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P edic o s o changing pa e ns o adhe ence o con ainmen measu es du ing he ea ly
s age o COVID-19 pandemic : an in e na ional longi udinal s udy
© The Au ho (s) 2023
Published e sion
Chong, Yuen Yu; Chien, Wai Tong; Cheng, Ho Yu; Lamnisos, Deme is; Ļubenko,
Jeļena; P es i, Gio amba is a; Squa i o, Vale ia; Cons an inou, Ma ios;
Nicolaou, Ch is iana; Papacos as, Sa as; Aydin, Gökçen; Ruiz, F ancisco J.;
Ga cia-Ma in, Ma ia B.; Obando-Posada, Diana P.; Segu a-Va gas, Miguel A.;
Vasiliou, Vasilis S.; McHugh, Louise; Hö e , S e an; Baban, Ad iana; Dias Ne o,
Da id; Nunes da Sil a, Ana; Mones ès, Jean-Louis; Al a ez-Gal ez, Ja ie ; Paez
Bla ina, Ma isa; Mon esinos, F ancisco; Valdi ia Salas, Sonsoles; Ő i, Do o ya;
Kleszcz, Ba osz; Lappalainen, Raimo; I ano ić, I a; Gosa , Da id; Dionne,
F ede ick; Me win, Rhonda M.; Glos e , And ew T.; Kassianos, Angelos P.;
Ka ekla, Ma ia
Chong, Y. Y., Chien, W. T., Cheng, H. Y., Lamnisos, D., Ļubenko, J., P es i, G., Squa i o, V.,
Cons an inou, M., Nicolaou, C., Papacos as, S., Aydin, G., Ruiz, F. J., Ga cia-Ma in, M. B.,
Obando-Posada, D. P., Segu a-Va gas, M. A., Vasiliou, V. S., McHugh, L., Hö e , S., Baban, A., . . .
Ka ekla, M. (2023). P edic o s o changing pa e ns o adhe ence o con ainmen measu es
du ing he ea ly s age o COVID-19 pandemic : an in e na ional longi udinal s udy. Globaliza ion
and Heal h, 19, A icle 25. h ps://doi.o g/10.1186/s12992-023-00928-7
2023
Chonge al. Globaliza ion and Heal h (2023) 19:25
h ps://doi.o g/10.1186/s12992-023-00928-7
RESEARCH Open Access
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Globaliza ion and Heal h
P edic o s o changing pa e ns
o adhe ence ocon ainmen measu es
du ing heea ly s age o COVID-19 pandemic:
anin e na ional longi udinal s udy
Yuen Yu Chong1* , Wai Tong Chien1, Ho Yu Cheng1, Deme is Lamnisos2, Jeļena Ļubenko3,
Gio amba is a P es i4, Vale ia Squa i o4, Ma ios Cons an inou5, Ch is iana Nicolaou6, Sa as Papacos as7,
Gökçen Aydin8, F ancisco J. Ruiz9, Ma ia B. Ga cia‑Ma in10, Diana P. Obando‑Posada10,
Miguel A. Segu a‑Va gas9, Vasilis S. Vasiliou11, Louise McHugh12, S e an Hö e 13, Ad iana Baban14,
Da id Dias Ne o15, Ana Nunes da Sil a16,17, Jean‑Louis Mones ès18, Ja ie Al a ez‑Gal ez19,
Ma isa Paez Bla ina20, F ancisco Mon esinos21, Sonsoles Valdi ia Salas22, Do o ya Ő i23, Ba osz Kleszcz24,
Raimo Lappalainen25, I a I ano ić26, Da id Gosa 27, F ede ick Dionne28, Rhonda M. Me win29,
And ew T. Glos e 30, Angelos P. Kassianos31,32 and Ma ia Ka ekla31
Abs ac
Backg ound Iden i ying common ac o s ha a ec public adhe ence o COVID‑19 con ainmen measu es can
di ec ly in o m he de elopmen o o icial public heal h communica ion s a egies. The p esen in e na ional longi u‑
dinal s udy aimed o examine whe he p osociali y, oge he wi h o he heo e ically de i ed mo i a ing ac o s (sel ‑
e icacy, pe cei ed suscep ibili y and se e i y o COVID‑19, pe cei ed social suppo ) p edic he change in adhe ence
o COVID‑19 con ainmen s a egies.
Me hod In wa e 1 o da a collec ion, adul s om eigh geog aphical egions comple ed online su eys beginning in
Ap il 2020, and wa e 2 began in June and ended in Sep embe 2020. Hypo hesized p edic o s included p osociali y,
sel ‑e icacy in ollowing COVID‑19 con ainmen measu es, pe cei ed suscep ibili y o COVID‑19, pe cei ed se e ‑
i y o COVID‑19 and pe cei ed social suppo . Baseline co a ia es included age, sex, his o y o COVID‑19 in ec ion
and geog aphical egions. Pa icipan s who epo ed adhe ing o speci ic con ainmen measu es, including physical
dis ancing, a oidance o non‑essen ial a el and hand hygiene, we e classi ied as adhe ence. The dependen a iable
was he ca ego y o adhe ence, which was cons uc ed based on changes in adhe ence ac oss he su ey pe iod and
included ou ca ego ies: non‑adhe ence, less adhe ence, g ea e adhe ence and sus ained adhe ence (which was
designa ed as he e e ence ca ego y).
Resul s In o al, 2189 adul pa icipan s (82% emale, 57.2% aged 31–59 yea s) om Eas Asia (217 [9.7%]), Wes Asia
(246 [11.2%]), No h and Sou h Ame ica (131 [6.0%]), No he n Eu ope (600 [27.4%]), Wes e n Eu ope (322 [14.7%]),
Sou he n Eu ope (433 [19.8%]), Eas e n Eu ope (148 [6.8%]) and o he egions (96 [4.4%]) we e analyzed. Adjus ed
*Co espondence:
Yuen Yu Chong
[email p o ec ed]
Full lis o au ho in o ma ion is a ailable a he end o he a icle
Page 2 o 11
Chonge al. Globaliza ion and Heal h (2023) 19:25
mul inomial logis ic eg ession analyses showed ha p osociali y, sel ‑e icacy, pe cei ed suscep ibili y and se e i y o
COVID‑19 we e signi ican ac o s a ec ing adhe ence. Pa icipan s wi h g ea e sel ‑e icacy a wa e 1 we e less likely
o become non‑adhe ence a wa e 2 by 26% (adjus ed odds a io [aOR], 0.74; 95% CI, 0.71 o 0.77; P < .001), while
hose wi h g ea e p osociali y a wa e 1 we e less likely o become less adhe ence a wa e 2 by 23% (aOR, 0.77; 95%
CI, 0.75 o 0.79; P = .04).
Conclusions This s udy p o ides e idence ha in addi ion o emphasizing he po en ial se e i y o COVID‑19 and
he po en ial suscep ibili y o con ac wi h he i us, os e ing sel ‑e icacy in ollowing con ainmen s a egies and
p osociali y appea s o be a iable public heal h educa ion o communica ion s a egy o comba COVID‑19.
Keywo ds P osociali y, Co ona i us, Adhe ence, Disease con ainmen measu es, Longi udinal s udy
In oduc ion
Since he ou b eak o co ona i us disease (COVID-19)
in 2019, go e nmen leade s wo ldwide ha e used a i-
ous measu es o con ain i s sp ead, such as physical dis-
ancing, a oiding la ge ga he ings, wea ing masks and
equen hand washing [1]. Resea ch has been conduc ed
o assess he impac o hese con ainmen measu es
[2]. Fo ins ance, cancelling small ga he ings has been
ound o dec ease he e ec i e ep oduc ion numbe o
se e e acu e espi a o y synd ome co ona i us 2 (SARS-
CoV-2) (R ) by up o 83% [3]; while sel -isola ion, house-
hold qua an ine and manual con ac acing can educe
COVID-19 ansmission up o 64% [4].
Public adhe ence o disease con ainmen measu es
emains c ucial o con olling he sp ead o COVID-19.
Howe e , such adhe ence a ies depending on he ypes
o measu es equi ed o be complied wi h, he in ensi ies
o go e nmen al en o cemen measu es and is in luenced
by he in e play o demog aphic, poli ical, and sociocul-
u al ac o s [5–7]. In a longi udinal s udy conduc ed
be ween Ma ch and Decembe 2020 in ol ing 238,797
pa icipan s om 14 coun ies, adhe ence o lowe -
cos and habi ua ing beha io s (e.g., mask-wea ing in
c owded a eas) was ound o inc ease p og essi ely o e
ime [8], while adhe ence o high-cos , sensi izing beha -
io s (e.g., physical dis ancing, a oiding c owds) g adually
dec eased due o pandemic a igue (i.e., o e all i ed-
ness o demo i a ion o ollow ecommended p o ec i e
beha io s) and educed isk pe cep ion o COVID-19 [8].
Psychological ac o s ha in luence adhe ence o
COVID-19 ela ed p o ec i e beha io s ha e been
ecen ly examined in se e al heo e ical amewo ks
[6]. The Heal h Belie Model [9], he Social Cogni i e
Theo y[10], he Reasoned Ac ion App oach [11] and
he Heal h Ac ion P ocess App oach a e heo ies cen-
e ed a ound sel -mo i a ion ha ha e been inc eas-
ingly adop ed in COVID-19- ela ed esea ch [12, 13].
These heo ies sugges ha inc eased sel -e icacy,
s onge pe cei ed suscep ibili y o COVID-19 in ec-
ion and be e ea men ou come expec ancies
a e associa ed wi h inc eased adhe ence o disease
con ainmen measu es [6], while lack o social suppo
is iden i ied as a beha io al ba ie o adhe ence [13].
The Capabili y, Oppo uni y and Mo i a ion Beha -
io (COM-B) model is ano he heo e ical model ha
has been used in ecen li e a u e ela ed o COVID-
19 [14–16], sugges ing ha changing an indi idual’s
beha io o comba COVID-19 can be a ec ed by (1)
capabili ies, which a e he ele an knowledge and
skills o engage in ha pa icula beha io ; (2) oppo -
uni ies, e e ing o esou ces, cul u al no ms and/o
social suppo and cues o acili a e he execu ion o he
beha io ; and (3) mo i a ion o d i e beha io al change
[15]. In ou p e ious in e na ional su eys, we adop ed
he Le en hal’s Common-Sense Model o Sel -Reg-
ula ion and ound ha isk pe cep ions o COVID-19
could shape adhe ence o con ainmen measu es, medi-
a ed by less a oidance-based coping and be e sel -e i-
cacy in disease p e en ion and managemen [17, 18].
The li e a u e has unde gone ex ensi e expansion
in ecen yea s ega ding he in es iga ion o ac o s
ha de e mine adhe ence o COVID-19 con ainmen
measu es. A e iew o 29 s udies conduc ed in wes e n
coun ies sugges s ha people who a e emale, olde ,
ha e highe socioeconomic s a us, us in go e nmen
o heal h au ho i ies, us in science o medicine and
access in o ma ion om adi ional media sou ces a e
mo e likely o adhe e o COVID-19 ela ed con ainmen
measu es [19]. This may be pa ly due o he inc eased
conce n abou hei own heal h isks held among hese
g oups [5, 7, 20, 21]. Fea and pe cei ed pe sonal h ea
o COVID-19 can also imp o e adhe ence [22], bu bo h
could also lead o anxie y and a oidance beha io s ha
may lead o lowe adhe ence [23, 24]. Cul u al no ms and
p ac ices (e.g., cul u es ha p io i ize collec i ism o e
indi idualism may be mo e likely o adhe e o measu es
ha bene i he g oup as a whole) [25], communica ion-
ela ed ac o s (e.g., cla i y, e ec i eness, each o com-
munica ion campaigns, channels and me hods used o
dissemina e ele an COVID-19 in o ma ion) may also
shape a i udes and beha io s in esponse o a ious con-
ainmen measu es [26].
Page 3 o 11
Chonge al. Globaliza ion and Heal h (2023) 19:25
In iew o he communal na u e o he COVID-19 pan-
demic, he e has been a call o explo e he ole o p oso-
ciali y in he con ex o cu bing he sp ead o COVID-19.
P osociali y e e s o an a i ude o a se o olun a y
ac ions ha an indi idual may adop o help, ca e o , o
com o o he s [27]. As sugges ed by he Social Iden i y
Theo y [28], he sense o belonging, iden i y and p oso-
ciali y would o en inc ease wi hin a g oup in suppo -
ing one ano he i g oup membe s pe cei e hemsel es
as acing c ises [29]. P osociali y equi es people o hink
and ac collec i ely wi h kindness, coope a ion and sensi-
i i y o o he s’ wel a e (e.g., p o ec o he s om COVID-
19). I has ecen ly been conside ed as an impo an
a ge o public heal h in e en ions o p omo e adhe -
ence o disease con ainmen measu es [30–33], adop ing
mobile applica ions o con ac acing [34] and accine
up ake [35, 36]. Howe e , he associa ion be ween p oso-
ciali y and adhe ence o up ake o COVID-19- ela ed
measu es has only been demons a ed in single-cen e ,
c oss-sec ional and co ela ional s udies [32–34, 36,
37], in which changing pa e ns o adhe ence beha io s
ha e been neglec ed. Indeed, a ia ions in mo al obliga-
ions, cul u al alues, social no ms and public leade ships
ac oss egions may a ec he deg ee o which indi idu-
als p io i ize he well-being o o he s o e hei own sel -
in e es s [38, 39]. Fu he mo e, di e ences in he se e i y
and p e alence o COVID-19 ac oss egions may impac
indi iduals’ pe cei ed needs o adhe ence o ela ed
con ainmen measu es. The e o e, in his longi udinal
s udy in ol ing an in e na ional sample o pa icipan s,
we aimed o examine whe he p osociali y, along wi h
o he known sel - ocused mo i a ing ac o s such as sel -
e icacy, pe cei ed suscep ibili y and se e i y o COVID-
19, and pe cei ed social suppo , can p edic changes in
adhe ence o COVID-19 con ainmen measu es du ing
he i s yea o he pandemic. This s udy will also ake
in o accoun o he demog aphic ac o s and he s a us o
COVID-19.
Me hods
Design ands udy pa icipan s
The s udy was pa o he in e na ional COVID-IMPACT
su ey, which aimed o examine he psychological and
beha io al esponses o he public o COVID-19 and i s
ela ed con ainmen measu es [18, 30, 40, 41]. Be ween
Ap il and June 2020, he i s wa e o he su ey (wa e 1)
was adminis e ed o a sample o adul s aged 18yea s o
olde who we e able o ead a leas one o he ollowing
languages: English, Chinese, Spanish, F ench, Ge man,
Tu kish, Po uguese, I alian, Du ch, Polish, Romanian,
G eek, Hunga ian, Pe sian, Finnish, Slo enian, La ian,
and Mon eneg in. These indi iduals we e ec ui ed om
51 coun ies ac oss he globe h ough a ious means,
such as p ess ou le s (e.g., newspape s, newsle e s, adio
s a ions), social media pla o ms, p o essional g oups’
mailing lis s, and ne wo ks, as well as mass mailings om
pa icipa ing uni e si ies. No exclusion c i e ia o pa ic-
ipa ion we e se . Those who olun ee ed o pa icipa e in
he s udy we e in i ed o p o ide hei in o med consen
elec onically and comple e a 20-min su ey on a secu e
online pla o m. Upon comple ion, he pa icipan s we e
di ec ed o ano he secu ed pla o m o indica e whe he
hey would like o be con ac ed o ollow-up da a collec-
ion and o p o ide hei email add esses. I ag eed, hey
we e econ ac ed be ween Augus and Sep embe 2020
o he second wa e o he su ey (wa e 2). Since he ime
spen o adminis e each su ey was app oxima ely less
han 20min, no compensa ion was p o ided. The s udy
ecei ed e hics app o al om he Cyp us Na ional Bio-
e hics Commi ee ( e .: EEBK E* 2020.01.60) and by he
local e hics boa ds whose esea ch eam membe s we e
in ol ed in collec ing da a. Ou epo ing ollowed he
S eng hening he Repo ing o Obse a ional S udies in
Epidemiology (STROBE) epo ing guidelines [42].
Measu es
Adhe ence oCOVID‑19 con ainmen measu es
In bo h wa e 1 and wa e 2 o he su ey, pa icipan s
we e asked o a e hei le el o adhe ence o (1) physical
dis ancing, (2) sel -isola ion, a oidance o non-essen ial
a el, and (3) hand hygiene du ing he pandemic, wi h
esponse op ions anging om ’1’ o non-adhe ence
o ’10’ o ully adhe ence. Pa icipan s who esponded
’7 = mos ly adhe en ’ o highe o all h ee i ems we e
conside ed as adhe ence. The ollowing explana o y a i-
ables we e assessed a wa e 1:
Sel ‑e icacy
Fi e i ems ( esponse: ‘1’ = s ongly disag ee o
‘7’ = s ongly ag ee) based on Bandu a’s sel -e icacy
heo y we e adop ed o measu e whe he he pa ici-
pan s pe cei ed hemsel es as compe en in ollowing he
COVID-19 con ainmen measu es. An example i em is “I
ha e he skills o ge h ough his di icul si ua ion”, wi h
a highe o al sco e indica ing be e sel -e icacy [17].
Pe cei ed suscep ibili y andse e i y
Six i ems ( esponse: ‘1’ = s ongly disag ee o
‘6’ = s ongly ag ee) based on he Heal h Belie Model
we e used o assess he pa icipan s’ o e all illness pe -
cep ions owa d COVID-19, wi h highe o al sco es indi-
ca ing s onge pe cep ions. One example i em assessing
pe cei ed suscep ibili y is “I am conce ned abou he isk
o ge ing he COVID-19”, while an example i em assess-
ing pe cei ed se e i y was “My li e will change i I ge
in ec ed by COVID-19” [43].
Page 4 o 11
Chonge al. Globaliza ion and Heal h (2023) 19:25
P osociali y
Six i ems ( esponse: ‘1’ = ne e o ‘5’ = always) adap ed
om he P osocialness Scale o Adul s we e used
o assess six di e en p osocial beha io s du ing he
COVID-19 pandemic, such as sha ing, helping, aking
ca e o o he s and showing empa hy. Example i ems a e ‘I
y o help o he s’ and ‘I am empa hic wi h hose in need’.
A highe o al sco e indica es g ea e p osocial mo i a-
ion [44].
Pe cei ed social suppo
Th ee i ems o he Oslo Social Suppo Scale we e used
o assess he a ailabili y o social suppo by asking he
numbe o people ha we e closed o he pa icipan
( esponse: ‘1’ = none o ‘4’ = mo e han 5 people), he
ex en o in e es and conce n ha people show in wha
he pa icipan s did ( esponse: ‘1’ = none o ‘5’ = a lo )
and he possibili y o ge ing p ac ical help om neigh-
bo s ( esponse: ‘1’ = e y di icul o ‘5’ = e y easy). A
highe o al sco e indica es be e social suppo [45].
The psychome ic p ope ies o he a o emen ioned
measu es ha e been s a ed in ou p e ious publica ions
[18, 30, 40, 41], wi h accep able in e nal consis encies
ac oss s udy egions (C onbach’s alphas = 0.76 o 0.85)
and sa is ac o y cons uc alidi y ( s = 0.68 o 0.82) o
hei co esponding alida ion measu es [18, 30, 40, 41].
De ails o he measu es appea in Supplemen a y Table1.
Sociodemog aphic a iables
The ollowing sociodemog aphic a iables we e assessed
a wa e 1, including sex (male/ emale), age in yea s
(18–30/ 31–59/ ≥ 60), educa ional le el (highe school o
below/ college o uni e si y/ pos g adua e o abo e/ o h-
e s), ma i al s a us (single/ in a ela ionship o engaged/
ma ied/ o he s), ha ing child en (yes/no), employmen
s a us (wo king as ull- ime/ pa - ime/ unemployed/
pa en al lea e/ e i ed), wo king as a heal hca e p o es-
sional (yes/no), as well as he pe sonal, pa ne and he
signi ican o he s’ his o y o COVID-19 in ec ion (yes/
unsu e/ no). Geog aphical egion was also included, ol-
lowing he ecommended classi ica ions gi en by he
Popula ion Di ision o he Depa men o Economic and
Social A ai s o he Uni ed Na ion (Eas Asia/ Wes Asia/
No h and Sou h Ame ica/ No he n Eu ope/ Wes e n
Eu ope/ Sou he n Eu ope/ Eas e n Eu ope o o he s)
[46]. De ails o he coun ies in ol ed in hese egions
appea in Supplemen a y Table2.
S a is ical analysis
To assess changes o adhe ence o COVID-19 con ain-
men measu es in he wo wa es o su eys, he pa ici-
pan s we e classi ied in o ou ypes o adhe ence g oups,
including (1) he ‘non-adhe ence g oup’, which e e ed
o hose who sco ed less han se en on all h ee ques-
ion i ems assessing adhe ence o COVID-19 con ain-
men measu es in bo h wa es o su eys; (2) he ‘less
adhe ence g oup’, which e e ed o hose who showed a
educed numbe o ques ion i ems wi h sco es equal o
o la ge han se en in wa e 2 when compa ed o wa e
1; (3) he ‘sus ained adhe ence g oup’, e e ing o hose
epo ed sco es g ea e han se en on all h ee ques ion
i em in bo h wa es o su eys; and (4) he ‘g ea e adhe -
ence g oup’, e e ing o hose who had an inc ease num-
be o ques ion i ems wi h sco es equal o o g ea e han
se en in wa e 2 when compa ed o wa e 1. Subsequen ly,
desc ip i e da a on sociodemog aphic cha ac e is ics o
he pa icipan s and ou come measu es we e compu ed
and summa ized. Uni a ia e analyses, such as one-way
analysis o a iance (ANOVA) and chi-squa e es , we e
conduc ed o examine whe he he means o dis ibu-
ions o p opo ions o explana o y a iables di e ed sig-
ni ican ly ac oss he ou adhe ence g oups. Mul inomial
logis ic eg ession was conduc ed o examine whe he
hose plausible ac o s, including p osociali y, sel -e i-
cacy, pe cei ed suscep ibili y and se e i y o COVID-19
and pe cei ed social suppo , we e associa ed wi h he
change in adhe ence o COVID-19 con ainmen meas-
u es. This analysis was adjus ed o co a ia es ( egion,
sex, age and his o y o COVID-19 in ec ion) ha showed
signi ican di e ences in he dis ibu ions o p opo ions
o hei co esponding a ibu es ac oss he ou adhe -
ence g oups. Resul s o eg ession analyses we e epo ed
as odds a io (OR) wi h 95% con idence in e al (CI).
All s a is ical es s conduc ed in IBM SPSS 26.0 (IBM
Co p, A monk: NY, USA) we e conside ed signi ican a
P- alue < 0.05, wo-sided.
Resul s
Sample cha ac e is ics
Among he 9565 pa icipan s who comple ed wa e 1
o he su ey, 8948 pa icipan s (93.5%) ag eed o be
econ ac ed. O hese, 2189 (24.4%) we e success ully
e-con ac ed o p o ide he ollow-up da a. The pa ici-
pan s (82% emale, 57.2% aged 31–59yea s) we e om
Eas Asia (217 [9.7%]), Wes Asia (246 [11.2%]), No h
and Sou h Ame ica (131 [6.0%]), No he n Eu ope
(600 [27.4%]), Wes e n Eu ope (322 [14.7%]), Sou he n
Eu ope (433 [19.8%]), Eas e n Eu ope (148 [6.8%]) and
o he egions (96 [4.4%]). The pa icipan s mainly had a
pos g adua e deg ee (1058 [48.3%]), we e ma ied (821
[37.5%]), had child en (902 [58.8%]), wo ked ull- ime
(1235 [56.4%] and less han one- i h (374 [17.4]) we e
heal h ca e p o essionals. Almos hal o he pa icipan s
(1206 [55.1%]) sus ained adhe ence in bo h wa es o su -
eys. We conduc ed wa e 1 o he su ey in Ap il 2020
and he e o e less han one- en h o esponden s (28

Page 5 o 11
Chonge al. Globaliza ion and Heal h (2023) 19:25
[1.3%]), hei pa ne s (24 [1.1%]) and signi ican o he s
(136 [6.2%]) we e in ec ed wi h COVID-19. Compa ed o
he o he h ee adhe ence g oups, he sus ained adhe -
ence g oup (1206 [55.1%]) epo ed he highes sco es in
he sel -e icacy o ollowing he COVID-19 con ainmen
measu es (M = 26.21), pe cei ed suscep ibili y (M = 9.14)
and pe cei ed se e i y o COVID-19 (M = 13.21), as well
as p osociali y (M = 22.87), espec i ely (see Table1).
P edic o s o changing pa e ns o adhe ence oCOVID‑19
con ainmen measu es
The mul inomial logis ic eg ession model was s a is i-
cally signi ican (χ2 (51) = 379.41, P < .001), wi h a o al
a iance o 28.1% explained (Nagelke ke R2) and co -
ec ly classi ying 69.5% o cases. Two sociodemog aphic
co a ia es, which we e sex and his o y o COVID-19
in ec ion, we e p edic i e o adhe ence. Taking he ‘sus-
ained adhe ence g oup’ as a e e ence g oup, male
(adjus ed odds a io [aOR], 2.34; 95% CI 1.64 o 3.35;
P < .001), hose who we e in ec ed wi h COVID-19 o
had COVID-19 symp oms a wa e 1 we e mo e likely
o become non-adhe ence a wa e 2 (aOR, 2.37, 95%
CI 1.55 o 3.63; P < .001). Sel -e icacy (aOR = 0.74,
95% CI 0.71 o 0.77; P < .001), pe cei ed suscep ibili y
(aOR = 0.93, 95% CI 0.88 o 0.99; P = 0.02), pe cei ed
se e i y (aOR = 0.90, 95% CI 0.85 o 0.94; P < .001), and
p osociali y (aOR = 0.85, 95% CI 0.81 o 0.89; P = .008)
measu ed a wa e 1 we e signi ican ac o s in lowe ing
he isk o becoming non-adhe ence a wa e 2. Simila ly,
sel -e icacy (aOR = 0.93, 95% CI 0.91 o 0.96; P < .001),
pe cei ed suscep ibili y (aOR = 0.96, 95% CI 0.93 o 1.00;
P = .04), pe cei ed se e i y (aOR = 0.96, 95% CI 0.93 o
0.99; P = .02), and p osociali y (aOR = 0.77, 95% CI 0.75
o 0.79; P = .04) measu ed a wa e 1 we e signi ican ac-
o s in lowe ing he isk o becoming less adhe ence a
wa e 2. No ably, a aining be e sel -e icacy a wa e 1
educed he likelihood o being non-adhe ence a wa e 2
by 26% (aOR = 0.74), while being mo e p osocial a wa e
1 educed he likelihood o becoming less adhe ence a
wa e 2 by 23% (aOR = 0.77, see Table2).
Discussion
The cu en s udy in es iga ed he changes o adhe -
ence in COVID-19 con ainmen measu es in a la ge
con enience sample o adul s om eigh geog aphical
egions be ween Ap il and Sep embe 2020 in which
he ea ly s age o COVID-19 pandemic occu ed. Hal
o he esponden s ully adhe ed o he sugges ed s a -
egies, such as physical dis ancing, sel -isola ion, and
hand hygiene, a six mon hs ollow-up a e he baseline.
Ac oss all he g oups in acco dance wi h he pa e ns
o adhe ence beha io s, he odds o no adhe ing o all
s a egies inc eased a leas wice i he pa icipan s we e
male and in ec ed wi h COVID-19. Indeed, he di e -
ences in sex and COVID-19 s a us a ec ing adhe ence o
COVID-19 con ainmen measu es ha e been discussed
in he li e a u e [47–50], in which lowe le els o pe -
cei ed h ea s o illness and adhe ence among males a e
conside ed as impo an ac o s explaining he inc eased
a es o COVID-19 ela ed mo bidi y and mo ali y com-
pa ed o women [47–50]. Ou indings a e also consis -
en wi h he exis ing body o knowledge suppo ing ha
a ious sociodemog aphic ac o s, such as olde age [50],
ca egi e s o elde ly o child en and wo king as pa - ime
o e i ed, could a ec adhe ence [5, 51].
Sel -e icacy, pe cei ed suscep ibili y and se e i y o
COVID-19 we e ound o be he signi ican ac o s in
lowe ing he isks o becoming non-adhe ence and less
adhe ence o COVID-19 con ainmen measu es a ol-
low-up. In e es ingly, we ound ha sel -e icacy a ained
a la ge educ ion in he isk o being non-adhe en
han ha o pe cei ed suscep ibili y and se e i y, sug-
ges ing ha an indi idual’s belie ha one can ca y
ou and adhe e o COVID-19 con ainmen measu es is
mo e impo an han one’s belie s abou he se e i y o
COVID-19 o he isk o ge ing in ec ed [52]. Indeed,
he Heal h Ac ion P ocess App oach also indica es ha
sel -e icacy is he p oximal de e minan o de eloping
an in en ion o change beha io , while isk pe cep ion is
conside ed a dis al de e minan [12].
Ou adjus ed analysis showed ha p osociali y con ib-
u ed signi ican educ ions in he isks o becoming non-
adhe ence and less adhe ence o COVID-19 con ainmen
measu es a ollow-up (i.e., 15% and 23%, espec i ely).
COVID-19 con ainmen measu es (e.g., accina ions
and social dis ancing) ha e been ecen ly discussed as
global public good whe e people can ’ ee- ide’ on o he s:
ecei ing social bene i s om o he s (e.g., educed isk
o in ec ion as o he s ollow he ules) wi hou paying
o he cos s (e.g., con inue dining ou ) [53]. Hence, p o-
mo ing adhe ence o COVID-19 con ainmen measu es
has been ecen ly amed as a p osocial ac . The ex an
li e a u e has iden i ied a numbe o con ibu o s ha
shape he p osocial mo i a ions in he ace o collec i e
ac ion p oblems (e.g., public heal h c ises like COVID-
19), including pe sonali y ai s, indi idual alues, co e
poli ical alues, empa hy and sympa hy owa d indi idu-
als ulne able o he p oblem [22, 54]. Ou indings u -
he ex end he unde s anding o p osociali y, in which
i s p o ec i e ole on non-adhe ence s ill emains and
e en exe s a s onge , longi udinal e ec when simul a-
neously compa ed o ha o sel -e icacy in spi e o he
he e ogenei y o he pa icipan s’ cha ac e is ics ac oss
s udy egions.
We ound ha pe cei ed social suppo did no a ec
he pa e ns o adhe ence o he COVID-19 con ainmen
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Chonge al. Globaliza ion and Heal h (2023) 19:25
Table 1 Cha ac e is ics o he pa icipan s by le el o adhe ence o COVID‑19 con ainmen measu es
Cha ac e is ics All
(N = 2189) Non‑adhe ence g oup
(n = 219) Less adhe ence g oup
(n = 674) Sus ained
adhe ence
g oup
(n = 1206)
G ea e
adhe ence
g oup
(n = 90)
χ2 o F(d )/ P alue
Regiona, No. (%)
Eas Asia 213 (9.7) 21 (9.6) 27 (4.0) 148 (12.3) 17 (18.9) 145 (21) < .001
Wes Asia 246 (11.2) 32 (14.6) 81 (12.0) 128 (10.6) 5 (5.6)
No h and Sou h Ame ica 131 (6.0) 7 (3.2) 20 (3.0) 93 (7.7) 11 (12.2)
No he n Eu ope 600 (27.4) 44 (20.1) 179 (26.6) 356 (29.5) 21 (23.3)
Wes e n Eu ope 322 (14.7) 47 (21.5) 135 (20.0) 123 (10.2) 17 (18.9)
Sou he n Eu ope 433 (19.8) 36 (16.4) 131 (19.4) 253 (21.0) 13 (14.4)
Eas e n Eu ope 148 (6.8) 22 (10.0) 69 (10.2) 56 (4.6) 1 (1.1)
O he s 96 (4.4) 10 (4.6) 32 (4.7) 49 (4.1) 5 (5.6)
Sex, No. (%)
Male 394 (18.0) 70 (32.0) 108 (16.0) 191 (15.8) 25 (27.8) 40.37 (3) < .001
Female 1795 (82.0) 149 (68.0) 566 (84.0) 1015 (84.2) 65 (72.2)
Age in yea s, No. (%)
Young adul s (18–30 yea s) 782 (35.7) 99 (45.2) 243 (36.1) 407 (33.7) 33 (36.7) 17.02 (6) .009
Middle‑aged (31–59 yea s) 1253 (57.2) 111 (50.7) 394 (58.5) 699 (58.0) 49 (54.4)
Olde adul s (≥ 60 yea s) 154 (7.0) 9 (4.1) 37 (5.5) 100 (8.3) 8 (8.9)
Educa ional le el, No. (%)
Highe school o below 212 (9.7) 30 (13.7) 68 (10.1) 107 (8.9) 7 (7.8) 10.77 (9) .29
College o uni e si y 884 (40.4) 92 (42.0) 262 (38.9) 495 (41.9) 35 (38.9)
Pos g adua e o abo e 1058 (48.3) 91 (41.6) 332 (49.3) 588 (48.8) 47 (52.2)
O he s 35 (1.6) 6 (2.7) 12 (1.8) 16 (1.3) 1 (1.1)
Ma i al s a us, No. (%)
Single 657 (30.0) 83 (37.9) 192 (28.5) 354 (29.4) 28 (31.1) 10.44 (9) .32
In a ela ionship/ engaged 556 (25.4) 57 (26.0) 169 (25.1) 307 (25.5) 23 (25.6)
Ma ied 821 (37.5) 67 (30.6) 259 (38.4) 463 (38.4) 32 (35.6)
O he s (di o ced/wid‑
owed/sepa a ed) 155 (7.1) 12 (5.5) 54 (8.0) 82 (6.8) 7 (7.8)
Ha ing child en, No. (%)
Yes 902 (41.2) 74 (33.8) 274 (40.7) 516 (42.8) 38 (42.2) 6.34 (3) .10
No 1287 (58.8) 145 (66.2) 400 (59.3) 690 (57.2) 52 (57.8)
Employmen s a us, No. (%)
Full‑ ime 1235 (56.4) 127 (58.0) 374 (55.5) 683 (56.6) 51 (56.6) 16.99 (12) .15
Pa ‑ ime 363 (16.6) 29 (13.2) 123 (18.2) 196 (16.3) 15 (16.7)
Unemployed 442 (20.2) 50 (22.8) 133 (19.7) 237 (19.7) 22 (24.4)
Pa en al lea e 50 (2.3) 9 (4.1) 16 (2.4) 25 (2.1) 0 (0.0)
Re i ed 99 (4.5) 4 (1.8) 28 (4.2) 65 (5.4) 2 (2.2)
Wo king as heal h ca e p o essionalsb, No. (%)
Yes 374 (17.4) 39 (17.9) 125 (18.9) 193 (16.3) 17 (19.1) 2.25 (3) .52
No 1780 (82.6) 179 (82.1) 537 (81.1) 992 (83.7) 72 (80.9)
Ha e you been in ec ed by COVID‑19?, No. (%)
Yes 28 (1.3) 7 (3.2) 9 (1.3) 11 (0.9) 1 (1.1) 32.29 (6) < .001
I am no su e bu I ha e
symp oms 234 (10.7) 40 (18.3) 85 (12.6) 99 (8.2) 10 (11.1)
No 1927 (88.0) 172 (78.5) 580 (86.1) 1096 (90.9) 79 (87.8)
Ha e you pa ne been
in ec ed by COVID‑19?, No.
(%)
9.53 (6) .15
Yes 24 (1.1) 4 (1.9) 6 (0.9) 13 (1.1) 1 (1.1)
Page 7 o 11
Chonge al. Globaliza ion and Heal h (2023) 19:25
measu es. This inding is con as wi h hose o ecen
s udies indica ing ha indi iduals who pe cei e mo e
social suppo om hei iends can in luence hei
heal h beha io s ei he posi i ely o nega i ely, due o
social no ms o pee p essu e [55, 56]. O no e, as a esul
o social dis ancing measu es (e.g., lockdowns, wo k-
om-home a angemen s) implemen ed du ing he su -
ey pe iod, i was mo e di icul o indi iduals o in e ac
socially and/o ga he , which explained he ela i ely low
pe cei ed le el o social suppo .
S udy s eng hs andlimi a ions
Ou indings we e based on an in e na ional, geog aphi-
cally di e se sample and he iming o da a collec ion was
wi hin one mon h a e he Wo ld Heal h O ganiza ion
decla ed COVID-19 as a pandemic. In addi ion, we clas-
si ied he pa icipan s in o subg oups in acco dance wi h
hei di e en pa e ns o adhe ence. The unde s anding
o he p edic o s and co a ia es in each subg oup p o-
ides u u e di ec ions o ailo ing public heal h p o-
g ams o messages in p omo ing adhe ence o COVID-19
con ainmen measu es.
I is impo an o conside he limi a ions o ou s udy
when in e p e ing he esul s. Ou s udy was conduc ed
in wo phases, and he assump ion o linea i y o asso-
cia ions be ween a iables limi s he scope o a mo e
ad anced longi udinal analysis, which conside s ime
e ec as an addi ional co a ia e. In o de o be e exam-
ine he e ec o changes in heal h- ela ed pe cep ion a -
iables on adhe ence beha io s o e ime, u u e esea ch
could employ la en g ow h cu e modelling analysis o
e alua e he ajec o y o change in bo h independen
and dependen a iables. This analy ical app oach allows
o he modeling o wi hin-pe son and be ween-pe son
a iabili y in he da a, hus p o iding a mo e comp ehen-
si e unde s anding o he ela ionship be ween he a i-
ables o e ime [57, 58]. While he ins umen s used in
ou s udy we e ound o ha e sa is ac o y psychome ic
p ope ies in e ms o alidi y and eliabili y, we did no
conduc a mul iple-g oup ac o analysis alignmen o
u he examine he measu emen equi alence o in a i-
ance o hese ins umen s ac oss di e en cul u al o
linguis ic g oups [59]. Implemen ing his me hod could
ha e s eng hened he c oss-cul u al alidi y o ou
s udy and ensu ed ha ou indings could be applied o a
b oade popula ion.
Ou assessmen o adhe ence o COVID-19 con ain-
men measu es dese es a en ion. The i s wa e o ou
su ey was conduc ed in Ap il 2020, du ing he ea ly
s age o he pandemic when he e was a lack o con-
sensus among global poli ical and public heal h leade s
on he necessi y o wea ing masks in communi y se -
ings [60, 61]. Misin o ma ion ega ding he u ili y o
masks, po en ial ad e se e ec s, and se e e sho ages
Table 1 (con inued)
Cha ac e is ics All
(N = 2189) Non‑adhe ence g oup
(n = 219) Less adhe ence g oup
(n = 674) Sus ained
adhe ence
g oup
(n = 1206)
G ea e
adhe ence
g oup
(n = 90)
χ2 o F(d )/ P alue
I am no su e bu I ha e
symp oms 149 (6.9) 21 (9.7) 55 (8.2) 70 (5.9) 3 (3.4)
No 1990 (92.0) 191 (88.4) 608 (90.9) 1107 (93.0) 84 (95.5)
Has you signi ican o he s being in ec ed
by COVID‑19, No. (%) 6.46 (6) .37
Yes 136 (6.2) 12 (5.5) 46 (6.8) 70 (5.8) 8 (8.9)
I am no su e bu I ha e
symp oms 196 (9.0) 24 (11.0) 69 (10.2) 95 (7.9) 8 (8.9)
No 1857 (84.8) 183 (83.6) 559 (82.9) 1041 (86.3) 74 (82.2)
Sel ‑e icacy, mean (SD) 25.69 (3.69) 23.67 (4.89) 25.56 (3.64) 26.21 (3.26) 24.58 (4.11) 34.50 (3) < .001
Pe cei ed suscep ibili y,
mean (SD) 8.75 (3.45) 7.83 (3.57) 8.40 (3.36) 9.14 (3.43) 8.50 (3.39) 13.03 (3) < .001
Pe cei ed se e i y, mean
(SD) 12.63 (3.71) 10.98 (3.97) 12.07 (3.66) 13.21 (3.56) 13.07 (3.51) 30.97 (3) < .001
P osociali y, mean (SD) 22.66 (4.08) 21.87 (4.27) 22.66 (3.99) 22.87 (4.07) 22.00 (4.14) 4.63 (3) .004
Pe cei ed social suppo ,
mean (SD) 9.81 (2.12) 9.50 (2.19) 9.99 (2.08) 9.79 (2.11) 9.53 (2.33) 3.83 (3) .012
a In his s udy, Eas Asia included Hong Kong; Wes Asia included Cyp us and Tu key; No he n and Sou he n Ame ica included Colombia and he Uni ed S a es;
No he n Eu ope included The Uni ed Kingdom, Finland, I eland and La ia; Wes e n Eu ope included Swi ze land, Ge many, Aus ia and F ance; Sou he n Eu ope
included G eece, Spain, I aly, Po ugal and Mon eneg o; Eas e n Eu ope included Poland, Romania and Hunga y
b 1.6% missing da a
Page 8 o 11
Chonge al. Globaliza ion and Heal h (2023) 19:25
o medical esou ces, including medical masks, u he
complica ed he si ua ion [60, 61]. As a esul , uni e sal
adop ion o mask wea ing was no achie ed [62], and
we did no collec da a on pa icipan s’ adhe ence o
his measu e o e ime. Fo u u e s udies in es iga -
ing adhe ence pa e ns o a ious con ainmen meas-
u es du ing ou b eaks o in ec ious diseases, assessing
adhe ence o p ope ace mask wea ing is highly ec-
ommended o gain a mo e comp ehensi e unde s and-
ing o adhe ence beha io s. As he assessmen s we e
based on sel - epo s, which we e ega ded as he bes
cap u e o how people ea ly esponded o he apid-
changing na u e o COVID-19. Ne e heless, objec-
i e measu emen o adhe ence o heal h beha io s a e
o en p e e able and less suscep ible o esponse biases.
The use o acking echnologies such as mobile apps,
wea able de ices, o loca ion acking ools may also
po en ially p o ide a mo e accu a e unde s anding o
eal- ime adhe ence beha io s [63].
I is no ewo hy ha he eg ession analysis included
key sociodemog aphic and heal h- ela ed pe cep ion
a iables based on Bandu a’s sel -e icacy heo y, he
Social Cogni i e Theo y, and he Heal h Belie Model,
which achie ed a co ec classi ica ion a e o up o
69.5%. Howe e , o he con ex ual o social de e minan s
o adhe ence o con ainmen measu es could be consid-
e ed in u u e esea ch, such as place o li ing, housing
quali y, poli ical pola iza ion and inclina ions, us in
go e nmen and scien i ic e idence, suscep ibili y o mis-
in o ma ion, as well as heal h o e-heal h li e acy le els
[64, 65]. Addi ionally, egional di e ences in adhe ence
o COVID-19 con ainmen measu es may be a ib-
u ed o a a ie y o ac o s, cul u al dispa i ies, access
o heal hca e and in o ma ion, socioeconomic s a us,
Table 2 Resul s o he mul inomial logis ic eg ession in es iga ing p edic o s o changing pa e ns o adhe ence o COVID‑19
con ainmen measu es
a In his s udy, Eas Asia included Hong Kong; Wes Asia included Cyp us and Tu key; No he n and Sou he n Ame ica included Colombia and he Uni ed S a es;
No he n Eu ope included The Uni ed Kingdom, Finland, I eland and La ia; Wes e n Eu ope included Swi ze land, Ge many, Aus ia and F ance; Sou he n Eu ope
included G eece, Spain, I aly, Po ugal and Mon eneg o; Eas e n Eu ope included Poland, Romania and Hunga y
Re e ence ca ego y o he dependen a iable is he sus ained adhe ence g oup (N = 1206)
Non‑adhe ence g oup
(N = 219) Less adhe ence g oup
(N = 674) G ea e adhe ence g oup
(N = 90)
aOR 95% CI P alue aOR 95% CI P alue aOR 95% CI P alue
Regiona
Eas Asia 1.05 0.42–2.63 .91 0.32 0.17–0.60 < .001 1.18 0.39–3.52 .77
Wes Asia 1.96 0.82–4.73 .13 1.11 0.65–1.92 .70 0.53 0.14–1.08 .34
No h and Sou h Ame ica 0.58 0.19–1.76 .34 0.39 0.20–0.76 .005 1.39 0.45–4.35 .58
No he n Eu ope 0.84 0.37–1.93 .69 0.81 0.50–1.33 .41 0.64 0.22–1.81 .40
Wes e n Eu ope 2.34 1.01–5.42 .05 1.66 0.99–2.78 .06 1.47 0.50–4.30 .48
Sou he n Eu ope 1.38 0.59–3.21 .46 0.92 0.56–1.53 .75 0.62 0.21–1.85 .39
Eas e n Eu ope 2.44 0.97–6.16 .06 1.98 1.11–3.54 .02 0.21 0.02–1.92 .17
O he s [Re e ence] [Re e ence] [Re e ence]
Sex
Male 2.34 1.64–3.35 < .001 1.02 0.77–1.34 .92 1.84 0.98–3.08 .05
Female [Re e ence] [Re e ence] [Re e ence]
Age in yea s
Young adul s (18–30 yea s) 1.44 0.67–3.13 .35 1.30 0.83–2.01 .25 .746 0.31–1.78 .51
Middle‑aged (31–59 yea s) 1.02 0.48–2.17 .96 1.21 0.80–1.84 .36 .745 0.33–1.69 .48
Olde adul s (≥ 60 yea s) [Re e ence] [Re e ence] [Re e ence]
In ec ed by COVID‑19
Yes/ ha e symp oms 2.37 1.55–3.63 < .001 1.35 0.99–1.84 .06 1.31 0.66–2.60 .44
No symp oms [Re e ence] [Re e ence] [Re e ence]
Mo i a ing ac o s
Sel ‑e icacy 0.74 0.71–0.77 < .001 0.93 0.91–0.96 < .001 0.88 0.84–1.05 .05
Pe cei ed suscep ibili y 0.93 0.88–0.99 .02 0.96 0.93–1.00 .04 0.94 0.87–1.01 .10
Pe cei ed se e i y 0.90 0.85–0.94 < .001 0.96 0.93–0.99 .02 1.00 0.92–1.07 .90
P osociali y 0.85 0.81–0.89 .008 0.77 0.75–0.79 .04 0.97 0.92–1.03 .31
Pe cei ed social suppo 1.00 0.93–1.09 .95 1.028 0.98–1.08 .32 1.01 0.90–1.14 .82