was the questionnaire developed by Delshad Noghabi et al.,[11] which included demographic variables and items related to the constructs of the health belief model. The first part of the questionnaire includes demographic information (age, gender, occupation, education, marital status, income status, disease status, physical activity status, and smoking or non-smoking). The second part includes the constructs of the health belief model, which are performance scale including 16 items (with a score range of 0–64), perceived sensitivity scale including 20 items (with a score range of 0–120), and perceived severity with 20 items (with a score range of 0–120). The scoring of the items was done based on a seven-point Likert scale (completely disagree, disagree, somewhat disagree, have no opinion, somewhat agree, agree, and completely agree). Each item receives 0–6 points. Also, four items of the perceived sensitivity scale and five items of the perceived severity scale are scored reversely. The perceived benefits scale includes 12 items (with a score range of 0–72), and the scale of perceived obstacles includes 12 items (with a score range of 0–72). Besides, six options (completely disagree, disagree, partially disagree, have no opinion, partially agree, agree, and completely agree) have been determined for scoring the items, and 0–6 points have been considered for each of them, respectively. The guide of action scale consists of eight items with a range of 0–32. To answer these items, five options (never, rarely, sometimes, often, and always) have been determined, which are assigned 0, 1, 2, 3, and 4 points, respectively. The self-efficacy scale includes 12 items, and the attainable score range is 0–48. Again, five options (I completely disagree, I disagree, I have no opinion, I agree, and I completely agree) have been determined to answer these items, and each of the answers is given 0, 1, 2, 3, and 4 points, respectively. Given the modification of some questionnaire items by the researchers, to measure the reliability of the questionnaire, a pilot study was conducted on 20 people from the target group, and Cronbach’s α was obtained for the perceived sensitivity construct (0.81), perceived severity (0.82), perceived benefits (0.90), perceived obstacles (0.82), action guide (0.72), self-efficacy (0.87), and performance (0.87). The content validity of the questionnaire was also checked, and the CVR and CVI scales were reported to be greater than 0.7 and 0.79, respectively, for all constructs. Statistical analysis of data was done with SPSS22 using descriptive and analytical statistics, t-test, and linear regression.

Ethical consideration

Informed written consent of the participants to participate in the study was obtained, and they were assured that if they do not want to continue their participation, they could leave the group at any stage and not complete the questionnaire. Besides, the necessity and purpose of the study were informed through the online space. The study was presented in the Ethics Committee of the Clinical Research Development Center of Shahid Rahnemoun Hospital and approved with the ethics code: IR.SSU.SRH.REC.1400.028.

Results

Based on the analysis of demographic variables in the vaccinated group, 366 people (73.2%) are female, 263 (52.6%) are married, 268 (53.6%) have a diploma or bachelor’s degree, 225 (45%) earn a salary of 6–12 million Tomans, 73 (14.6%) are smokers, and 13 (2.6%) people had underlying diseases. Besides, 210 (42%) people had moderate physical activity and 200 (40%) people had free jobs. Based on the analysis of demographic variables in the group of unvaccinated citizens, 270 (54%) are male, 348 (69.6%) are married, 224 (44.8%) have a master’s degree and PhD, 273 (54.6%) have an income level above 12 million Tomans, 307 (61.4%) people smoke, and 251 (50.2%) have underlying diseases. Further, 344 (68.8%) people had a lot of physical activity and 172 (34.4%) people were retired. Based on the performed data analysis, a significant difference was observed in the three variables of income level, smoking, and employment status between two vaccinated and non-vaccinated groups (P <0.05), so that at lower income levels, more people have received the vaccine. Moreover, in the non-vaccinated group, most of the people who smoked (307 people) did not want to be vaccinated and did not receive the vaccine. In terms of employment, people who have had official and free jobs have received vaccines to a greater extent [Table 1].

Table 1 Comparison of the frequency (percentage) of background variables between the two vaccinated and non-vaccinated groups

Background variables	Vaccination status	P	
	Vaccinated	Non-vaccinated		
Gender		
    Female	366 (73.2)	230 (46)	0.948	
    Male	134 (26.8)	270 (54)		
Marital status		
    Single	263 (52.6)	152 (30.4)	0.094	
    Married	237 (47.4)	348 (69.6)		
Education level		
    Pre-diploma	150 (30)	105 (21)	0.786	
    Diploma to BA/BS	268 (53.6)	171 (34.2)		
    MSc to PhD	83 (16.6)	224 (44.8)		
Income level		
    <60 million Rials	165 (33)	88 (17.6)	0.019	
    60–120 million Rials	225 (45)	139 (27.8)		
    >120 million Rials	110 (22)	273 (54.6)		
Smoking		
    No	427 (85.4)	193 (38.6)	    <0.001	
    Yes	73 (14.6)	307 (61.4)		
Underlying disease		
    No	487 (97.4)	249 (49.8)	0.323	
    Yes	13 (2.6)	251 (50.2)		
Physical activity		
    Low	88 (17.6)	46 (9.2)	0.990	
    Moderate	210 (42)	110 (22)		
    High	202 (40.4)	344 (68.8)		
Occupational status		
    Free job	200 (40)	60 (12)	0.025	
    Retired	75 (15)	172 (34.4)		
    Housewife	59 (11.8)	117 (24.4)		
    Governmental	89 (17.8)	69 (13.8)		
    High school or university	77 (15.4)	82 (16.4)		
    Student		

Based on the findings presented in Table 2, the mean score of the perceived self-efficacy construct was higher in the group receiving the vaccine (29.05 ± 5.20). In the non-vaccinated group, the behavior construct had the highest score (29.13 ± 4.7).

Table 2 Distribution of the mean and standard deviation of the constructs of the health belief model between the vaccinated and non-vaccinated groups

Vaccination	Perceived sensitivity	Perceived severity	Perceived benefits	Perceived obstacles	Action guide	Perceived self-efficacy	Behavior	
Yes		
    Mean	16.94	22.04	28.73	28.11	20.75	29.05	28.58	
    SD	3.560	5.058	4.312	6.499	4.866	5.203	5.522	
No		
    Mean	14.68	22.24	24.15	27.83	19.00	28.19	29.13	
    SD	3.291	4.430	5.141	4.581	4.253	5.068	4.794	
P	<0.001	0.565	<0.001	0.490	<0.001	0.018	0.145	

Based on Table 3, the main goal in propensity score matching is the adjustment of the effect of individuals’ tendency to one of the two groups being compared due to uncontrollable variables. In this study, demographic variables may affect people’s inclination for one of the vaccine and non-vaccine groups, changing their opinion about the behavior; so, with this matching method, its effect is adjusted. The following table shows the comparison of scores of behavior dimensions after matching. Regression model was used to explore the ability of predicting behavior by the constructs of the health belief model. The results showed that the prediction of the constructs of perceived sensitivity, perceived benefits, action guide, and perceived self-efficacy was significant in the group so in all constructs above, it was significantly higher in the vaccinated group. In the meantime, the prediction level of perceived benefits (β = 3.67) was more than other variables and the variables of perceived sensitivity and action guide ranked next.

Table 3 Estimation of the effect of vaccination on behavioral variables after matching by the propensity adjustment method

Variable	Regression coefficient	SD	Confidence interval (95%)	Statistical test	P	
Perceived sensitivity	2.43	0.29	(1.86,3.00)	8.33	<0.001	
Perceived severity	-0.86	0.37	(-1.58,-0.13)	-2.31	0.021	
Perceived benefits	3.67	0.43	(2.83,4.52)	8.51	<0.001	
Perceived obstacles	0.56	0.47	(-0.37,1.49)	1.17	0.240	
Action guide	1.56	0.38	(0.81,2.31)	4.07	<0.001	
Perceived self-efficacy	0.89	0.43	(0.05,1.72)	2.09	0.037	
Behavior	-0.46	0.44	(-1.32,0.39)	-1.05	0.249	
*Variables used in calculating the propensity score: Gender, age, income, marital status, education level, physical activity, and smoking were considered. *The coefficients show the mean difference of behavior dimensions in vaccinated versus non-vaccinated people

Discussion

The present study determined the predictors of performing preventive behaviors against affliction with COVID-19 in two vaccinated and unvaccinated groups based on the health belief model in the Iranian population aged 15–65 years. Generally speaking, it can be concluded that the prediction of the constructs of perceived sensitivity, perceived benefits, action guide, and perceived self-efficacy was significant in both groups; yet, in all constructs above, it has been significantly higher in the vaccinated group. So; the use of preventive methods and vaccination injections can have a significant impact on reducing health costs.[12] Based on the results of the study, a significant difference was observed in terms of vaccination or non-vaccination among different occupational groups. Nonetheless, in the study by Keshmiri et al.[13], the mean score of vaccine acceptance behavior was not significantly different among different occupational groups. The reason for this inconsistency can be the different cultural contexts of the society. In the present study, there was no significant difference between the two groups of vaccinated and non-vaccinated patients, and this finding was consistent with the study by Keshmiri et al.[13]. It appears that the acceptance of the vaccine works like a double-edged sword, that is, people with chronic diseases are afraid of vaccination and are worried about the negative effects of the vaccine on their disease status; however, due to the high sensitivity of people with chronic diseases, these individuals pay special attention to vaccine injection. Thus, this two-way behavior cannot create a significant effect between the vaccinated and non-vaccinated groups. Moreover, in the current study, there was no significant difference between the two vaccinated and non-vaccinated groups; this was consistent with the study by Keshmiri et al.[13] It seems that due to the lack of awareness of all people at all levels of education regarding COVID-19, the role of education in the acceptance of the vaccine is weak and ignorable. Based on the results of the study, the perceived sensitivity in vaccinated people was higher than non-vaccinated people and this difference was significant. Perceived sensitivity means that a person sees himself as susceptible to the disease; so, he tries to perform protective behaviors, including vaccination. This finding was consistent with other studies.[14,15,16] In the study by Mirzaei et al., conducted in Iran, no significant relationship was observed between the dimension of perceived sensitivity and preventive behaviors.[17] Based on the results of the present study, there was no significant difference between the two groups of vaccinated and non-vaccinated groups. Perceived severity shows people’s perception of the severity of the complications and effects of the disease. In this study, although vaccinated people saw themselves as very susceptible to catching COVID-19, they did not consider COVID-19 as a dangerous disease. Perhaps the lack of difference in perceived severity between the two groups indicates that people do not consider this disease serious due to the similarity of its symptoms to colds and flu. This finding is not consistent with the results of other studies.[17,18,19,20] In the present study, there was a significant difference between the two groups of vaccinated and non-vaccinated groups, and vaccinated people had higher perceived benefits than non-vaccinated groups. Perceived benefits mean that people are sufficiently aware of the benefits of preventive behaviors. As a rule, when people are aware of the advantages of preventive behaviors, they tend to perform that behavior more frequently; this was consistent with the findings of other studies.[14,15,21] In the current study, there was no significant difference in perceived obstacles between the two groups of vaccinated and non-vaccinated groups. This means that the barriers or obstacles are felt similarly between the two groups. Perceived obstacles are actually the brakes that a person experiences on the way to perform a behavior, and sometimes the benefits of a behavior are great. Hence, obstacles cannot stop a person from performing the behavior. In various studies, the perceived obstacles of people were at a low level.[12,14,15] In the study by Mirzaei et al. in Iran, a strong correlation was observed between the dimensions of perceived benefits and perceived obstacles and the occurrence of preventive behaviors.[17] Based on the results, there was a significant difference between the two groups of vaccinated and non-vaccinated action guides in a way that vaccinated people had a higher action guide; that is, more external and internal resources led them to perform the behavior. In the present study, most of the people stated that the source of their information was television programs and mass media; this is consistent with the findings of other studies.[22,23] Furthermore, in the current study, the self-efficacy of the vaccinated group was significantly higher than that of the non-vaccinated group; that is, the vaccinated people had more confidence in performing preventive behaviors against catching COVID-19. This finding was consistent with the findings of other studies.[16,19,24,25] It seems that when people receive high perceived benefits from perceived sensitivity due to extensive mass media information, they will have higher self-efficacy. In the present study, there was no significant difference in behavioral performance between the two groups of vaccinated and non-vaccinated persons. That is, both groups were in a similar situation in terms of performing preventive behaviors against catching COVID-19. It was the case that the non-vaccinated group had a higher behavioral performance score than the vaccinated group. The reason could be attributed to the fact that unvaccinated people feel more at risk due to the lack of vaccination, and as a result, they have acted more strongly in preventive behaviors.

Limitations and recommendation

Completing the questionnaire online and using virtual space are among the main limitations of the study, which also led to the possibility of completing the form by one person several times as a limitation.

Conclusion

Greater awareness and perceived self-efficacy in the vaccinated group can indicate that correct and sufficient information about vaccination has been provided to this group. As a result, to prevent the spread of diseases, it is very important to increase people’s awareness and information about the benefits of vaccination and pay attention to individual demographic characteristics in vaccination programs.

In addition, the results of this study show that the constructs of perceived sensitivity, perceived benefits, action guidance, and perceived self-efficacy can be considered as important factors in determining people’s willingness to be vaccinated. Therefore, education and information programs should be focused on these factors to increase people’s willingness to be vaccinated.

In addition, this study showed that the analysis of demographic variables can be a useful tool in vaccination planning. For example, considering characteristics such as age, gender, education, marital status, and income level can be effective in preventing the spread of diseases and increasing vaccination coverage.

Financial support and sponsorship

This project financially supported by Research and Technology Vice-Chancellor, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.

Conflicts of interest

There are no conflicts of interest.

Acknowledgement

We are grateful to the person who completed the questionnaire. This research project is approved by the Clinical Research Development Center of Shahid Rahnemoun Hospital in Yazd with code 12440.
==== Refs
1 Pandey K Thurman M Johnson SD Acharya A Johnston M Klug EA Mental health issues during and after COVID-19 vaccine era Brain Res Bull 2021 176 161 73 34487856
2 Davies NG Abbott S Barnard RC Jarvis CI Kucharski AJ Munday JD Estimated transmissibility and impact of SARS-CoV-2 lineage B.1.1.7 in England Science 2021 372 eabg3055 33658326
3 Campbell F Archer B Laurenson-Schafer H Jinnai Y Konings F Batra N Increased transmissibility and global spread of SARS-CoV-2 variants of concern as at June 2021 Euro Surveill 2021 26 2100509 34142653
4 World Health Organization Coronavirus disease (COVID-19) 12 October 2020
5 Aghaei M Yunesian M The necessity to keep taking health protocols in people receiving the Covid-19 vaccine Management Strategies in Health System 2021 6 83 6
6 Harris AM Hicks LA Qaseem A High Value Care Task Force of the American College of Physicians and for the Centers for Disease Control and Prevention* Appropriate antibiotic use for acute respiratory tract infection in adults: advice for high-value care from the American College of Physicians and the Centers for Disease Control and Prevention Annals of internal medicine 2016 Mar 15 164 6 425 34 26785402
7 World Health Organization COVID-19 advice for the public: Getting vaccinated 2021
8 Abraham C Sheeran P The health belief model Predicting and changing health behavior McGraw-Hill Retrieved from https://www researchgate.net/publication/290193215_The_Health_Belief_Mode 2015
9 Movahed E Arefi Z Ameri M The effect of health belief model-based training (HBM) on self-medication among the male high school students Iran J Health Educ Health Promot 2014 2 65 72
10 Askari R Mir Hosseini R Montazeral Faraj R Jambarsang S Evaluation of the Effect of Implementing Health Promoting Hospitals Program on the Level of Attitude of Cardiac Patients Health Educ Health Promot 2022 10 2 341 346
11 Delshad Noghabi A Yoshany N Mohammadzadeh F Javanbakht S Predictors of Covid-19 preventive behaviors in Iranian population over 15 years old: An application of health belief model J Maz Univ Med Sci 2020 30 13 21
12 Pakdaman M Geravandi S Askari R Askarishahi M Afzali HR The effect of macroeconomic indicators on health-care expenditure in Iran J Educ Health Promot 2019 Jun 27 8 123 doi: 10.4103/jehp.jehp_453_18. PMID: 31334275; PMCID: PMC6615124 31334275
13 Keshmiri S Darabi AH Tahmasebi R Vahdat K Noroozi A Factors influencing COVID-19 vaccine acceptance based on the behavioral change wheel model in Bushehr province in 2021: A web-based study Hayat 2021 27 190 205
14 Sesagiri Raamkumar A Tan SG Wee HL Use of health belief model-based deep learning classifiers for COVID-19 social media content to examine public perceptions of physical distancing: Model development and case study JMIR Public Health Surveill 2020 6 e20493 32540840
15 Jose R Narendran M Bindu A Beevi N L M Benny PV Public perception and preparedness for the pandemic COVID 19: A health belief model approach Clin Epidemiol Glob Health 2021 9 41 6 33521389
16 Clark C Davila A Regis M Kraus S Predictors of COVID-19 voluntary compliance behaviors: An international investigation Glob Transit 2020 2 76 82 32835202
17 Mirzaei A Kazembeigi F Kakaei H Jalilian M Mazloomi S Nourmoradi H Application of health belief model to predict COVID-19-preventive behaviors among a sample of Iranian adult population J Educ Health Promot 2021 10 69 doi: 10.4103/jehp.jehp_747_20 34084816
18 Kwok KO Li KK Chan HHH Yi YY Tang A Wei WI Community responses during early phase of COVID-19 epidemic, Hong Kong Emerg Infect Dis 2020 26 1575 9 32298227
19 Lin Y Hu Z Alias H Wong LP Influence of mass and social media on psychobehavioral responses among medical students during the downward trend of COVID-19 in Fujian, China: Cross-sectional study J Med Internet Res 2020 22 e19982 32584779
20 Karimy M Bastami F Sharifat R Heydarabadi AB Hatamzadeh N Pakpour AH Factors related to preventive COVID-19 behaviors using health belief model among general population: A cross-sectional study in Iran BMC Public Health 2021 21 1934 34689728
21 Sarwar F Panatik SA Jameel HT Understanding Public’s Adoption of Preventive Behaviour during COVID-19 Pandemic using Health Belief Model: Role of Appraisals and Psychological Capital Preprint 2020 17 10
22 Shabu SA M-Amin K Mahmood KI Shabila NP Risk perception and behavioral response to COVID-19: A survey of university students and staff in the Iraqi Kurdistan region Soc Work Public Health 2021 36 474 85 33866952
23 Seyrafi N Mohsseni S Hassani L Predicting the preventive health behaviors of people towards COVID-19 in Bandar Abbas, Iran based on the health belief model Int J Prev Med 2022 9 230 41
24 Shahnazi H Ahmadi-Livani M Pahlavanzadeh B Rajabi A Hamrah MS Charkazi A Assessing preventive health behaviors from COVID-19: A cross sectional study with health belief model in Golestan Province, Northern of Iran Infect Dis Poverty 2020 9 157 33203453
25 Jahanshahi-Amjazi R Rezaeian M Abdolkarimi M Nasirzadeh M Predictors of the intention to receive the COVID 19 vaccine by Iranians 18-70 year old: Application of health belief model J Educ Health Promot 2022 11 175 35847130
