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Factors associated with preventive behaviors for COVID-19 among adolescents in South Korea

      Highlights

      • Perceived susceptibility, severity, subjective norms, and perceived behavioral control had indirect effects on behaviors.
      • Intention had a direct effect on behaviors.
      • It is necessary to increase adolescents’ adherence to COVID-19 preventive behaviors by evidence-based education.

      Abstract

      Purpose

      COVID-19's infection rate among adolescents is increasing; hence, it is important to prevent it as it can spread in the community through transmission in schools. It is crucial to determine the extent to which adolescents follow COVID-19 preventive measures and identify factors relating to such behaviors to implement more effective health education. This study aimed to understand factors related to COVID-19 preventive behaviors using the theory of planned behavior (TPB) and the health belief model (HBM) among adolescents in South Korea.

      Design and methods

      A cross-sectional face-to-face questionnaire survey was conducted among 272 adolescents in South Korea. Structural equation modeling was used to examine the relationships between perceived susceptibility, perceived severity, attitude, subjective norms, perceived behavioral control, intention, and COVID-19 preventive behaviors.

      Results

      Among adolescents' COVID-19 preventive behavior scores, wearing masks was the highest and distancing was the lowest. Adolescents' adherence to COVID-19 preventive behaviors was directly or indirectly associated with their perceived susceptibility, perceived severity, subjective norms, perceived behavioral control, and intention.

      Conclusions

      Attention to mitigate social isolation is important to improve compliance with COVID-19 preventive behaviors. Perceived susceptibility, perceived severity, subjective norms, perceived behavioral control, and intention explained 61.3% of adolescents' COVID-19 preventive behaviors, there is a need for education to promote relevant factors.

      Practice implications

      To increase adolescent awareness of COVID-19 and increase attitudes, subjective norms, and perceived behavior control, nurses need to provide education including the evidence for COVID-19 preventive behavior to increase adolescents' understanding and active implementation of those behaviors.

      Keywords

      Introduction

      The COVID-19 pandemic has introduced changes in adolescents' routines. Physical and social distancing from loved ones, avoiding in-person gatherings, wearing masks in public settings, and a drop in academic effort have resulted in difficulties for adolescents (
      • Centers for Disease Control and Prevention (CDC)
      COVID-19 parental resources kit – Adolescence.
      ). Unfortunately, the COVID-19 infection rate among adolescents is constantly increasing, and as this group is largely asymptomatic, they are likely to remain undiagnosed and spread it to others (
      • Dong Y.
      • Mo X.
      • Hu Y.
      • Qi X.
      • Jiang F.
      • Jiang Z.
      • Tong S.
      Epidemiology of COVID-19 among children in China.
      ). Adolescents' COVID-19 infection has a significant impact, as it can spread to local communities through transmission within schools (
      • Choi J.S.
      • Ha J.Y.
      • Lee J.S.
      • Lee Y.T.
      • Jeong Se U.
      • Shin D.J.
      • Seo D.U.
      Factors affecting MERS-related health behaviors among male high school students.
      ). Secondary transmission of COVID-19 infection can occur in school settings when preventive measures are not followed (
      • Stein-Zamir C.
      • Abramson N.
      • Shoob H.
      • Libal E.
      • Bitan M.
      • Cardash T.
      • Miskin I.
      A large COVID-19 outbreak in a high school 10 days after schools’ reopening, Israel, May 2020b.
      ).
      Nurses are the frontline healthcare professionals who have been working across schools and the community during the pandemic (
      • Chen S.C.
      • Lai Y.H.
      • Tsay S.L.
      Nursing perspectives on the impacts of COVID-19.
      ). Therefore, it is necessary to identify factors that are related to adolescents' COVID-19 preventive behavior and to provide effective education based on this. However, recent review showed that COVID-19-related studies in the field of nursing mainly focused on improving the health of COVID-19 patients, nursing education, and enhancing nurses' competencies in COVID-19 situations. Only one study proved the effectiveness of COVID-19 preventive behaviors and suggested strategies to improve it (
      • Oh J.Y.
      • Kim A.K.
      A bibliometric analysis of COVID-19 research published in nursing journals.
      ). In addition, previous studies have focused mostly on adult groups (
      • Ahamad M.
      • Iram K.
      • Jabeen G.
      Perception-based influence factors of intention to adopt COVID-19 epidemic prevention in China.
      ;
      • Bashirian S.
      • Jenabi E.
      • Khazaei S.
      • Barati M.
      • Karimi-Shahanjarini A.
      • Zareian S.
      • Moeini B.
      Factors associated with preventive behaviours of COVID-19 among hospital staff in Iran in 2020: An application of the Protection Motivation Theory.
      ;
      • Cvetković V.M.
      • Nikolić N.
      • Nenadić U.R.
      • Öcal A.
      • Noji E.K.
      • Zečević M.
      Preparedness and preventive behaviors for a pandemic disaster caused by COVID-19 in Serbia.
      ;
      • Kwok K.O.
      • Li K.K.
      • Chan H.H.H.
      • Yi Y.Y.
      • Tang A.
      • Wei W.I.
      • Wong S.Y.S.
      Community responses during the early phase of the COVID-19 epidemic in Hong Kong.
      ), and thus, adolescents' behaviors for preventing infection have been largely overlooked.
      Various theories have been suggested to clarify the related factors of infection preventive behaviors among adolescents. One such framework is the theory of planned behavior (TPB). The TPB assumes that actions are determined by intention and perceived behavioral control, whereas intentions are determined by attitudes toward behavior, subjective norms, and perceived behavioral control (
      • Ajzen I.
      The theory of planned behavior.
      ). This theory has been used in various studies to identify factors that affect behavior, such as actions taken to prevent infection (
      • Ayodele O.
      The theory of planned behavior as a predictor of HIV testing intention.
      ;
      • White K.M.
      • Jimmieson N.L.
      • Obst P.L.
      • Graves N.
      • Barnett A.
      • Cockshaw W.
      • Paterson D.
      Using a theory of planned behaviour framework to explore hand hygiene beliefs at the “5 critical moments” among Australian hospital-based nurses.
      ). A previous study demonstrated that teenagers believe that their preventive actions are effective, and their perception of the extent to which family and local governments urged them to adhere to said actions was significantly correlated with their compliance with respiratory hygiene guidelines (
      • Wong C.Y.
      • Tang C.S.K.
      Practice of habitual and volitional health behaviors to prevent severe acute respiratory syndrome among Chinese adolescents in Hong Kong.
      ).
      Among the many factors that related to COVID-19 preventive behaviors, it is important to identify adolescents' perceived susceptibility and severity, two important factors that are addressed in the health belief model (HBM). Adolescents are generally ill-equipped to assess the potential dangers of a disease appropriately; consequently, this endows them with a strong belief that they cannot be infected (
      • Millstein S.G.
      • Halpern-Felsher B.L.
      Adolescent risk and vulnerability: Concepts and measurement.
      ). This distorted thinking can lead to neglecting health advice and exposing oneself to destructive behaviors that increase the chance of infection (
      • Wong C.Y.
      • Tang C.S.K.
      Practice of habitual and volitional health behaviors to prevent severe acute respiratory syndrome among Chinese adolescents in Hong Kong.
      ). Greater levels of perceived susceptibility and severity, which reflect adolescents' perception of a disease, may serve as important factors promoting good health behaviors. A study on the factors affecting adolescents' preventive behavior for Middle East respiratory syndrome (MERS) reported that of the many individual factors influencing behavioral changes, perception of fear and severity of MERS were the most influential (
      • Choi J.S.
      • Ha J.Y.
      • Lee J.S.
      • Lee Y.T.
      • Jeong Se U.
      • Shin D.J.
      • Seo D.U.
      Factors affecting MERS-related health behaviors among male high school students.
      ). The TPB and HBM are well-known and empirically supported theories of health behavior. An integration of the most powerful predictors of behavior may yield a more complete explanation of health behavior (
      • Baranowski T.
      Integration of two models, or dominance of one?.
      ). Previous studies showed that some HBM variables influenced behavioral intention through TPB variables (
      • Reid A.E.
      • Aiken L.S.
      Integration of five health behaviour models: Common strengths and unique contributions to understanding condom use.
      ;
      • Yang Z.J.
      Predicting young adults’ intentions to get the H1N1 vaccine: An integrated model.
      ). Therefore, it will be useful to integrate the HBM and TPB to explain the COVID-19 preventive behaviors of adolescents.
      This study aimed to understand factors related to COVID-19 preventive behaviors using the TPB and HBM among adolescents in South Korea. The findings will provide a foundational framework for developing a more efficient and practical curriculum for COVID-19 and other respiratory infections, ultimately contributing to preventing the spread of infections in schools and large communities.

      Theoretical framework

      Fig. 1 shows the theoretical framework of the current study. We integrated the TPB and HBM to determine the relationships among the latent variables. Attitudes toward behavior, subjective norms, and perceived behavioral control—the key elements of the TPB—are influenced by behavioral, normative, and control beliefs. These beliefs are associated with the HBM, in which an individual's beliefs, such as perception of the susceptibility or severity, can lead to an action. Thus, perceived susceptibility and severity constructs of the HBM were selected in addition to the TPB.

      Methods

      Design, sampling, and participants

      Participants were recruited by convenience sampling at a middle school in Jeju, South Korea. Data were collected from August 3 to 14, 2020. We were interested in adolescents who are considered to have cognitive characteristics that accompany risk-taking behaviors (
      • Thomson K.C.
      • Schonert-reichl K.A.
      • Eva O.
      Optimism in early adolescence: Relations to individual characteristics and ecological assets in families, schools, and neighborhoods.
      ). In this study, we included students from only second year of middle school for the convenience of the school that cooperated with the data collection.
      Due to COVID-19, the school opening period in South Korea was delayed, so in-person classes were held during the period of data collection, and a face-to-face survey could be conducted. Recruitment posters containing study details were displayed on the school's bulletin board. The parents' informed consent forms were distributed to students who saw the poster and agreed to participate. Students' informed consent forms and questionnaires were handed out to them after their parents gave written consent. Of the 330 adolescents and their parents, 50 declined to participate because of a lack of interest. In total, 280 adolescents completed the survey (participation rate = 84.8%). Eight individuals were excluded from the final analysis because of missing essential information. After deleting the eight sets of incomplete data, 272 datasets were finally used for the analysis (effective response rate = 82.4%). In a structural equation modeling (SEM) analysis, at least 150 samples are required, and 200–400 samples are preferable (
      • Yu J.P.
      The misunderstanding and prejudice of structural equation models.
      ). Therefore, the sample size in this study was acceptable.

      Variables and measurements

      Based on our theoretical framework, a self-administered questionnaire was developed to identify the factors associated with Korean adolescents' COVID-19 preventive behaviors. First, we clarified the definition of the concept we wanted to measure by using the conceptual definition in the TPB and HBM. After that, a number of previous studies, guidelines, and news articles were reviewed according to the conceptual definition, and based on this, 34 initial questions were developed. Then, we conducted content validity testing with five experts (two nursing professors, one COVID-19 infection control nurse, one school nurse, and one respiratory physician). Definitions of the measurement concepts were presented to the group of experts. The content validity experts were asked to rate the clarity and relevance of each item on a 4-point scale (1 = not at all, 2 = largely not, 3 = mostly, 4 = very). Comments were elicited for each item. The item content validity index (I-CVI) for each item was the proportion of experts who rated it 3 or 4. The I-CVI exceeded the cutoff of 0.78 (
      • Shi J.
      • Mo X.
      • Sun Z.
      Content validity index in scale development.
      ), except for two items. One of the two items (“I will be infected with COVID-19 more easily than others.”) was not excluded because it was reported as an important item influencing adolescents' infection preventive behaviors in previous studies (
      • Choi J.S.
      • Ha J.Y.
      • Lee J.S.
      • Lee Y.T.
      • Jeong Se U.
      • Shin D.J.
      • Seo D.U.
      Factors affecting MERS-related health behaviors among male high school students.
      ). The other item (“I tend to follow information about COVID-19 from my friends.”) also had an I-CVI of 0.6, but it was not deleted because peer social norms have been found to be an important factor in adolescents' health behaviors (
      • Wang Y.
      • Chen M.
      • Lee J.H.
      Adolescents’ social norms across family, peer, and school settings: Linking social norm profiles to adolescent risky health behaviors.
      ). In addition, according to experts' opinions, the phrases were revised to be easy for teenagers to understand. Then, we confirmed the final 34 items on the main variables.
      Finally, the questionnaire consisted of eight sections: (1) demographic characteristics (age, gender, education experience of COVID-19, experience of accessing COVID-19 promotional materials, isolation experience related to COVID-19, fever [above 37.5 °C] and/or respiratory symptoms for the past 1 week), (2) perceived susceptibility to COVID-19, (3) perceived severity, (4) attitude, (5) subjective norms, (6) perceived behavioral control, (7) intention, and (8) preventive behaviors. The items used in the study are shown in Appendix A.

      Perceived susceptibility to COVID-19

      Perceived susceptibility to COVID-19 refers to an individual's belief of whether they can be infected with the virus. This factor was modified based on an earlier study examining high school students' perception of MERS infection risk (
      • Choi J.S.
      • Ha J.Y.
      • Lee J.S.
      • Lee Y.T.
      • Jeong Se U.
      • Shin D.J.
      • Seo D.U.
      Factors affecting MERS-related health behaviors among male high school students.
      ). We collected data through a two-part questionnaire on participants' fear of becoming infected with COVID-19 and belief on whether they were more susceptible to the disease compared to others. Responses were indicated on a five-point Likert scale, ranging from 1 “strongly disagree” to 5 “strongly agree.” The internal consistency of the instrument as measured by Cronbach's α was 0.46 in this study, indicating unacceptable internal consistency. Thus, we removed a less descriptive question (“I will be infected with COVID-19 more easily than others.”) and analyzed the data using a single item on participants' fear of being infected with COVID-19.

      Perceived severity of COVID-19

      Perceived severity of COVID-19 refers to an individual's belief of how seriously their everyday life will be impacted after contracting the virus. The corresponding questionnaire consisted of four questions based on prior research (
      • Jouybari T.A.
      • Hatamzadeh N.
      • Fattahi M.
      • Gharibnavaz H.
      • Khashij S.
      • Mahboubi M.
      Cognitive determinants of influenza preventive behaviors among students: An application of the health belief model (HBM).
      ) and the developmental stages of adolescents (
      • Havighurst R.J.
      Developmental tasks and education.
      ).
      • Jouybari T.A.
      • Hatamzadeh N.
      • Fattahi M.
      • Gharibnavaz H.
      • Khashij S.
      • Mahboubi M.
      Cognitive determinants of influenza preventive behaviors among students: An application of the health belief model (HBM).
      used five items (e.g., “Influenza complication could seriously affect my life.”) for assessing perceived severity. We replaced “my life” with the developmental tasks of adolescents such as studies, daily life, and maintaining relationships with family and friends. Additionally, it was modified to language that adolescents could easily understand (e.g., “If I get COVID-19, I'll have a problem with my studies.”). Responses were indicated on a five-point Likert scale, ranging from 1 “strongly disagree” to 5 “strongly agree.” In this study, the Cronbach's α was 0.78, indicating an acceptable internal consistency.

      Attitudes toward COVID-19 preventive behaviors

      Attitudes toward COVID-19 preventive behaviors refers to participants' positive or negative attitude toward taking preventive measures for COVID-19. The corresponding questionnaire consisted of four questions; it was modified to fit the study and supplemented by the method used in
      • Ajzen I.
      • Madden T.J.
      Prediction of goal-directed behavior: Attitudes, intentions, and perceived behavioral control.
      study to verify the TPB. Specific questions were prepared by referring to the research by
      • Lee S.J.
      • Park O.K.
      • Park M.Y.
      A structural equation model of pressure ulcer prevention action in clinical nurses.
      . Attitude was measured using a semantic differential scale that asked participants which preventive behaviors for COVID-19 they performed. Adjective pairs (e.g. “beneficial-harmful”) were rated on a scale from 1 to 7. A higher summative score indicated a more positive attitude toward COVID-19 preventive behaviors. The Cronbach's α was 0.85, indicating good reliability.

      Subjective norms about COVID-19 preventive behaviors

      Subjective norms about COVID-19 preventive behaviors refer to the level of external pressure perceived by an individual to take preventive measures. The corresponding questionnaire consisted of six questions: three on norms and three on their motivation to conform to preventive behaviors. It was modified to fit the study and supplemented by the method used by
      • Ajzen I.
      • Madden T.J.
      Prediction of goal-directed behavior: Attitudes, intentions, and perceived behavioral control.
      to verify the TPB. In this study, important referents were defined as parents, teachers, and friends, by referring to previous studies (
      • Jouybari T.A.
      • Hatamzadeh N.
      • Fattahi M.
      • Gharibnavaz H.
      • Khashij S.
      • Mahboubi M.
      Cognitive determinants of influenza preventive behaviors among students: An application of the health belief model (HBM).
      ;
      • Kalolo A.
      • Kibusi S.M.
      The influence of perceived behaviour control, attitude and empowerment on reported condom use and intention to use condoms among adolescents in rural Tanzania.
      ). Responses were indicated on a five-point Likert scale, ranging from 1 “strongly disagree” to 5 “strongly agree.” Cronbach's α was 0.85 in this study.

      Perceived behavioral control of COVID-19 preventive behaviors

      Perceived behavioral control of COVID-19 preventive behaviors refers to an individual's perception of their ability to control factors that hinder their preventive actions. The corresponding questionnaire consisted of five questions. It was modified to fit the study and supplemented by
      • Ajzen I.
      • Madden T.J.
      Prediction of goal-directed behavior: Attitudes, intentions, and perceived behavioral control.
      method to verify the TPB. Specific questions were prepared by referring to previous studies (
      • Lee S.J.
      • Park O.K.
      • Park M.Y.
      A structural equation model of pressure ulcer prevention action in clinical nurses.
      ;
      • Shenal Jr., B.V.
      • Radonovich L.J.
      • Cheng J.
      • Hodgson M.
      • Bender B.S.
      Discomfort and exertion associated with prolonged wear of respiratory protection in a health care setting.
      ) and qualitative data from news articles (;
      • Yonhap News
      “It's frustrating” from the heatwave to the mask… Classroom where both students and teachers are breathtaking.
      ). Participants were asked about their confidence in their willingness to take preventive measures when they were busy, lazy, feeling uncomfortable wearing their masks, feeling lonely because they were unable to meet other people, and feeling that preventive actions had little to no effect. Responses were indicated on a five-point Likert scale, ranging from 1 “strongly disagree” to 5 “strongly agree.” Cronbach'α was 0.89 in this study.

      Intention to perform COVID-19 preventive behaviors

      To assess participants' intention to perform COVID-19 preventive behaviors, a questionnaire consisting of four items was modified to fit the study and supplemented by
      • Ajzen I.
      • Madden T.J.
      Prediction of goal-directed behavior: Attitudes, intentions, and perceived behavioral control.
      method and the guidelines for preventing COVID-19 (;
      • World Health Organization (WHO)
      Coronavirus disease (COVID-19) advice for the public.
      ). Responses were indicated on a five-point Likert scale, ranging from 1 “strongly disagree” to 5 “strongly agree.” Cronbach's α was 0.77 in this study.

      COVID-19 preventive behaviors

      To assess COVID-19 preventive behaviors, we developed a nine-item questionnaire based on the COVID-19 prevention guidelines provided by the
      • World Health Organization (WHO)
      Coronavirus disease (COVID-19) advice for the public.
      and the . Participants were asked about their practices of handwashing, hygiene habits, mask-wearing, and distancing. Responses were indicated on a five-point Likert scale, ranging from 1 “strongly disagree” to 5 “strongly agree.” Cronbach's α was 0.86 in this study.

      Data analysis

      SPSS 26.0 was used to calculate descriptive statistics, Cronbach's α of the measures, and t-test. To observe the relationship between perceived susceptibility, perceived severity, attitude, subjective norms, perceived behavioral control, intention, and COVID-19 preventive behaviors, SEM was conducted with Mplus version 7.4. We conducted a hypothetical model test according to the two-step approach proposed by
      • Anderson J.C.
      • Gerbing D.W.
      Structural equation modeling in practice: A review and recommended two-step approach.
      . We first verified the fit and validity of the measurement model through confirmatory factor analysis (CFA) and correlation analysis between latent variables in step 1, and then estimated and evaluated a SEM that models the theoretical relevance between the factors in step 2. Model fit was evaluated with the following indices: χ2, normed fit index (NFI), comparative fit index (CFI), root mean square error approximation (RMSEA), and standardized root of the mean square residual (SRMR). Values of NFI and CFI above 0.90 (
      • Bentler P.M.
      Comparative fit indexes in structural models.
      ), RMSEA and SRMR below 0.08 indicate a good fitting model (
      • Steiger H.J.
      Understanding the limitations of global fit assessment in structural equation modeling.
      ). A p-value of <0.05 was considered statistically significant.

      Ethical considerations

      This cross-sectional study was approved by the institutional review board of the academic institution with which the researcher is affiliated (IRB No. JJNU-IRB-2020-025).

      Results

      Demographic characteristics and preventive behaviors for COVID-19

      The demographic characteristics and preventive behaviors for COVID-19 in participants are shown in Table 1. Of the 272 respondents, 62.1% were female and 37.9% male. Students' average age was 14.94 ± 0.27 years, ranging from 13 to 15 years. The preventive behaviors score was significantly higher in the group who received education for COVID-19 than the group who did not (t = 3.095, p < 0.01).
      Table 1Descriptions of adolescents' demographic characteristics and COVID-19 preventive behaviors (n = 272).
      Demographicsn(%)Preventive behaviorst
      Gender
       Male103(37.9)32.17 ± 7.20−0.501
       Female169(62.1)32.58 ± 5.99
      Education experience on COVID-19
      With missing values.
       Yes204(75.0)33.14 ± 6.033.095
      p < 0.01.
       No66(24.3)30.35 ± 7.35
      Experience of accessing COVID-19 promotional materials provided by national agencies
      With missing values.
       Yes192(70.6)32.04 ± 6.59−1.412
       No77(28.3)33.27 ± 6.13
      Isolation experience related to COVID-19
       Yes2(0.7)34.50 ± 3.540.455
       No270(99.3)32.41 ± 6.48
      Fever (above 37.5 °C) and/or respiratory symptoms for the past 1 week
      With missing values.
       Yes12(4.4)30.92 ± 5.25−0.828
       No259(95.2)32.50 ± 6.53
      a With missing values.
      low asterisklow asterisk p < 0.01.

      Descriptive statistics for measurement scales

      The descriptive statistics for measurement scales are shown in Table 2 and Appendix A. The average score of perceived sensitivity was 3.23 ± 1.13, and out of the total sample, 61 (22.4%) adolescents reported high levels of perceived susceptibility. Adolescents reported moderate to high perceived severity (16.35 ± 3.01), and they evaluated the most serious effects of COVID-19 on their families (4.44 ± 0.79). The people who encouraged adolescents to follow COVID-19 preventive behaviors were teachers, parents, and friends (4.19 ± 0.78, 4.04 ± 0.85 and 3.22 ± 0.96, respectively). It was difficult for adolescents to overcome and perform preventive behaviors when they felt lonely because they couldn't meet people often (3.75 ± 1.00). Among the COVID-19 preventive behaviors, the score for the item wearing a mask was the highest (4.53 ± 0.72), and the score for the distancing item was the lowest (2.97 ± 1.09).
      Table 2Descriptive statistics for measurement scales (n = 272).
      VariablesMean ± SDRangeSkewnessKurtosis
      Perceived susceptibility3.23 ± 1.131–5−0.3012.504
      Perceived severity16.35 ± 3.014–20−1.2725.481
      Attitude25.26 ± 3.334–28−1.1963.788
      Subjective norms46.10 ± 14.833–75−0.4493.543
      Perceived behavioral control19.22 ± 3.855–25−0.4893.621
      Intention15.73 ± 2.694–20−0.2182.837
      Behavior32.43 ± 6.479–45−0.1312.94.
      Note. SD, standard deviation.
      Prior to SEM, we confirmed skewness and kurtosis to see if each measurement variable satisfied the normal distribution assumption (Table 2). As a result, the skewness and kurtosis of all measurement variables did not exceed the absolute values of 2 and 7, respectively, which do not violate the assumption of normal distribution (
      • Curran P.J.
      • West S.G.
      • Finch J.F.
      The robustness of test statistics to nonnormality and specification error in confirmatory factor analysis.
      ). To confirm multicollinearity, the correlation between the study variables was analyzed (Table 3) and the correlation coefficients between intention and perceived behavioral control/behavior were higher than 0.80, but the values of the variance inflation factor were all less than 10 (1.16–2.22) and the problem of multicollinearity was considered acceptable.
      Table 3Correlations of latent variables and verification of construct validity (n = 272).
      Variablesr (r2)AVECR
      Perceived susceptibilityPerceived severityAttitudeSubjective normsPerceived behavioral controlIntention
      Perceived susceptibility10.8430.843
      Perceived severity0.351 (0.123)
      p < 0.05.
      10.5510.784
      Attitude0.139 (0.019)
      p < 0.01.
      0.288 (0.084)
      p < 0.01.
      10.6050.860
      Subjective norms0.307 (0.094)
      p < 0.01.
      0.288 (0.085)
      p < 0.01.
      0.559 (0.316)
      p < 0.01.
      10.5180.840
      Perceived behavioral control0.255 (0.066)
      p < 0.01.
      0.122 (0.017)0.502 (0.249)
      p < 0.01.
      0.680 (0.452)
      p < 0.01.
      10.6080.885
      Intention0.277 (0.088)
      p < 0.01.
      0.141 (0.023)0.540 (0.292)
      p < 0.01.
      0.715 (0.531)
      p < 0.01.
      0.884 (0.774)
      p < 0.01.
      10.4770.732
      Behavior0.323 (0.101)
      p < 0.01.
      0.089 (0.007)
      p < 0.01.
      0.442 (0.203)
      p < 0.01.
      0.614 (0.376)
      p < 0.01.
      0.722 (0.507)
      p < 0.01.
      0.801 (0.658)
      p < 0.01.
      0.4680.858
      Note. AVE, Average Variance Extracted; CR, Construct Reliability; r, correlation estimate; r2, coefficient of determination.
      low asterisk p < 0.05.
      low asterisklow asterisk p < 0.01.

      Model testing

      First, CFA was conducted to verify the validity and relationship of the scales used to measure the study variables. Five items with a factor loading of 0.5 or less were removed (
      • Hair Jr., J.F.
      • Black W.C.
      • Babin B.J.
      • Anderson R.E.
      Multivariate data analysis.
      ). The overall fit information for the model was [χ2 = 438.475 (p < 0.05), RMSEA = 0.040, SRMR = 0.045, NFI = 0.967, CFI = 0.960], indicating that the model was acceptable. For convergent validity verification, the average variance extraction (AVE) was found to have value above 0.50 (0.52–0.84) in perceived susceptibility, perceived severity, attitude, subjective norms, and perceived behavioral control, but intention and behaviors were 0.48 and 0.47, respectively. However, the construct reliability was shown to be 0.70 or higher (0.73–89) in all variables (Table 2), providing partial convergent validity (
      • Fornell C.
      • Larcker D.F.
      Evaluating structural equation models with unobservable variables and measurement error.
      ). Table 3 shows the discriminant validity of each latent variable. If the coefficient of determination (r2) is greater than the AVE, then there is a problem with the discriminant validity of each latent variable (
      • Fornell C.
      • Larcker D.F.
      Evaluating structural equation models with unobservable variables and measurement error.
      ). The independent variables of perceived susceptibility and severity were r2 of 0.123, less than the AVE of 0.551–0.843, and the same mediator variables, attitude, subjective norms, and behavior control, were also r2 of 0.249–452, less than the AVE of 0.518–0.608.
      Second, we included COVID-19 preventive behaviors, perceived susceptibility, perceived severity, attitude, subjective norms, perceived behavioral control, and intention into the SEM. The overall fit information for the model was [χ2 = 622.133 (p < 0.05), RMSEA = 0.060, SRMR = 0.141 NFI = 0.909, CFI = 0.925], indicating that the model was acceptable. Perceived susceptibility was positively associated with preventive behaviors by indirect effect through the mediations of subjective norms, perceived behavioral control, and intention. Perceived severity was positively associated with preventive behaviors by indirect effect through the mediation of attitude, subjective norms, and intention. Perceived susceptibility, perceived severity, subjective norms, perceived behavioral control, and intention explained 61.3% of adolescents' COVID-19 preventive behaviors. Subjective norms and perceived behavioral control had an indirect effect on preventive behaviors through the mediating role of intention. The intention also predicted COVID-19 preventive behaviors (Table 4, Fig. 2).
      Table 4Direct, indirect, and total effects.
      Endogenous variablesExogenous variablesDirect effectIndirect effectTotal effectSMC
      βββ
      AttitudePerceived susceptibility0.0660.0660.122
      Perceived severity0.321⁎⁎⁎0.321
      p < 0.001.
      Subjective normsPerceived susceptibility0.260
      p < 0.01.
      0.260
      p < 0.01.
      0.180
      Perceived severity0.260
      p < 0.01.
      0.260
      p < 0.01.
      Perceived behavioralControlPerceived susceptibility0.259
      p < 0.001.
      0.259
      p < 0.01.
      0.097
      Perceived severity0.1040.104
      IntentionPerceived susceptibility0.286
      p < 0.001.
      0.286
      p < 0.001.
      0.788
      Perceived severity0.194
      p < 0.05.
      0.194
      p < 0.05.
      Attitude0.1140.114
      Subjective norms0.291
      p < 0.001.
      0.291
      p < 0.001.
      Perceived behavioral control0.780
      p < 0.001.
      0.780
      p < 0.001.
      BehaviorPerceived susceptibility0.223
      p < 0.001.
      0.223
      p < 0.001.
      0.613
      Perceived severity0.153
      p < 0.05.
      0.153
      p < 0.05.
      Attitude0.0910.091
      Subjective norms0.233
      p < 0.01.
      0.233
      p < 0.01.
      Perceived behavioral control−0.0220.625
      p < 0.001.
      0.603
      p < 0.01.
      Intention0.801
      p < 0.001.
      0.801
      p < 0.001.
      Note. SMC, Squared multiple correlation; β, Standardized regression coefficients.
      low asterisk p < 0.05.
      low asterisklow asterisk p < 0.01.
      low asterisklow asterisklow asterisk p < 0.001.
      Fig. 2
      Fig. 2The final model for evaluating the preventive behavior for COVID-19 among adolescents.

      Discussion

      This study aimed to understand factors related to COVID-19 preventive behaviors using the TPB and HBM among adolescents in South Korea. COVID-19 preventive behaviors were measured using a questionnaire on hand hygiene, wearing a mask, and distancing. Compared to prior studies that measured similar behaviors in adults (
      • Breakwell G.M.
      • Fino E.
      • Jaspal R.
      The COVID-19 preventive behaviors index: Development and validation in two samples from the United Kingdom.
      ;
      • Cvetković V.M.
      • Nikolić N.
      • Nenadić U.R.
      • Öcal A.
      • Noji E.K.
      • Zečević M.
      Preparedness and preventive behaviors for a pandemic disaster caused by COVID-19 in Serbia.
      ), this study showed low scores in hand hygiene and distancing, but not wearing masks, confirming the need to improve compliance with COVID-19 preventive behaviors in adolescents. Specifically, it was found that the score was exceptionally low on the item related to distancing (4.15 ± 1.12/3.99 ± 1.14 in previous studies vs. 2.97 ± 1.09 in the current study).
      Among adolescents, perceived susceptibility to COVID-19 infection influenced the subjective norms about preventive behavior and perceived behavioral control. Additionally, perceived susceptibility indirectly affected adolescents' willingness to practice COVID-19 preventive behaviors; this finding is consistent with a previous study involving high school students during the MERS and influenza pandemics (
      • Najimi A.
      • Golshiri P.
      Knowledge, beliefs and preventive behaviors regarding influenza a in students: A test of the health belief model.
      ). The average score of perceived susceptibility in this study was 3.23 ± 1.13, which is higher than that reported for adolescents' perceived susceptibility during the MERS outbreak (1.8 ± 1.07) (
      • Choi J.S.
      • Ha J.Y.
      • Lee J.S.
      • Lee Y.T.
      • Jeong Se U.
      • Shin D.J.
      • Seo D.U.
      Factors affecting MERS-related health behaviors among male high school students.
      ). However, the current study demonstrated that 22.4% of adolescents had high levels of perceived susceptibility, which is lower than that in a recent report of adults' perceived susceptibility to COVID-19 (40.7%) (
      • Shahnaz H.
      • Ahmadi-Livani M.
      • Pahlavanzadeh B.
      • Rajabi A.
      • Hamrah M.S.
      • Charkazi A.
      Assessing preventive health behaviors from COVID-19: A cross sectional study with health belief model in Golestan Province, Northern of Iran.
      ). This is similar to the results of previous studies, which showed that adolescents have lower perceptions of disease risk than adults do (
      • Rahman M.
      • Berenson A.B.
      • Herrera S.R.
      Perceived susceptibility to pregnancy and its association with safer sex, contraceptive adherence and subsequent pregnancy among adolescent and young adult women.
      ). Adolescents may believe that they are not susceptible to COVID-19 infection, leading to non-compliance with health promotion behavior, so it is necessary to increase their perceived susceptibility to the virus to prevent infection.
      In this study, parents and teachers' subjective norms influenced COVID-19 preventive behavior, indicating the importance of enhancing adolescents' subjective norms. For this, it is necessary to help parents and adults improve adolescents' ability to implement COVID-19 preventive behavior. Additionally, because adolescents tend to imitate their parents' behaviors (
      • Tapera R.
      • Mbongwe B.
      • Mhaka-Mutepfa M.
      • Lord A.
      • Phaladze N.A.
      • Zetola N.M.
      The theory of planned behavior as a behavior change model for tobacco control strategies among adolescents in Botswana.
      ), parents should become role models to their children and promote COVID-19 preventive behaviors. However, many parents find it burdensome to educate their children about these behaviors because of the suspension of schools, having to work from home, and enduring economic difficulties, as well as managing their own fear and anxiety about the pandemic (
      • Witt A.
      • Ordóñez A.
      • Martin A.
      • Vitiello B.
      • Fegert J.M.
      Child and adolescent mental health service provision and research during the COVID-19 pandemic: Challenges, opportunities, and a call for submissions.
      ). Therefore, it is appropriate that education for adolescents is mainly carried out by school nurses. In this study, the COVID-19 preventive behavior score was significantly different depending on the education experience related to COVID-19. This supports previous findings that school-based education enhances the practice of adolescents' health behavior (
      • Nurumal M.S.
      • Zain S.H.M.
      • Mohamed M.H.N.
      Effectiveness of school-based Smoking Prevention Education Program (SPEP) among nonsmoking adolescents: A quasi-experimental study.
      ;
      • Swartz K.L.
      • Kastelic E.A.
      • Hess S.G.
      • Cox T.S.
      • Gonzales L.C.
      • Mink S.P.
      • Raymond DePaulo Jr., J.
      The effectiveness of a school-based adolescent depression education program.
      ). In the infection crisis, school nurses face difficulties due to work overload and lack of rapid information sharing with health authorities (
      • Lee I.S.
      • Yoon J.H.
      • Hong E.J.
      • Kim C.Y.
      Schools’ response to MERS (MERS-CoV) outbreak: Schools’ discretionary response in absence of control tower.
      ). Therefore, it is necessary to reduce the burden on school nurses and focus on student education through support of assistant personnel and establishment of a system for infectious diseases centered on regional offices of education.
      These findings can be used as a basis for planning educational and publicity measures to promote COVID-19 preventive behavior among adolescents. In a previous study of pregnancy preventive interventions for adolescents, an education program was developed to help adolescents recognize the possibility of becoming pregnant, which yielded positive results (
      • Yakubu I.
      • Garmaroudi G.
      • Sadeghi R.
      • Tol A.
      • Yekaninejad M.S.
      • Yidana A.
      Assessing the impact of an educational intervention program on sexual abstinence based on the health belief model amongst adolescent girls in Northern Ghana, a cluster randomised control trial.
      ). Similarly, it is necessary to develop an intervention to raise adolescents' awareness of their susceptibility to COVID-19. However, since excessive worry about COVID-19 can lead to psychological problems, such as anxiety (
      • Scott S.R.
      • Rivera K.M.
      • Rushing E.
      • Manczak E.M.
      • Rozek C.S.
      • Doom J.R.
      “I Hate This”: A qualitative analysis of adolescents’ self-reported challenges during the COVID-19 pandemic.
      ), pediatric nurses should also acknowledge adolescents' values and beliefs regarding COVID-19 and help them positively express their thoughts and feelings. In addition, fear of COVID-19 is related to media exposure (
      • Mertens G.
      • Gerritsen L.
      • Duijndam S.
      • Salemink E.
      • Engelhard I.M.
      Fear of the coronavirus (COVID-19): Predictors in an online study conducted in March 2020.
      ). Therefore, it is necessary for an authoritative institution to produce and distribute promotional materials that can increase their perceived susceptibility. However, it is appropriate to avoid sensational or provocative content, as these media should not create distress about COVID-19.
      In this study, the greater the perceived severity of the impact of COVID-19 infection on one's studies, friends, daily life, and family, the greater the effect on participants' attitudes and subjective norms about COVID-19 preventive behavior. Consistent with previous findings (
      • Puspita R.C.
      • Tamtomo D.
      • Indarto D.
      Health belief model for the analysis of factors affecting hypertension preventive behavior among adolescents in Surakarta.
      ), perceived severity did have an indirect effect on the performance of COVID-19 preventive behaviors. However, in those studies, perceived severity of COVID-19 was focused on medical consequences, such as death and severe health problems (
      • Luo Y.
      • Cheng Y.
      • Sui M.
      The moderating effects of perceived severity on the generational gap in preventive behaviors during the COVID-19 pandemic in the U.S.
      ;
      • Zareipour M.A.
      • Ardakani M.F.
      • Moradali M.R.
      • Jadgal M.S.
      • Movahed E.
      Determinants of COVID-19 prevention behavior in the elderly in Urmia: Application of health belief model.
      ). This study defined perceived severity as perceptions of COVID-19's impact on daily life and relationships. The mortality rate is not high when children and adolescents develop COVID-19 (
      • Bhopal S.S.
      • Bagaria J.
      • Olabi B.
      • Bhopal R.
      Children and young people remain at low risk of COVID-19 mortality.
      ). However, confirmation of COVID-19 in adolescence can affect academic interruption, disruption in daily life, and spread to valuable people such as friends and family. This suggests that not only medical diagnosis but also everyday aspects should be considered when defining the severity of COVID-19 (
      • de Figueiredo C.S.
      • Sandre P.C.
      • Portugal L.C.L.
      • Mázala-de-Oliveira T.
      • da Silva Chagas L.
      • Raony Í.
      • Bomfim P.O.S.
      COVID-19 pandemic impact on children and adolescents’ mental health: Biological, environmental, and social factors.
      ).
      In this study, adolescents' perceived behavioral control influenced their intention to perform COVID-19 preventive behaviors.
      • Cutrín O.
      • Fadden I.M.
      • Ayers S.L.
      • Kulis S.S.
      • Gómez-Fraguela J.A.
      • Marsiglia F.F.
      Applicability of the theory of planned behavior for predicting alcohol use in Spanish early adolescents.
      reported similar findings that the better the adolescents' self-control, the higher the degree of health behavior performance. Therefore, continuous support and encouragement are needed to reduce difficulties in following COVID-19 preventive behaviors. Consistent with a previous study (
      • Oosterhoff B.
      • Palmer C.A.
      • Wilson J.
      • Shook N.
      Adolescents’ motivations to engage in social distancing during the COVID-19 pandemic: Associations with mental and social health.
      ), this study also found that adolescents have the most difficulty overcoming loneliness when performing preventive behaviors. Humans are social beings, and from a developmental point of view, adolescents may experience great emotional distress from social distancing for COVID-19 prevention (
      • Witt A.
      • Ordóñez A.
      • Martin A.
      • Vitiello B.
      • Fegert J.M.
      Child and adolescent mental health service provision and research during the COVID-19 pandemic: Challenges, opportunities, and a call for submissions.
      ). Therefore, it is necessary to encourage preventive behaviors using the term “physical distancing” rather than “social distancing.” Distancing does not necessarily mean a break in social relations; the use of video conferencing systems, mobile communication, and social network services should be promoted so that adolescents can cope with their socially stressful situations and feel a sense of social belonging.
      Our results indicate that adolescents' attitudes toward COVID-19 preventive behaviors did not significantly affect their intention to perform COVID-19 preventive behaviors. This finding does not corroborate those of other studies (
      • Cha K.S.
      • Kim K.M.
      The factors related to mothers’ intention to vaccinate against hepatitis A: Applying the theory of planned behavior.
      ), which reported that positive attitudes about the usefulness or importance of health behaviors influence health behavior performance. The recommendations for transmission-based precautions required for COVID-19 vary in terms of droplet and contact precautions. While one study revealed that the SARS-CoV-2 virus was airborne (
      • Chia P.Y.
      • Coleman K.K.
      • Tan Y.K.
      • Ong S.W.X.
      • Gum M.
      • Lau S.K.
      • Singapore 2019 Novel Coronavirus Outbreak Research Team
      Detection of air and surface contamination by SARS-CoV-2 in hospital rooms of infected patients.
      ), another study reported that it was not airborne (
      • Wong S.C.Y.
      • Kwong R.T.S.
      • Wu T.C.
      • Chan J.W.M.
      • Chu M.Y.
      • Lee S.Y.
      • Lung D.C.
      Risk of nosocomial transmission of coronavirus disease 2019: An experience in a general ward setting in Hong Kong.
      ). Thus, adolescents may be unsure of the benefits of COVID-19 preventive behaviors. Prior research suggests that attitudes are linked to behavior only when shaped by appropriate information, which consequently improves people's confidence (
      • Glasman L.R.
      • Albarracín D.
      Forming attitudes that predict future behavior: A meta-analysis of the attitude–behavior relation.
      ). The COVID-19 prevention guidelines have been prepared based on evidence. For example,
      • Chu D.K.
      • Akl E.A.
      • Duda S.
      • Solo K.
      • Yaacoub S.
      • COVID-19 Systematic Urgent Review Group Effort (SURGE) study authors
      Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: A systematic review and meta-analysis.
      systematic review demonstrated that physical distancing of 1 m or more and using face masks reduce the infection rate. Therefore, when educating and promoting preventive behaviors to adolescents, it is necessary to convey the evidence supporting those behaviors, making it possible for adolescents to have positive attitudes toward COVID-19 preventive behaviors.
      There are several limitations in this study. Using the cross-sectional design, causality relationships cannot be inferred between variables. Second, this study was based on the variables of the HBM and TPB, but it is uncertain whether COVID-19 infection can always be prevented by these individual factors, and it cannot be overlooked that the level of quarantine measures in the country and community are also influencing factors. Third, there are limitations related to the generalization of the findings, as this study targeted students in only one school. In addition, even though there are many different age groups in adolescence, only second year middle school students were selected. Therefore, future research needs to include longitudinal studies and models adding and verifying social and institutional variables that can contribute to COVID-19 preventive behavior by targeting more adolescents in the local community. Fourth, as there is currently no standardized tool to measure factors related to COVID-19 preventive behaviors, the tools were developed for use in this study. Moreover, regarding the tool for assessing perceived susceptibility, data were collected using two items; however, as the tool had a low reliability (Cronbach‘s α = 0.46), one item with a low explanatory power was removed. Because it is not recommended to use single item measurements in SEM (
      • Lee J.Y.
      Advanced nursing statistics.
      ), care should be taken in interpreting variables related to perceived susceptibility. Additional research is required to identify the factors associated with COVID-19 preventive behaviors among adolescents with more reliable measures.
      Based on the study findings, we suggest the following. First, since this study investigated the level of adherence to COVID-19 preventive behaviors using a self-administered questionnaire, future studies should determine the exact degree of performance using an observation method. Second, in addition to the HBM and TPB variables, studies need to identify other factors associated with adolescents' COVID-19 preventive behaviors. Lastly, it is necessary to develop a systematic intervention to increase perceived susceptibility and severity to COVID-19, attitude, subjective norms, and perceived behavioral control to promote COVID-19 preventive behaviors.

      Conclusions

      The COVID-19 pandemic brought about a worldwide crisis. Furthermore, COVID-19 infections among adolescents are constantly increasing. To protect society as a whole, and to decrease household transmission of COVID-19, it is important to prevent COVID-19 among adolescents. In this study, perceived susceptibility and perceived severity was positively associated with preventive behaviors through the mediation of some TPB variables. Therefore, to increase adolescent awareness of COVID-19 and increase attitudes, subjective norms, and perceived behavior control, nurses need to provide education including the evidence for COVID-19 preventive behavior to increase adolescents' understanding and active implementation of those behaviors. Additionally, taking the characteristics of adolescents, who value social relationships, into account, awareness of maintaining “physical” distance while maintaining social relationships should be increased to mitigate social isolation.

      Funding

      This work was supported by the research grant of College of Nursing, Jeju National University Fund in 2020.

      Declaration of Competing Interest

      The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

      Acknowledgments

      The authors would like to acknowledge Ms. Han Sol Kim, Ms. Kyoung A Kim, Ms. Jin Sook Kim, Ms. Hyang-Ran Lee, and Mr. Gil Myeong Seong for their contribution to preparing the study plan and data collection. We are thankful to all the students who participated in the study.

      Appendix A. Supplementary data

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