The Adoption of Preventive Behaviors during the COVID-19 Pandemic in China and Israel

"...behavioral changes as a response to public health recommendations are heavily dependent on the acquisition of new social norms of interaction....The COVID-19 pandemic provides us with a natural laboratory for the investigation of rapid and dramatic changes in social behavior..."

In the absence (so far) of available and effective pharmaceutical treatments and vaccines, dealing with the COVID-19 public health crisis has required significant changes in people's behaviour worldwide, including the adoption of social distancing measures. Since some of these behavioural changes involve significant social and economic costs, personal, social, cultural, and developmental factors affect the decision to adopt them. With a focus on China and Israel, this study uses the 3Cs model - confidence, complacency, and constraint - that has been used to predict the adoption of vaccination behaviour, with the goal of testing its applicability to other preventive behaviours, such as in response to the COVID-19 pandemic, and evaluating the extent to which the 3Cs model is invariant according to culture.

The researchers explain that China and Israel vary a great deal in the nature of their societies. As a country with a Western culture, Israelis are more likely than the Chinese to express their emotions with close physical contact such as kissing and hugging. In addition, Israeli society is more inclined to individualism, whereby personal desires often outweigh social demands. In China, the COVID-19 pandemic coincided with the Chinese spring festival, during which it is customary to visit friends and family. However, China is a collectivistic society characterised by a strong commitment to social norms and strict punishment for deviation from these norms, making compliance with social distancing requirements more likely.

Originally used as a framework to analyse vaccine hesitancy by the Strategic Advisory Group of Experts (SAGE) on Immunization, the 3Cs model has been used to understand how individuals' confidence, complacency, and constraint influence decision-making on immunisation. The paper includes a literature review that explores how each of these concepts have been studied in the past, looking at issues of trust, expected utility, and structural and psychological barriers. In short, the model indicates that confidence in social institutions, complacency (fear of and assessments about the risk of becoming ill), and constraints (levels of self-efficacy and confidence in being able to engage in the behaviours) are predictors of adopting preventive behaviours.

Data were collected in China and Israel through an online survey of 703 members of each population (n = 1,406). The researchers used latent variables and structural equation modeling to test the hypotheses derived from the 3Cs model. They alo measured how frequently the participants engage in specific avoidant behaviours - e.g., wear a face mask - on a 5-point scale.

Overall, the findings indicate some differences in the types of preventive behaviours adopted in the 2 countries. For example: In Israel, higher levels of confidence predicted the adoption of avoidant behaviours, and more constraints predicted engaging in fewer avoidant behaviours; in China, more constraints also contributed to the adoption of fewer avoidant behaviours, but people's level of confidence fully mediated this result. In Israel, complacency is negatively related to the adoption of avoidant behaviour, whereas in China, this relationship is positive. Other selected findings:

• Both the Israeli and Chinese participants expressed consistent and high levels of confidence in social institutions. However, the Chinese participants were more confident in the Chinese institutions than the Israeli participants were in the Israeli institutions.
• With regard to complacency, the study found that, while during the outbreak and in daily life both groups indicated they thought the virus was serious and they were very susceptible to it, the Israelis thought they were more susceptible to it than the Chinese.
• In terms of constraints, both the Israeli and Chinese participants thought engaging in healthy behaviours was beneficial for preventing disease in their daily life. The level of this belief was slightly more intense when compared to the statistics during the outbreak. At the same time, they reported strong assessments about their self-efficacy in being able to engage in healthy behaviours in their daily life or during the outbreak. Nevertheless, the Chinese participants expressed more self-efficacy in this regard than the Israeli participants.
• For avoidant behaviour as a dependent variable, the most salient difference was that Chinese participants were significantly more likely to use a face mask when going out than Israelis.
• Multivariate analysis revealed that the original proposed model was a good fit with the data.

In reflecting on the results, the researchers point to the role constraints were shown to play in behavioural changes. Therefore, eliminating perceptions about constraints leading to low expectations about outcomes and efficacy could be key for public health communications, especially during the ever-changing, uncertain period of a pandemic.

In addition, the study's findings indicate that only when people believe that the behaviours are beneficial (outcome expectations) and they are confident they can engage in them (efficacy expectations) will they actually adopt them. Thus, efforts should be made to promote more confidence in people's ability to engage in behavioural change by enhancing their understanding of the outcomes of doing so and developing their efficacy to engage in such behaviour. "Communication strategies during a pandemic should put more emphasis on encouraging people to engage in avoidant behavior by raising their expectations about the beneficial outcomes of doing so and inspiring their efficacy expectations."

One other practical implication of the study is that the "government should work closely with the health care system to build a transparent and responsive communication to the public, to assess individual's perception, emotional status and increase public support. In the meantime, difficulties in employment, need for daily supplies, epidemic prevention and control supplies, transportation could be the sources of public negative perception and behavior adoption. Policies concerning these issues should be implemented to ease this hardship."

In conclusion, this study has demonstrated that the 3Cs model can be generalised from getting vaccinated to adopting avoidant behaviours and that the model can be used across cultures and countries.