Risk perception related to COVID-19 among the Iranian general population: an application of the extended parallel process model

The novel coronavirus disease 2019 (COVID-19) has emerged as a major global public health challenge [1]. This potentially fatal infectious disease, which has affected most countries worldwide, is characterized by a steady speed of spread, leading to the World Health Organization (WHO) classifying it as a pandemic [2]. In Iran, apparently the two first cases of deaths related to COVID-19 were reported on February 19, 2020 from Qom, a city in the central part of the country. As of April 13, 73,303 Iranian people have been infected with the COVID-19. In total, 4585 have died and 45,983 have recovered when we were carrying this study [3].

The COVID-19 is transmitted from human to human through respiratory droplets or direct contact. Available findings show that avoiding exposure is the key to preventing COVID-19 infection, which is why quarantining, physical distancing, and isolation have become the primary strategies for reducing COVID-19 incidence and mortality. Quarantine restricts the movement of people and reduces the infection rate for contagious diseases [4]; physical or social distancing involves staying at least two meters away from other persons; and isolation is the state of separating patients with COVID-19 from otherwise healthy people [5]. Maintaining hygiene practices, such as proper hand washing, wearing a mask in crowded places, and staying at home, all are recommended for controlling the spread of the disease and breaking the transmission chain [6].

During the early stages of the coronavirus pandemic in Iran, several social media campaigns were launched to inform people about the risks of coronavirus and to persuade them to follow health care recommendations. Therefore, providing necessary information about people’s perception related to COVID-19 is important for health policy makers in implementing effective and appropriate strategies in order to prevent and control of the disease.

There are several factors that might affecting COVID-19 response behaviors [7]. Multiple health models suggest that risk perception of the COVID-19 is a vital component for any behavior change [8]. Of these, the extended parallel process model (EPPM) is very relevant [9]. According to the EPPM, when people are exposed to a risky situation, they go through two cognitive appraisals: one related to the efficacy of the recommended advice and one related to the perceived threat [10]. The EPPM therefore indicates that the perception of a risk depends on efficacy, defensive response and perceived threat [11]. Thus, in order to influence people’s behavior to follow the COVID-10 health recommendations it is important to understand how people perceive the COVID-19 pandemic, how they are assessing these risks, and how such assessments might lead them to change their behaviors. This study aimed to investigate on how people have perceived the COVID-19 outbreak using the components of the EPPM (efficacy, defensive responses, perceived threat) and how these might contribute to possible behavioral responses to the prevention and control of the disease.

This EPPM-based study was conducted to assess the risk perceptions, overall perceived danger and fear control processes among Iranian people during the early stages of the COVID-19 pandemic. The study provides a timely assessment and initial evidence related to the risk perceptions and psychological responses of more than 3727 individuals across the country who took part in the study. In this study, the risk perception was evaluated through three dimensions of the EPPM including efficacy (self-efficacy and response efficacy), defensive response (denial, reactance, and avoidance), and threat (susceptibility and severity).

The study results showed that 56.4% of respondents were motivated by danger control responses and 43.6% by fear control responses. This indicates that more than half of all participants had high perceived efficacy (i.e., self-efficacy and response efficacy). According to the EPPM, two cognitive appraisals might initiate after a person learns about a health risk: one related to the threat it poses and a second related to the efficacy to follow the recommended responses. When the threat of COVID-19 is perceived to be more significant and efficacy is low, people are usually act to protect themselves from the fear rather than the danger itself (fear control process). Conversely when perceived efficacy is significantly high, even if the perceived treat would be high, people usually are motivated to protect themselves from the danger and could manage the threat (danger control process) [13].

Self-efficacy scores were significantly higher among participants who were older, female, single, lived in rural areas, or had good economic status. Self-efficacy is a positive mental state that is part of the cognitive appraisal process reducing stress and tension [14]. A current study from China showed an association between self-efficacy and social support among patients who had been treated for coronavirus [15]. This is inconsistent with our results, where it was found that participants with a history of coronavirus had lower self-efficacy scores. Respondents who had a family member with coronavirus and those with three or more comorbidities had lower self-efficacy scores for controlling COVID-19. The results showed that respondents with high self-efficacy were better able to control their emotions. Self-efficacy contributes to preventive behavior and the ability to conduct healthy behavior [16]. In this regard, a study by Liao et al. showed that self-efficacy was significantly associated with trust in government and media information on pandemic of A/H1N1 influenza [17]. We found that efficacy was significantly higher among respondents who were well-educated and had good economic status. It seems that these individuals believed that they can carry out the recommended responses to protect themselves from the COVID-19.

Individuals usually use psychological defense strategies to control their fears. These strategies include denial, avoidance, and reactance. Our results showed that higher defensive response scores correlated with better responses from participants. Defensive avoidance occurs when individuals block out feelings and thoughts about a threat or ignore further information about it, for example, switching the television channel or skipping COVID-19-related news. People in younger age groups had lower reactance scores and lower self-efficacy scores, indicating that younger people tended to take more risks and ignore health recommendations [18].

The results also showed that respondents who were male, older, well-educated, and married had significantly higher perceptions of susceptibility. In fact, these individuals were simply thinking about the threat of the COVID-19 and believed that the threat was relevant to them. According to the WHO, older people are at higher risk of contracting COVID-19 [19]. The Iranian health care system and media provided significant coverage of the COVID-19 pandemic, recommending that all people, especially older people take good care of themselves. This likely resulted in older people learning that they were more susceptible to the disease. However, some studies reported that after the initial stage of a pandemic the media attention to the topic declined and perceived susceptibility and severity declined accordingly [20‐22].

More than half of all participants motivated by danger control. This indicated that more than half of participants had high perceived efficacy (i.e., self-efficacy and response efficacy). The results suggest that the risk perception of COVID-19 differs by socio economic and demographic characteristics. Indeed, the knowledge provided by the current study will likely contribute to the effectiveness of COVID-19 control and prevention measures.