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Abstract

Objective:

This systematic review aimed to assess the global application of behavioral change theory and models on COVID-19 preventive behaviors.

Methods:

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses procedure. Databases such as PubMed/MIDLINE, Web of Science, Scopus, EMB ASE, World Health Organization libraries, and Google Scholar were used to search all published articles in the area of application of behavioral change theory and model on COVID-19 preventive behavior until October 1, 2022. Studies published in another language other than English were excluded. Two independent reviewers did the article selection and quality check. A third reviewer asked if any disagreement were found.

Result:

Seventeen thousand four hundred thirty-six total articles were retrieved from all sources after the removal of duplicated articles and those not evaluating the outcome of interest were excluded. Finally, 82 articles done using behavioral change theory and model on COVID-19 preventive behaviors were included. The health belief model (HBM) and theory of planned behavior (TPB) were most commonly used in COVID-19 preventive behaviors. The constructs of most behavioral theories and models were significantly associated with COVID-19 preventive behaviors such as hand washing, face mask use, vaccine uptake, social isolation, self-quarantine, social distance, and use of sanitizers.

Conclusion:

This systematic review summarizes comprehensive evidence on the application of behavioral change theory and model on COVID-19 preventive behaviors globally. A total of seven behavioral change theories and models were included. The HBM and TPBs were most commonly used for COVID-19 preventive behaviors. Therefore, the application of behavioral change theory and models is recommended for developing behavioral change interventional strategies.

Keywords

Theory model COVID-19 preventive behavior systematic review\

Introduction

A cluster of pneumonia cases in Wuhan, China, near the end of 2019 was caused to a severe acute respiratory syndrome coronavirus 2, which then spread like wildfire.¹ The amount and length of exposure, the implementation of preventative measures, and individual characteristics all affect the risk of COVID-19 transfer from one person to another.² COVID-19 is transmitting through respiratory droplets, close contact with infected individuals, secretions, saliva, and respiratory droplets produced when an infected person talks, sneezes, or coughs. A reverse transcription polymerase chain reaction test is used to detect the virus.³

Behavioral change theories and models are a set of interrelated concepts, definitions, and prepositions that describe, explain, predict, or control behaviors.⁴ They are used to understand why people do or do not practice health-promoting behaviors; identify what information is needed to design an effective intervention strategy; and help to set priorities for health education and promotion interventions.⁵ The health belief model (HBM), theory of reasoned action (TRA), theory of planned behaviors (TPBs), trans theoretical model (TTM), extended parallel process model (EPPM), socio-ecological model (SEM), social cognitive theory (SCT), and diffusion of innovation theory are the most commonly used in behavioral change interventional strategies. The HBM is used to understand the failure of people to adopt disease prevention strategies or screening tests for the early detection of disease. It has six constructs (perceived susceptibility, perceived severity, perceived barrier, perceived benefit, self-efficacy, and cues to action).⁶ TPB and TRA state that behavioral achievement depends on behavioral intention. TRA constructs (attitude and subjective norm) were predictors of COVID-19 preventive behaviors such as hand washing, mask wearing, and COVID-19 vaccination.⁷ The TTM focuses on the decision-making of the individual with intentional change, with five stages (pre-contemplation, contemplation, preparation, action, and maintenance).⁵

The EPPM suggests that if people do not believe there is a consequence of failing to use certain behaviors, they will not be motivated to use them.⁵ SEM is an all-encompassing framework that describes how an individual’s behaviors are influenced by intrapersonal, interpersonal, organizational, community, and public policy factors. SCT states that learning occurs in a social context with a dynamic and reciprocal interaction of the person, environment, and behavior.⁸

Different COVID-19 preventive behaviors are advised by the World Health Organization (WHO), such as receiving the recommended doses of the COVID-19 vaccine, maintaining a safe distance from others, donning a mask, washing one’s hands, covering one’s mouth when coughing or sneezing, and remaining at home.⁹ The HBM structure is recognized as an important predictor of influenza vaccination exposure, and its structure differs depending on the national context and epidemiological conditions.¹⁰ The study demonstrated that behavioral change models, such as the HBM and TPB, might be used to determine the factors that influence vaccine uptake.^11,12

The studies showed that there are global variations in vaccine acceptance among different populations. The vaccine-acceptance rates were the highest among adults in Ecuador (97%), Malaysia (94.3%), and Indonesia (93.3%) and the lowest among adults in Lebanon (21.0%).¹³ Overall, COVID-19 vaccination intention globally ranged from 27.7% to 93.3% and sociodemographic differences, perceptions of risk and susceptibility to COVID-19, and vaccine attributes influenced vaccination intention.¹⁴ The studies showed that adequate knowledge, attitudes, and risk perception, source of information, self-efficacy, trust in health authorities, people’s beliefs were determinants of adherence to COVID-19 preventive measures, and population behavior changes depend on the population’s knowledge about the disease and individuals’ ability to perceive risks associated with the virus and to adapt their behavior accordingly.^15–18

The study using TPB showed that more attitudes that are positive, greater social norms increased perceived control, and higher intentions were related to higher adherence to hand washing.¹⁹ Participants’ subjective norms and perceived behavioral control were the factors associated with their intention and good knowledge and a positive attitude was found to be significant factors associated with the participants’ preventive practice.^20,21

The study revealed that adherence to COVID-19 precautionary measures was wearing a face mask (96.4%), and social distancing (42.3%) and their adherence to those measures were found to be significantly associated with HBM constructs.²² Individual level higher scores of COVID-19 fear, knowledge, age, and personal attitudes, at the interpersonal level COVID-19 information sharing, cultural norms and household income, and better evaluation of the national government policies about COVID-19 at the policy level were positively associated with COVID-19 preventive behaviors.^23–26 Therefore, the purpose of this systematic review was to assess the applicability of behavioral change theory and models on COVID-19 preventive behavior globally.

Research question

What is the application of behavioral change theory and model on COVID-19 preventive behavior?

How do behavioral change theory and model predict COVID-19 preventive behaviors?

Methods

Search strategy

We have used online databases such as PubMed/MIDLINE, EMB ASE, Web of Science, Google Scholar, WHO libraries, and African Journals used to retrieve articles that were done on the applicability of behavioral change theory and model on COVID-19 preventive behavior. The search term was developed by using the following key terms: HBM, TRA, TPB, EPPM, SCT, SEM, TTM, COVID-19 preventive behavior or preventive measure (Vaccine acceptance, intention to the vaccine, hand washing, social distance, face mask wear, use of sanitizer, avoid public transport, social isolation, and avoid party meeting) and Boolean operators “AND” and “OR” were used for this purpose.

Inclusion and exclusion

This systematic review includes all publications which fulfil the following parameters: publications studying COVID-19 preventive behaviors using behavioral change theory and models like HBM, TRA, EPPM, TPB, SCT, TTM, AND SEM were included, whereas publications in a language other than English, short reports, letters to editors, and discussions were excluded in the present systematic review.

Eligibility criteria

Included articles in this systematic review were all articles published in English, articles published until October 1, 2022, all cross-sectional studies included, and we excluded articles based on the following criteria: articles with poor quality, study protocols, systematic reviews, unpublished articles, and letters to editors.

Data extraction

Articles extracted from databases were exported to Endnote version 9 software, after removing the duplicates, all articles were exported to a Microsoft Excel spread sheet. TFA and ETF were done for data extraction. Studies were retrieved by using search terms from all databases and additional sources screened for inclusion criteria. Then, articles that fulfilled the inclusion criteria were undertaken full-text review for admissibility and extraction. Preferred Reporting Item for Systematic Review and Meta-analysis flowchart used throughout all steps.

Quality assessment

Two reviewer writers independently evaluated the quality of the studies included in this systematic review, and a third reviewer settled disagreements. The Newcastle–Ottawa Scale (NOS) criteria were used for quality assessment to include this systematic review. For observational investigations, this tool provides 10 points in each of the three modified NOS component domains.²⁷ Studies that received five or more points were included (Table 1).

Table 1.

Modified Newcastle–Ottawa Scale regarding star allocation to assess the quality of cross-sectional studies for (out of a total of seven stars) included in the systematic review of application of behavioral change theory and model on COVID-19 preventive behaviors globally, 2022.

Studies assessed	Quality assessment item
	A sample representative of the target population	Clear objective (study aim stated	Response rate specified and non-response bias minimal	Inclusion and exclusion criteria stated	Acceptable case definition used in the study	Reliability and validity of measures justified	Appropriate statistical analysis use	Total
Seangpraw et al.²⁹	Y	Y	Y	Y	N	Y	Y	6
Caple et al.³⁰	Y	Y	N	Y	Y	N	Y	5
Yu et al.³¹	Y	Y	Y	Y	Y	N	Y	6
Le et al.³²	Y	Y	Y	Y	N	Y	Y	6
Okmi et al.³³	Y	Y	N	Y	N	Y	Y	5
Berni et al.³⁴	Y	Y	Y	Y	Y	N	Y	7
Tao et al.³⁵	Y	Y	N	Y	Y	Y	Y	6
Wong et al.³⁶	Y	Y	N	Y	Y	Y	Y	6
Al-Metwali et al.³⁷	Y	Y	N	Y	Y	N	Y	5
Lee et al.³⁸	Y	Y	Y	Y	Y	Y	Y	7
Youssef et al.³⁹	Y	Y	Y	Y	Y	Y	Y	7
Wong et al.⁴⁰	Y	Y	Y	Y	Y	Y	Y	7
Cai et al.⁴¹	Y	Y	N	Y	Y	Y	Y	6
Li et al.⁴²	Y	Y	N	Y	Y	Y	Y	6
Tong et al.⁴³	Y	Y	N	Y	Y	Y	Y	6
Tam et al.⁴⁴	Y	Y	N	Y	Y	Y	Y	6
Kim et al.⁴⁵	Y	Y	Y	Y	N	Y	Y	6
Shitu et al.⁴⁶	Y	Y	Y	Y	Y	Y	Y	7
Shewasinad Yehualashet et al.⁴⁷	Y	Y	N	Y	Y	Y	Y	6
Tadesse et al.⁴⁸	Y	Y	N	Y	Y	Y	Y	6
Tajeri Moghadam et al.⁴⁹	Y	Y	Y	Y	N	Y	Y	6
Kamran et al.⁵⁰	Y	Y	N	Y	N	Y	Y	5
Fathian-Dastgerdi et al.⁵¹	Y	Y	Y	Y	N	Y	Y	6
Delshad Noghabi et al.⁵²	Y	Y	Y	Y	N	Y	Y	6
Shahnazi et al.⁵³	Y	Y	N	Y	N	Y	Y	5
Mirzaei et al.⁵⁴	Y	Y	Y	Y	Y	Y	Y	7
Karimy et al.⁵⁵	Y	Y	Y	Y	Y	Y	Y	7
Baek et al.⁵⁶	Y	Y	Y	Y	Y	Y	Y	7
Arceo et al.⁵⁷	Y	Y	N	Y	Y	Y	y	6
Syed et al.⁵⁸	Y	Y	Y	Y	N	Y	Y	6
Alagili et al.⁵⁹	Y	Y	Y	Y	Y	Y	Y	7
Mortada et al.⁶⁰	Y	Y	Y	Y	Y	Y	Y	7
Mahindarathne⁶¹	Y	Y	Y	Y	N	Y	Y	6
Mehanna et al.⁶²	Y	Y	Y	Y	Y	Y	Y	7
Tsai et al.⁶³	Y	Y	Y	Y	N	Y	Y	6
Hansen et al.⁶⁴	Y	Y	N	Y	N	Y	Y	5
Alsulaiman et al.⁶⁵	Y	Y	Y	Y	Y	Y	Y	7
Guidry et al.⁶⁶	Y	Y	Y	Y	N	Y	Y	6
Wollast et al.⁶⁷	Y	Y	Y	N	Y	Y	Y	6
Yu et al.⁶⁸	Y	Y	Y	Y	Y	Y	Y	7
Berg et al.⁶⁹	Y	Y	Y	Y	Y	N	Y	6
Le An et al.⁷⁰	Y	Y	Y	Y	Y	Y	Y	7
Barile et al.⁷¹	Y	Y	N	Y	Y	N	Y	5
Tran et al.⁷²	Y	Y	Y	Y	Y	Y	Y	7
Frounfelker et al.⁷³	Y	Y	Y	Y	Y	Y	Y	7
Li et al.⁷⁴	Y	Y	Y	Y	Y	Y	Y	7
Mao et al.⁷⁵	Y	Y	Y	Y	Y	N	Y	6
Asmare et al.⁷⁶	Y	Y	Y	Y	Y	Y	Y	7
Prakash et al.⁷⁷	Y	Y	Y	Y	Y	N	Y	6
Servidio et al.⁷⁸	Y	Y	Y	Y	Y	Y	Y	7
Kim et al.⁷⁹	Y	Y	Y	Y	Y	Y	Y	7
Callow et al.⁸⁰	Y	Y	Y	Y	Y	Y	Y	7
Sin et al.⁸¹	Y	Y	N	Y	Y	Y	Y	6
Ullah et al.⁸²	Y	Y	N	Y	Y	Y	Y	6
Irfan et al.⁸³	Y	Y	Y	Y	Y	Y	Y	7
Li et al.⁸⁴	Y	Y	N	Y	Y	Y	Y	6
Prasetyo et al.⁸⁵	Y	Y	N	Y	Y	Y	Y	6
Issrani et al.⁸⁶	Y	Y	Y	Y	Y	Y	Y	7
Park et al.⁸⁷	Y	Y	Y	Y	Y	Y	Y	7
Sun et al.⁸⁸	Y	Y	Y	Y	Y	Y	Y	7
Seddig et al.⁸⁹	Y	Y	N	Y	Y	Y	Y	6
Aschwanden et al.⁹⁰	Y	Y	Y	Y	Y	Y	Y	7
Hayashi et al.⁹¹	Y	Y	Y	Y	Y	N	Y	6
Gibson et al.⁹²	Y	Y	N	Y	Y	Y	Y	6
Ahmad et al.⁹³	Y	Y	Y	Y	Y	N	Y	6
Constant et al.⁹⁴	Y	Y	Y	Y	Y	Y	Y	7
Shirahmadi et al.⁹⁵	Y	Y	N	Y	Y	Y	Y	6
Jahangiry et al.⁹⁶	Y	Y	N	Y	Y	Y	Y	6
Babafunke et al.⁹⁷	Y	Y	N	Y	Y	Y	Y	6
Yoon et al.⁹⁸	Y	Y	Y	Y	Y	Y	Y	7
Lin et al.⁹⁹	Y	Y	Y	Y	Y	Y	Y	7
Nazione et al.¹⁰⁰	Y	Y	Y	Y	Y	Y	Y	7
She et al.¹⁰¹	Y	Y	N	Y	Y	Y	Y	6
Hoti et al.¹⁰²	Y	Y	N	Y	Y	Y	Y	6
Shiloh et al.¹⁰³	Y	Y	Y	Y	Y	N	Y	6
Chen et al.¹⁰⁴	Y	Y	Y	Y	Y	Y	Y	7
Ali-Saleh et al.¹⁰⁵	Y	Y	N	Y	Y	Y	Y	6
Mat Dawi et al.¹⁰⁶	Y	Y	Y	N	Y	Y	Y	6
Akther et al.¹⁰⁷	Y	Y	N	Y	Y	Y	Y	6
Norman et al.¹⁰⁸	Y	Y	Y	Y	Y	Y	Y	7
Sumerlin et al.¹⁰⁹	Y	Y	Y	Y	Y	Y	Y	7
Dayton et al.¹¹⁰	Y	Y	Y	Y	Y	Y	Y	7

Data analysis

Descriptive statics were used to summarize the study findings. Due to the heterogeneity of study participants, we cannot conduct a meta-analysis.

Result

A total of 17,436 articles were retired from all sources after the removal of 8496 duplicated articles and 8940 articles were assessed by using titles/abstracts from these 8537 articles were excluded due to not evaluating the outcome of interest (COVID-19 preventive behavior) and did not apply behavioral change theory and model as a conceptual framework. Four hundred three articles underwent full-text review and finally, 82 articles were included in this review (Figure 1).

Figure 1.

Preferred Reporting Item for Systematic Review and Meta-analysis flowchart of the study selection process on applicability of behavioral change theory and model on COVID-19 preventive behavior globally, systematic review.

Characteristics of articles included in this review

This systematic review includes studies done on the applicability of behavioral change theory and model on COVID-19 preventive behaviors studies published until October 1, 2022, and eighty-two articles that were done globally. The study design used for all studies was cross-sectional. The most commonly used behavioral change theory and model used on COVID-19 preventive behavior are HBM (38) and TPB (27) articles. Most studies using behavioral change theory and model on COVID-19 preventive behavior done in China (17) out of this HBM (7) and TPB (7), United States (12) TPB (6) and HBM (4) and Iran (9) HBM (7) and EPPM (2).

Application of behavioral change theory and model on COVID-19 preventive behavior

In this systematic review, behavioral change theory and model applied to describe COVID-19 preventive behavior were HBM, TRA, TPB, EPPM, SCT, TTM, and SEM.

There are 38 studies based on HBM in this systematic review, and constructs of HBM (perceived vulnerability, perceived severity, perceived barrier, perceived advantages, cues to action, and self-efficacy) were positively associated with COVID-19 preventive behavior. The most typical preventive behaviors such as planning to get vaccinated, accepting vaccinations, wearing a face mask, keeping social distance, washing hands with soap and water, using hand sanitizer, self-quarantining, staying at home, not touching one’s face, and not going to public meetings. In this review, COVID-19 vaccine acceptance was positively correlated with all HBM constructs (perceived susceptibility, perceived severity, perceived barrier, perceived benefit, cues to action, and self-efficacy),^23,28–32 and constructs were also correlated with behavioral intention to engage in COVID-19 preventive behavior.^24,33–37

The application of TPB to COVID-19 preventive behaviors is based on 27 articles included in this systematic review, and the dimensions of TPB (attitude, social norm, and perceived behavioral control) were significantly associated with COVID-19 preventive behaviors. In the United States and China, respectively, seven and six studies based on TPB were published. A study done based on TPB behavioral intention ranges from 64.9% to 70.6%to take COVID-19 vaccine uptake and the behavioral intention was positively associated with COVID-19 vaccine acceptance.^38–44 This systematic review also included articles done using TRA five, EPPM seven, TTM two, SEM two, and SCT one.

Participants from a diverse range of studies, including adults, people over the age of 60, parents of young children, adolescents, high school, college, and university students, pregnant women, nurses, doctors, dentists, and pharmacists, as well as government employees, were included in this systematic review (Table 2).

Table 2.

Descriptive of the results of the applicability of behavioral change theory and models on COVID-19 preventive behaviors, worldwide: Systematic review.

Author	Year	Country	Sample size	Sampling technique	Study design	population	Key findings
Seangpraw et al.²⁹	2021	Thailand	1024	Simple random sampling	Cross-sectional	Age >20 years	All HBM constructs were positively associated with decision making to take COVID-19 vaccine
Caple et al.³⁰	2021	Philippines	7193	Online	Cross-sectional	Age >18 years	62.5% were willing to vaccinated for COVID-19.HBM constructs (PS, PS, PB) were associated with vaccination intention
Yu et al.³¹	2020	China	2254	Online	Cross-sectional	Healthcare workers	HBM constructs (perceived severity, barriers, cues to action, and self-efficacy) were significantly associated with the intention to take vaccine.
Le et al.³²	2021	Vietnam	911	Convenience sampling	Cross-sectional	Health professional students	HBM constructs (cues to action and perceived barrier) were positive predictors of vaccine acceptance.
Okmi et al.³³	2019	Saudi Arabia	1939	Online	Cross-sectional	Age >18 years general population	More than 73% were willing to take the vaccine perceiving risk, perceived severity and cues to action were positively associated with vaccination willingness.
Berni et al.³⁴	2021	Morocco	3800	Online	Cross-sectional	Age >18 years general population	Perceived susceptibility and benefits were the strongest predictors of acceptance of the COVID-19 vaccine.
Tao et al.³⁵	2020	China	1392	Multistage sampling	Cross-sectional	Pregnant women	The acceptance rate of a COVID-19 vaccine was 77.4% , high level of perceived susceptibility, perceived benefit, cues to action and low level of perceived barriers were positively associated with vaccine acceptance.
Wong et al.³⁶	2020	Malaysia	1159	Online	Cross-sectional	Adult population (age 18–70 years )	HBM constructs (perception of benefits, perceived susceptibility, and low perceived barriers) were predictors of intention to COVID-19 vaccination.
Al-Metwali et al.³⁷	2020	Iraq	1680	Online	Cross-sectional	Health worker and general population	COVID-19 vaccine acceptance rate of 61.7%. HCWs had high perceived susceptibility and severity of the COVID-19 infection compared to the general population.
Lee et al.³⁸	2022	China	800	Telephone	Cross-sectional	Adults age >18 years	28.9% participants had intention to receive a COVID-19 vaccine. PB, PS, PBr, and cues to action were significantly associated with vaccination intention.
Youssef et al.³⁹	2020	Lebanese	1800	Online	Cross-sectional	Health worker	COVID-19 vaccine among surveyed HCWs was 58% cues to action were significant factor for VA.
Wong et al.⁴⁰	2020	China	1200	Telephone interview	Cross-sectional	All adults aged 18 years	The overall vaccine acceptance rate was 37.2% perceived severity, perceived benefits of the vaccine, cues to action, were positive correlates of acceptance.
Cai et al.⁴¹	2021	China	1640	Online	Cross-sectional	Adult age >18 years	The precautions taken were wearing a mask (67.0%) and avoiding gathering together (71.3%).PB and cues to action were positively associated with vaccination.
Li et al.⁴²	2021	USA	326	Online	Cross-sectional	Pharmacy students	HBM constructs (perceived benefits, cue to action, and self-efficacy) were positively associated with face mask wearing.
Tong et al.⁴³	2020	China	616	Stratified random sampling	Cross-sectional	Adults aged 18–87 years	Face mask wearing 96.4% and social distancing; 42.3%.perceived benefit and cues-to-action were positively association with adherence to proper hand washing, face mask wearing, and social distancing
Tam et al.⁴⁴	2020	China	1225	Web-based surveys	Cross-sectional	College students	Perceived barriers, perceived susceptibility and self-efficacy has positive association with self-quarantine and social distancing
Kim et al.⁴⁵	2021	Korea	526	Online	Cross-sectional	Health college students from universities in Korea	HBM constructs were positively associated with prevention behavior.
Shitu et al.⁴⁶	2020	Ethiopia	370	Stratified sampling	Cross sectional	High school students	97 (26.2%), 121 (32.7%), and 108 (29.2%) of the students had good practice in keeping physical distance, frequent hand washing, and face mask use, respectively.HBM explained 43% of the variance inperceived barrier and self-efficacy were significant predictor for preventive practice.
Shewasinad Yehualashet et al.⁴⁷	2020	Ethiopia	683	Multistage sampling	Cross-sectional	Adults age >18 years	The overall adherence level was 44.1%.Self-efficacy, perceived benefits, perceived barriers, and perceived susceptibility of COVID-19 were important predictors of adherence to COVID-19 preventive behaviors.
Tadesse et al.⁴⁸	2020	Ethiopia	628	Systematic sapling method	Multicentered cross-sectional	Employees selected from four organizations in Addis Ababa	(68.8%) of them had poor COVID-19 prevention practice.Perceived barrier, cues to action, and self-efficacy were significantly associated with prevention practice of COVID-19.
Tajeri Moghadam et al.⁴⁹	2020	Iran	304	Online	Cross-sectional	Rural youth (between 18 and 30 years)	All HBM constructs were positively associated with preventive behaviors. HBM constructs explain 59% of variance on preventive behaviors.
Kamran et al.⁵⁰	2020	Iran	1861	Online	Descriptive–analytical study	Adults aged 20–70 years	Perceived susceptibility perceived severity, and perceived benefits were significant predictors of COVID-19 preventive practice.
Fathian-Dastgerdi et al.⁵¹	2020	Iran	797	Online	Cross-sectional	(ages between 12 and 18 years)	Self-efficacy, perceive severity and perceived benefit were the strongest predictor.
Delshad Noghabi et al.⁵²	2020	Iran	1020	Convenience sampling	Cross-sectional	Age of 15 years old or older	All HBM constructs were significant predictors of COVID-19 preventive behaviors.
Shahnazi et al.⁵³	2019	Iran	720	Convenience sampling	Cross-sectional	Age >18 years	Self-efficacy and perceived benefits had significant association with preventive behaviors.
Mirzaei et al.⁵⁴	2020	Iran	558	Online convenience sampling	Cross-sectional	Adults population age >18 years	HBM predicted 29.3% of the preventive behaviors of COVID-19.Perceived benefits, perceived barriers, and self-efficacy significantly predicted the preventive behaviors.
Karimy et al.⁵⁵	2020	Iran	1090	Multistage cluster sampling method	Cross-sectional	15 years of age or older	HBM constructs explained 27% of variance of COVID-19 preventive behaviors.Perceived benefits, perceived barriers, and cues to action were significantly associated with COVID-19 preventive behaviors.
Baek et al.⁵⁶	2020	Korea	1027	Online survey	Cross-sectional	Aged 20–59 years	Perceived susceptibility and self-efficacy positively influence the adoption of preventive behavior.
Arceo et al.⁵⁷	2020	Philippines	304	Online	Cross-sectional	18 years old	HBM constructs (cues to action, self-efficacy, and perceived barrier) have a significant association with COVID-19 preventive behavior.
Syed et al.⁵⁸	2020	Saudi Arabia	900	Online	Cross-sectional	Adults population age >18 years	Perceived susceptibility, severity, benefits, and cue to action were significant predictors of preventive behavior.
Alagili et al.⁵⁹	2020	Saudi Arabia	1027	Online	Cross-sectional	Adults population age >18 years	38% of participants adhered to all COVID-19 preventive behaviors. HBM constructs (perceived benefits, perceived barriers and cues to action) were associated with adherence to COVID-19 preventive behaviors.
Mortada et al.⁶⁰	2020	Saudi Arabia	286	Online	Cross-sectional	Health sciences female university	57% of the respondents adhere satisfactorily to COVID-19 precautionary behavior. Perceived benefits and cues to action were a significant determinant of adherence to COVID-19 preventive behavior.
Mahindarathne⁶¹	2020	Serilanka	307	Online	Cross-sectional	Age >18 years	Perceived benefits and self-efficacy had significant effect on COVID-19 preventive practice.
Mehanna et al.⁶²	2021	Sudan	680	Online	Cross-sectional	Adult population age >18 years	HBM constructs (perceived benefit, severity, and self-efficacy) were significant predictors of the willingness to adhere to the precautionary measures against COVID-19.
Tsai et al.⁶³	2021	Thiwan	361	Purposive sampling was	Cros-sectional	Nursing students	Self-efficacy is strongly associated with behavioral intention.
Hansen et al.⁶⁴	2020	United States	425	Convenience sample	Cros-sectional	Adults age >18 years	Perceived susceptibility and perceived benefits were significantly associated with increased compliance to social distancing recommendations.
Alsulaiman et al.⁶⁵	2020	United States	1723	Simple random sample	Cross-sectional	College students	HBM constructs and perceived threat are significantly associated with COVID-19 preventive measures.
Guidry et al.⁶⁶	2020	United States	500	Online	Cross-sectional	Adults age >18 years	Self-efficacy predicted three behavioral intentions: staying home while sick, not touching one’s face, and social distancing.Susceptibility predicted staying away from sick people and not attending large meetings. Perceptions of severity were the least impactful and only significantly predicted social distancing adherence intent and intent to not touch one’s face.
Wollast et al.⁶⁷	2020	Belgium and France	4804	Online survey	Cross-sectional	Adult population	TPB constructs (AT, SN, PBC) and intention were significantly associated with hand washing practice.
Yu et al.⁶⁸	2020	China	300	Random telephone interview	Cross-sectional	Adult population	80% practice social distanceTPB construct (positive AT, SN, and PB) had significantly associated with social distance.
Berg et al.⁶⁹	2020	United States	337	Quota sampling	Cross-sectional	Adult population	70.6% had intention to take COVID-19 vaccine, HBM (perceived barrier) and TPB (AT, SN) had significantly associated with intention to COVID-19 vaccine uptake.
Le An et al.⁷⁰	2021	Vietnam	854		Cross-sectional	Health science students	77.1% vaccine acceptance rateHBM (perceived benefits, cues to action) and TPB (PBC, positive AT) had significantly associated with COVID-19 vaccine intention.
Barile et al.⁷¹	2020	United States	1004		Cross-sectional	Adult population	47% of participants had strongly agree to have intention to use face covering, TPB constructs (SN and PBC) had positively associated with wearing face cover
Tran et al.⁷²	2020	Vietnam	597	Simple random	Cross-sectional	Nurse students	Positive intention to participate in COVID-19 prevention activities. TPB constructs (AT, SN, and PBC) were significantly associated with intention to participate in prevention activities.
Frounfelker et al.⁷³	2020	Canada	3183	Online survey	Cross-sectional	Adult population	TPB constructs (AT, SN, and PBC) had positively associated to follow social distance behavior.
Li et al.⁷⁴	2020	China	3693	Online survey	Cross-sectional	University students	TPB constructs (AT, SN, and PBC) had significantly associated with preventive behaviors of students to COVID-19.
Mao et al.⁷⁵	2020	China	4827	Online survey	Cross-sectional	Adult population	52.8% respondents had uptake of preventive behaviors. TPB constructs (positive AT, SN, and PBC) had strongly correlated with uptake of preventive practice of COVID-19.
Asmare et al.⁷⁶	2021	Ethiopia	1080	Online survey	Cross-sectional	Adult population	64.9% had intention to take COVID-19 vaccine. TPB constructs (positive AT, SN, and PBC) significantly associated with intention to take COVID-19 vaccine.
Prakash et al.⁷⁷	2021	India	228	Online survey	Cross-sectional	Adult population	TPB constructs (AT and SN) had positively associated with intention to take COVID-19 vaccine.
Servidio et al.⁷⁸	2021	Italy	276	Online survey	Cross-sectional	Adult cancer population	TPB constructs (SN and PBC) has significantly associated with vaccine uptake.
Kim et al.⁷⁹	2020	Korean	545	Online	Cross-sectional	Adult population	TPB constructs (AT and PBC) were significantly associated with intention to wear mask for COVID-19 prevention, total variance explained 82.39%.
Callow et al.⁸⁰	2020	United States	242	Convenience sample	survey	Older adult (age >60 years)	HBM explained 74.7% of variance of attitude toward social isolation, HBM Constructs (perceived barrier, benefit and barrier) significant effect on social isolation. TPB (AT and SN) positively associated with BI
Sin et al.⁸¹	2021	China	122	Email survey	Cross-sectional	Nurse	81.93% practice hand hygiene. TPB constructs (PBC and SN) had positively associated with BI and hand hygiene practice and 41.5% variance explained BI
Ullah et al.⁸²	2020/2021	Pakistan	1034	Online	Cross-sectional	Population age >15 years	TPB constructs had significantly associated with intention to take COVID-19 vaccine
Irfan et al.⁸³	2020	Pakistan	738	Convenience	Cross-sectional	Adult population	TPB explained 74% of variance. AT and SN were positively associated with public willingness to wear face mask
Li et al.⁸⁴	2022	China	11,141	Convenience	Cross-sectional	Parents having children age 5–12 years	HBM constructs (perceived susceptibility and benefit) and TPB constructs (AT and SN) were positively associated with parents intention to vaccine their child for COVID-19
Prasetyo et al.⁸⁵	2020	Philippine	649	Online survey	Cross-sectional	Adult population (age 15–75 years)	TPB constructs (AT, SN, and PBC) had positively associated with intention to preventive behavior (enhanced community quarantine)
Issrani et al.⁸⁶	2020	Saudi	756	Convenient sample	Cross-sectional	Adult population	TPB constructs (SN and PBC) positively associated with intention to willingness of self- isolation, model explains 71.9%
Park et al.⁸⁷	2020	Korea	272	Convenient sample	Cross-sectional	Adolescents	HBM (perceived susceptibility, severity) and TPB constructs (AT, SN, and PBC) and BI were positively associated with adherence to preventive behavior and which explain 61.3% adolescent preventive behavior (mask wear) .
Sun et al.⁸⁸	2020	China	477	Convenient sample	Cross-sectional	International university students	TPB constructs(AT, SN, and PBC) positively associated with intention to wear mask and total variance explained by model were 69.64%
Seddig et al.⁸⁹	2021	German	5044	Quota	Cross-sectional	Adult population	TPB constructs only AT were positively associated with intention to COVID-19 vaccine
Aschwanden et al.⁹⁰	2020	United States	2256	Online	Cross-sectional	Adult population	TPB constructs (AT, SN, and PBC) were positively associated with COVID-19 preventive behavior(washing hands; using hand sanitizer; not touching your face; social distancing; wearing a face mask; disinfecting surfaces; coughing in your elbow; staying home if sick) independently
Hayashi et al.⁹¹	2021	United States	172	Online	Cross-sectional	adults	TPB constructs (AT and PBC) were positively with BI to COVID-19 vaccine and the model accounted 72.5% of the variance for BI.
Gibson et al.⁹²	2020	United States	507	Online survey	Cross-sectional	Adult population	TPB constructs (AT, SN, and PBC) were positively associated with intention to social distance and BI were positively associated with social distance
Ahmad et al.⁹³	2020	China	302	Online	Cross-sectional	Students, instructors, health professionals	TPB constructs only AT were positively associated with intention to adopt COVID-19 preventive behaviors
Constant et al.⁹⁴	2020	France	2004	Stratified sample	Cross-sectional	Adults population	86.1% practice preventive practice. EPPM constructs (perceived efficacy, perceived fear and perceived severity ) were positively associated with acceptance of preventive behavior
Shirahmadi et al.⁹⁵	2020	Iran	300	Online	Cross-sectional	Dental students	93.33% practice hand washing with soap and water and use sanitizer. EPPM constructs (perceived threat and efficacy ) were high 94.6% and 95% which influence dentist to willingness to practice preventive behavior
Jahangiry et al.⁹⁶	2020	Iran	3727	Online	Cross-sectional	Adult population	EPPM 54.6% of participants were engaged in danger control (preventive behavior) high perceived efficacy (self and response)
Babafunke et al.⁹⁷	2020	Nigeria	5132	Convenience and snowball	Cross-sectional	Adult population	Only 15% participants had high threat and efficacy domain (follow preventive behavior), high exposure to COVID-19 preventive message had positively associated to perceived severity, self- efficacy, and response efficacy
Yoon et al.⁹⁸	2020	South Korea	813	Quota sampling	Cross-sectional	Adult population	Self-efficacy were positively associated with danger control (practice personal hygiene and social distance)
Lin et al.⁹⁹	2020	Taiwan	1012	Convenient sample	Cross-sectional	Adult population	Perceived threat were positively associated with fear arousal and fear arousal positively associated with preventive behavior practice and self-esteem are predictors of preventive behavior
Nazione et al.¹⁰⁰	2020	United States	698	Online	Cross-sectional	Adults with chronic condition	Perceived (susceptibility, severity and efficacy) had positively associated with preventive behavior (hand washing practice). 27.5% of variance explained preventive behavior
She et al.¹⁰¹	2020	China	2287	Online	Cross-sectional	Health professional	70% of HCW had intention to take COVID-19 vaccines. Physical (protective effect of vaccination) and self -evaluative outcome expectation (anticipated regret), self- efficacy, norm (DN, SN, professional norm, moral norm) were positively associated with intention to take COVID-19 vaccine
Hoti et al.¹⁰²	2020	Australia	264	Online	Cross-sectional	Pharmacists professional	87.9% implemented practice preventive behavior
Shiloh et al.¹⁰³	2020	Israel	309	Online	Cross-sectional	Adult population	TTM model variance explained 86% of vaccine intention. Attitude and perceived barrier are significantly associated with vaccine intention
Chen et al.¹⁰⁴	2020	China	1591	Online survey	Cross-sectional	Adult population	TRA model explained only 20% of the variance. AT, SN, and BI were positively associated with preventive behavior (wearing mask, stay home, wash hand, avoid party gathering, avoid public transport)
Ali-Saleh et al.¹⁰⁵	2020	Israel	810	Snow ball sampling	Cross-sectional	Adult Arab population	Perceived severity, AT, and SN were positively correlated with compliance with quarantine
Mat Dawi et al.¹⁰⁶	2020	Malaysia	404	Convenient	Cross-sectional	Adult population	TRA constructs (AT and SN) were positively associated to intention to preventive behavior
Akther et al.¹⁰⁷	2022	Bangladesh	351	Online survey	Cross-sectional	University students	TRA constructs (AT and SN) were positively associated to COVID-19 vaccination
Norman et al.¹⁰⁸	2020	United Kingdom	477	Quota sampling	Cross-sectional	Adult population	68% practice not visit friend or other family members and 64% practice hand washing when returning to home. BI and capacity were predictors of compliance to preventive behavior
Sumerlin et al.¹⁰⁹	2021	China	581	Online	Cross-sectional	Female foreign domestic workers	Agreeing to take vaccine, encouraged by their employer and family member were positively associated with vaccine uptake
Dayton et al.¹¹⁰	2021	United States	297	Online	Cohort	Parents who had children	44% parents have intention to vaccinate their children

AT: attitude; BI: behavioral intention; SN: subjective norm; DN: descriptive norm; EPPM: extended parallel process mode; HBM: health belief model; PBC: perceived behavioral control; TTM: trans theoretical model; HCW: health care worker; PB: perceived benefit; PS: perceived severity; PBr: perceived barrier; VA: vaccine accepatnce.

Discussion

The WHO advises many measures to avoid the epidemics of COVID-19. To have an adequate understanding of the barriers and facilitators of implementing preventive behaviors, researchers have employed a variety of behavioral change theories and models. This systematic review’s objective was to assess the application of behavioral change theory and model on COVID-19 preventative behaviors across the globe. This systematic review incorporated 82 articles based on different behavioral change theories and models to predict COVID-19 preventive behaviors. From this HBM (38), TPB (27), EPPM (7), TRA (5), TTM, SEM (2) each, and SCT (1) articles were incorporated.

According to a review of 38 articles based on HBMs conducted in various nations, acceptability of the COVID-19 vaccine ranges from 37.2% to 77.4% with the highest acceptance recorded in China among pregnant women.^{24,28–31,33,45,46} This difference might be the use of diverse assessment instruments, and the heterogeneous study participants from various nations with distinct cultures, norms, and beliefs may be the likely causes of the variation in variance explained by HBM components.

HBM constructs (perceived susceptibility, perceived severity, perceived barrier. perceived benefits, cues to action, and self-efficacy) were positively associated with COVID-19 preventive behavior like face mask wearing,^47–49 avoid gathering together,⁴⁸ social distance,^47,50,51 self-quarantine,⁵¹ adherence to COVID-19 preventive behaviors.^30,52–62 This result shows that the HBMs can predict health preventive behavior.

In this systematic review, TPB was identified in 27 articles across the globe to predict COVID-19 preventive behaviors. Based on TPB the immediate predictors of the behavior are behavioral intention with constructs of attitude, subjective norm, and perceived behavioral control.⁵ The TPB constructs (attitude, subjective norm, and perceived behavioral control) and behavioral intention were positively associated with hand washing practice,^19,63,64 social distance,^65–67 face mask-wearing,^64,68–71 social isolation,^72,73 and enhanced community quarantine.⁷⁴ This finding suggested that the TPB could be used to predict health preventive behavior; therefore, it is important to guide the development of effective healthy messages on COVID-19 preventive behaviors.

In this systematic review, there were six studies done with the application of EPPM on COVID-19 preventive behaviors in different study populations and types of preventive behaviors. It was stated that 86.1% of the adult population in France practice preventive behavior,⁷⁵ and 93.33% of dental nurse students in Iran practice hand washing with soap and water and use sanitizer.⁷⁶ The EPPM constructs such as perceived efficacy, perceived fear and perceived severity, response efficacy, and perceived susceptibility were positively associated with COVID-19 preventive behaviors.^75–78 It was evidenced that 15% of the adult population in Nigeria had a high threat and efficacy domain⁷⁸ to practice preventive behavior, and among the adult population in Iran 54.6% of the participants were engaged in danger control and high-perceived efficacy.⁷⁷ This evidence explains the predictive ability of the EPPM on healthy preventive behavior.

This systematic review also evidenced that TRA predicts healthy preventive behaviors during COVID-19 epidemics. The constructs of TRA (AT, SN, and BI) were positively associated with COVID-19 preventive behavior such as wearing masks (79), COVID-19 vaccine,^79–81 stay home,⁸² wash hand,^81,82 avoid party gathering,⁷⁹ avoid public transport, and compliance with quarantine.⁸¹ In the adult population in the United Kingdom, 68% practice not visiting friends or other family members, and 64% practice hand washing when returning home.⁸¹ A study in China revealed that the TRA model explained only 20% of the variance in preventive behaviors.⁸³

The study done on SEM showed that agreeing to take vaccines, encouraged by their employer family members, was positively associated with vaccine uptake,⁷⁹ and in the United States, 44% of parents have the intention to vaccinate their children.⁸⁴

A study done in China with SCT revealed that 70% of HCWs had the intention to take COVID-19 vaccines. The physical protective effect of vaccination and self-evaluative outcome expectation, self-efficacy, descriptive norm, subjective norm, professional norm, and moral norm were positively associated to take the COVID-19 vaccine.⁸⁵

The study done in Australia with the application of TTM showed that 87.9% of pharmaceutical professionals implemented preventive behavior.⁸⁶ A study in Israel using the TTM model variance explained 86% of vaccine intention.⁸⁷ This shows that the TTM had a significance to predict healthy preventive behavior.

Strength and limitation: This systematic review shows comprehensive evidence of the application of the behavioral change theory and model on COVID-19 preventive behaviors as strength. The limitation of this review was all the studies were cross-sectional that could not show a cause-effect relationship with the outcome variable, and the heterogeneity of the study participants prevent us from doing a meta-analysis.

Conclusion

This systematic review summarizes comprehensive evidence on the application of the behavioral change theory and model on COVID-19 preventive behaviors globally. The study participants were heterogeneous. A total of 82 articles use the behavioral change theory, and models including HBM, TRA, TPB, EPPM, SCT, SEM, and TTM were used on COVID-19 preventive behaviors in different countries around the world. The constructs of most behavioral theories and models were significantly associated with COVID-19 preventive behavior such as hand washing, face mask use, vaccine uptake, social isolation, self-quarantine, social distance, and use of sanitizers. Therefore, the application of the behavioral change theory and models was recommended to use to develop behavioral change interventional strategies.

Footnotes

Acknowledgements

We acknowledge the team members of this systematic review.

Author contributions

TFA and ETF contributed to data extraction, TFA, ETF, and MGT contributed to the quality check of extracted data, synthesis of result, write-up of discussion, and preparation of manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Tadele Fentabil Anagaw

Misganaw Guadie Tiruneh

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Application of behavioral change theory and models on COVID-19 preventive behaviors,worldwide: A systematic review

Abstract

Objective:

Methods:

Result:

Conclusion:

Keywords

Introduction

Research question

Methods

Search strategy

Inclusion and exclusion

Eligibility criteria

Data extraction

Quality assessment

Data analysis

Result

Characteristics of articles included in this review

Application of behavioral change theory and model on COVID-19 preventive behavior

Discussion

Conclusion

Footnotes

Acknowledgements

Author contributions

Declaration of conflicting interests

Funding

ORCID iDs

References