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The role of health belief model constructs and content creator characteristics in social media engagement: insights from covid-19 vaccine tweets.

1. Introduction

1.1. hbm construct and social media messages, 1.2. social media user engagement, 1.3. the present study.

• RQ1: Which constructs of the HBM are evident in COVID-19 vaccine tweets?
• RQ2: What are the demographic characteristics of the Twitter content creators responsible for generating tweets about the COVID-19 vaccine?
• RQ3: Do the demographic characteristics of Twitter content creators use specific HBM constructs in their tweets?
• RQ4: Are there specific demographic characteristics associated with Twitter content creators that result in higher user engagement?
• RQ5: What HBM constructs are typically used in tweets that lead to higher user engagement?

2.1. Sample

• Selection Based on Significant Events: To ensure the sample was relevant to significant COVID-19 vaccine events, at least one significant event related to the COVID-19 vaccine (e.g., CDC recommends pausing the J&J vaccine) had to have occurred on that date.
• Exclusion of Retweets: Our study focused on the characteristics of tweets and creators leading to user engagement. Therefore, we included only original tweets and excluded retweets.
• High Engagement Tweets: Our sample prioritized tweets with high user engagement that consisted of the top 1000 tweets with the most retweets and the top 1000 tweets with the most favorites.
• Bot Exclusion: To filter out bot-generated tweets, Botometer was used, a tool that assigns a Complete Automation Probability (CAP) score to each Twitter account. Accounts with a CAP score above 95% were labeled as bots.

2.2. Coding Scheme

2.3. coding procedures, 2.4. data analysis, 3.1. descriptive statistics, 3.2. characteristics of covid-19 vaccine-related posts, 3.3. characteristics of content creators and user engagement, 3.4. characteristics of content creators and use of hbm in social media posts, 3.5. relationship between hbm use in social media posts and user engagement, 4. discussion, 4.1. implications, 4.2. limitations and future research, 5. conclusions, supplementary materials, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Jia, X.; Ahn, S.; Seelig, M.I.; Morgan, S.E. The Role of Health Belief Model Constructs and Content Creator Characteristics in Social Media Engagement: Insights from COVID-19 Vaccine Tweets. Healthcare 2024 , 12 , 1845. https://doi.org/10.3390/healthcare12181845

Jia X, Ahn S, Seelig MI, Morgan SE. The Role of Health Belief Model Constructs and Content Creator Characteristics in Social Media Engagement: Insights from COVID-19 Vaccine Tweets. Healthcare . 2024; 12(18):1845. https://doi.org/10.3390/healthcare12181845

Jia, Xiaofeng, Soyeon Ahn, Michelle I. Seelig, and Susan E. Morgan. 2024. "The Role of Health Belief Model Constructs and Content Creator Characteristics in Social Media Engagement: Insights from COVID-19 Vaccine Tweets" Healthcare 12, no. 18: 1845. https://doi.org/10.3390/healthcare12181845

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ORIGINAL RESEARCH article

Testing the effectiveness of the health belief model in predicting preventive behavior during the covid-19 pandemic: the case of romania and italy.

• 1 School of Psychology, Victoria University of Wellington, Wellington, New Zealand
• 2 D’Or Institute for Research and Education, São Paulo, Brazil
• 3 Centre for Applied Behavioral Economics, Department of Applied Economics and Quantitative Analysis, University of Bucharest, Bucharest, Romania
• 4 Department of Economics, Society and Politics, University of Urbino “Carlo Bo”, Urbino, Italy

We use a cultural psychology approach to examine the relevance of the Health Belief Model (HBM) for predicting a variety of behaviors that had been recommended by health officials during the initial stages of the COVID-19 lockdown for containing the spread of the virus and not overburdening the health system in Europe. Our study is grounded in the assumption that health behavior is activated based on locally relevant perceptions of threats, susceptibility and benefits in engaging in protective behavior, which requires careful attention to how these perceptions might be structured and activated. We assess the validity of the HBM in two European countries that have been relatively understudied, using simultaneous measurements during acute periods of infection in Romania and Italy. An online questionnaire provided a total of ( N = 1863) valid answers from both countries. First, to understand individual difference patterns within and across populations, we fit a General Linear Model in which endorsement was predicted by behavior, country, their interaction, and a random effect for participants. Second, we assess the effect of demographics and health beliefs on prevention behaviors by fitting a multi-group path model across countries, in which each behavior was predicted by the observed health belief variables and demographics. Health beliefs showed stronger relationships with the recommended behaviors than demographics. Confirming previously reported relationships, self-efficacy, perceived severity, and perceived benefits were consistently related to the greater adoption of individual behaviors, whereas greater perceived barriers were related to lower adoption of health behaviors. However, we also point to important location specific effects that suggest that local norms shape protective behavior in highly contextualized ways.

Introduction

The interest in psychological theories able to contribute to a design of effective public health interventions and health promotions is high ( Murphy and Bennett, 2004 ; Uutela et al., 2004 ). This is particularly true in the current environment where public health officials need insights into effective COVID – 19 responses ( Bavel et al., 2020 ), which has severely impacted many aspects of individuals lives across the globe ( Osei-Tutu et al., 2021b ). At the same time, there is increasing evidence that protective behaviors are culturally molded, requiring a focused examination of perceptions and behaviors within their respective contexts ( Fischer and Karl, 2021 ). We focus on one of the most successful frameworks in the literature, the Health Belief Model (HBM) ( Rosenstock, 1974b ) and use a cultural psychology perspective ( Fontaine, 2011 ; Wang, 2016 ) to examine how individuals in two European contexts perceive core constructs within the theory and how well this model works for COVID-19 relevant health behaviors across two cultural contexts. Cultural psychology focus on the interplay between the person, the mind and culture ( Shweder, 1991 ) and tries to understand how beliefs and behaviors are interrelated within cultures. Cultural psychology permits careful comparisons, but focuses on processes (how are beliefs related to behaviors) rather than a variable focus in cross-cultural psychology which explicitly focuses on quantitative comparison. A further distinction is that classic cross-cultural psychology assumes that culture is an external variable that can be easily measured with self-report measures and be treated as an antecedent, cultural psychology does not assume that cultural processes are distinct and conceptual antecedents that need to be measured separately, but rather form part of all measures (e.g., Greenfield, 2000 ; Smith et al., 2013 ). Hence, we use this cultural perspective to examine how a model of beliefs relates to individual behaviors during the early stages of the COVID-19 pandemic.

The HBM proved effective in the past in describing a wide range of preventive behaviors for diseases and behaviors that are well documented, increase the probability of early detection of diseases and for which implications of any behavior changes are generally well understood ( Carpenter, 2010 ; Sulat et al., 2018 ). However, in most cases the contexts where the model has been applied and tested were relatively established health contexts, which allowed people to understand and assess risks to make informed decisions on their personal health behavior ( Chen and Land, 1986 ; Bond et al., 1992 ; Ahmadi Jouybari et al., 2017 ; Fall et al., 2018 ; Jeihooni et al., 2019 ; Khani-jeihooni et al., 2020 ). Importantly, any behavior is culturally shaped, especially if behavior affects others and individuals strategically adapt their responses to align with expectations of others ( Yamagishi et al., 2008 ). This cultural interpretation of behavior is immediately relevant for the HBM because the target of the behavior is crucial. Previous research primarily focused on preventive behaviors related to non-communicable diseases or conditions, which are typically individually focused behaviors that differ to a great extent from those related to pandemics where the actions of each individual have follow-on effects on others. Some cultural environments are more likely to focus the attention of individuals toward their group members, in particular cultural environments emphasizing interdependence ( Markus and Kitayama, 1991 ). To the extent that individuals are culturally conditioned to be concerned about the wellbeing of others, their behavior in a pandemic environment is likely to change. At the same time, even within more independent and individualistic contexts, health interventions have much to gain by emphasizing the wellbeing of others, as the case study of a highly individualistic country such as New Zealand has demonstrated ( Manning, 2021 ).

Our first goal is therefore to explore whether the HBM can be applied in such an acute pandemic context that has collective action properties ( Fontaine, 2011 ; Templeton et al., 2020 ; Fischer and Karl, 2021 ). To the best of our knowledge, there is relatively little work that takes a cultural psychology perspective to examine how perceptions within the HBM operate within and across cultural contexts. In addition, insufficient evidence regarding the effectiveness of the HBM model in predicting the adoption of recommended behaviors in emergency or high-risk situations that vary across contexts and affect a large number of individuals and are marked by high levels of anxiety. As mentioned previously, the relatively limited literature available suggests that the HBM seems to work better in North America and Western Europe when the targeted behavior is focused on prevention of individually relevant risk factors, compared to adherence to recommended behaviors during an acute public crisis ( Carpenter, 2010 ; Sulat et al., 2018 ). This better alignment of individualistically focused behaviors in more individualistic oriented contexts could be expected from a cultural perspective ( Smith et al., 2013 , for divergence of promotion vs. prevention focused messages in United States and British contexts vs. Japan and other East Asian countries, see Hamamura et al., 2009 , Uskul et al., 2009 ). This makes the COVID – 19 pandemic a unique and valuable context to test the applicability of the overall framework. Given the absence of effective medical treatment or vaccines against COVID – 19 at the outset of the pandemic as well as the rapid spread of the virus, the only effective protection and prevention measures available were behavior based. Even today with the widespread availability of vaccines, the most effective interventions are behavior-based interventions and they remain important with the emergence of new variants ( Bish and Michie, 2010 ; Park et al., 2010 ; Agüero et al., 2011 ; Fischhoff et al., 2018 ). However, these preventive behaviors recommended by local and national governments depend on the cooperation of the population which can substantially vary across cultural contexts ( Ai et al., 2021 ). Even with the availability of vaccines, governments depend on their citizens to cooperate in vaccine uptake and to follow continuing health guidelines till the pandemic is under control. Here, cultural perspectives are important as behavior is typically strategic and follows situational logics ( Yamagishi et al., 2008 ; Chiu et al., 2010 ). Hence, it is crucial to study which variables may influence adherence to official health guidelines, and whether pre-existing theoretical backgrounds can facilitate the adoption of these guidelines.

Second, although there has been support for the overall model in general in a number of different cultural contexts, there is very limited research on the relevance of these perceptions and the comparative effectiveness of the HBM in different social, economic and cultural contexts. Our second goal is to directly test the validity of the HBM for predicting a variety of behaviors that had been recommended during the initial stages of the pandemic for containing the spread of the virus and to prevent overburdening the health system during the first COVID – 19 lockdowns, in two European countries, Romania and Italy. As a secondary goal, we also examine whether individuals in these two contexts perceive the core constructs in the same way, as it is well established that culture and mind reciprocally constitute each other ( Kim, 2000 ; Shweder, 2000 ). Therefore, we add to the existing research by explicitly exploring the performance of the model in predicting preventive behavior within specific cultural contexts. We include two countries that are located in close geographic proximity, share closely related languages but have different profiles of infection susceptibility and severity at the time of measurement. These two countries differ principally along survival vs. self-expression values ( Welzel, 2013 ), which are important for health behaviors and the control of infectious diseases ( Schaller, 2011 ). Therefore, we can rule out a number of competing explanations linked to shared social and cultural aspects due to a common Latin heritage, and examine the extent to which the HBM is dependent on the interaction between cultural values related to protection vs. self-expression values and the state of the health system. Taking this cultural psychology perspective, we offer new insights into the role of cultural context at different stages of dissemination of the virus and on broader dynamics of adopting health behavior during a global pandemic.

Finally, an important part of any cultural psychology analysis is to provide a better understanding of individual behavior in context. Hence, we assess to what extent different demographic groups within each culture adopted the recommended preventive behaviors, adoption further referred to as adherence. This adds new evidence on individual strategies at a behavioral level and can help health officials in identifying groups that may need specific targeting for reducing risk behaviors within their cultural context.

In summary, our contributions are threefold: (a) report an application of the HBM in an acute crisis setting, (b) explicitly test the cultural validity of the model in two closely related cultural contexts that vary in (1) the level of infection rates and (2) salient socio-economic characteristics such as income rates, health infrastructure and (3) in survival vs. self-expression values which are important cultural orientations that are relevant for reducing infections. Finally, (c) we explore demographic differences to provide insights into the behavior of individuals within cultural contexts.

The rest of the paper is organized as follows: the next section presents the HBM and the cultural context as well as pandemic situation in Romania and Italy when the data was collected; Section “Materials and Methods” provides information about data, measurement and methods; Section “Results” presents the results, while the final sections present the findings, discuss the limitations as well as the theoretical and practical implications of our work.

Theoretical and Practical Background

The health beliefs model.

The Health Beliefs Model traditionally includes four major types of beliefs: Perceived susceptibility, perceived severity, perceived benefits of preventive actions, and perceived barriers ( Rosenstock, 1974a , b ). The belief to be able to successfully adopt the behavior, also known as self – efficacy, was added later ( Rosenstock et al., 1988 ), and has been shown to improve the applicability of the model ( Champion and Skinner, 2008 ). Previous studies suggested that barriers and benefits are the strongest predictors of health behavior ( Carpenter, 2010 ; Sulat et al., 2018 ), with stronger effects for these two variables when focusing on prevention behaviors compared to acute diseases/sickness.

The HBM has been shown relevant for influenza vaccinations, breast self-examination, diet, exercise, smoking and seat-belt use ( Prentice-Dunn and Rogers, 1986 ), HIV ( Steers et al., 1996 ), Type 2 Diabetes Mellitus ( Tan, 2004 ; Chao et al., 2005 ), dental health ( Chen and Land, 1986 ), adherence to disease modified therapy in multiple sclerosis ( Turner et al., 2007 ; Yoshitake et al., 2019 ), skin cancer ( Jeihooni and Rakhshani, 2019 ), oral cancer ( Jeihooni et al., 2019 ), nutritional behaviors ( Vahedian-Shahroodi et al., 2019 ), or developing preventive behaviors in young adults ( Luquis and Kensinger, 2019 ).

There is relatively little work on the HBM from a cultural psychology perspective ( Arnault, 2018 ). Self-efficacy is one core component of HBM and conceptualizations of self-efficacy have been shown to systematically vary by cultural models of self-hood ( Markus and Kitayama, 1991 ; Oettingen, 1995 ; Vignoles et al., 2016 ). Similarly, the literature regarding the effectiveness of the model in contexts of epidemics, including virus outbreaks, is scant. We found research addressing preventive behavior based on the HBM paradigm in case of seasonal influenza ( Karimi et al., 2016 ; Ahmadi Jouybari et al., 2017 ; Fall et al., 2018 ), and the H1N1 influenza ( Rezaeipandari et al., 2018 ; Zhang et al., 2019 ; Khani-jeihooni et al., 2020 ). These studies found that the HBM framework is effective in predicting preventive behavior in case of seasonal influenza, however, the predictive power of the HBM dimensions differs by context. In Iran, the most influential predictors of preventive behavior in case of influenza were perceived susceptibility and severity, along with self-efficacy ( Ahmadi Jouybari et al., 2017 ), in France the best predictor was self-efficacy ( Fall et al., 2018 ), whereas in Canada perceived susceptibility, benefits and barriers were all strongly correlated with health behavior ( Karimi et al., 2016 ). However, each of these studies was conducted in isolation and it is not possible to determine whether the individual components were perceived in similar ways by participants ( Fischer and Karl, 2019 ). Therefore, there is relatively little literature available that provides insights whether the perceptions of core concepts with the HBM are perceived similarly or not within distinct cultural contexts.

The context of COVID-19 requires evidence-based practices to provide more effective protection of the most vulnerable within a population. The importance of health beliefs in this context has been discussed by some authors ( Czeisler et al., 2020 ; Ko et al., 2020 ) and HBM relevant variables such as risk perceptions have been shown to be on the minds of people across different cultural contexts ( Iorfa et al., 2020 ; Sobków et al., 2020 ). We identified one contribution that relates health beliefs with health anxiety ( Asmundson and Taylor, 2020 ). Overall, the potential of HBM has been clearly identified by a number of commentators, including for reinforcing behaviors that limit the spread of the virus ( Carico et al., 2020 ), and for managing mental health concerns ( Mukhtar, 2020 ). Focusing on empirical studies, a Polish study found that dark personality traits such as psychopathy correlated with health beliefs related to the COVID – 19 and undermined effective actions ( Nowak et al., 2020 ). Another study Elgzar et al. (2020) found that HBM implemented within an educational program in Saudi Arabia increased students’ perceived susceptibility, severity, benefits and self-efficacy in overcoming perceived barriers in the adoption of protective and preventive behavior.

Clark et al. (2020) reported a study that directly aligns with our goals and assessed the contribution of various health beliefs on voluntary compliance with recommended preventive behaviors across seven countries, including Italy ( Clark et al., 2020 ). They found that after controlling for demographics, the most important predictor of taking health precautions was self-efficacy, while perceived severity and susceptibility were of little importance. However, the authors did not assess how individuals perceived these beliefs and whether cultural dynamics may influence the performance of the HBM. Culture, perceptions and behavior are intrinsically linked, which makes cultural psychology indispensable when examining work with immediate real-world impact ( Wang, 2016 ).

In summary, the HBM shows promise as a useful tool for COVID-19 relevant information and behavior change ( Carico et al., 2020 ; Nowak et al., 2020 ), but little work has been done to examine effectiveness across different cultural contexts. We examine the HBM in a high stakes public health emergency, which alters the usual decision making environment in two different countries with different profiles at the time of measurement.

The Case Studies Context

We focus on Italy and Romania because of their cultural characteristics and specific pandemic situation at the time of the data collection. The two countries are historically closely related, sharing a Romance language and long stretches of shared distal history. Yet, Romania was part of the former Soviet bloc, leading to divergent political and social conditions for more than 40 years. Consequently, the two countries currently have somewhat different cultural values with Italy being part of a Catholic European value cluster, whereas Romania is part of an Orthodox value cluster within Europe (World Values Survey, no date). The World Values Survey provides the most rigorous, representative and frequent analysis of cultural orientations on a global scale, with representative data going back to 1985 ( Welzel and Inglehart, 2010 ). Two major dimensions have emerged that can be used to understand broad cultural dynamics ( Inglehart and Baker, 2000 ). Italy and Romania differ primarily on the Survival vs. Self-Expression dimension, which differentiates an emphasis on security and a motivation to avoid threats vs. an orientation to life which takes survival for granted and prioritizes self-expression and quality of life. These value distinctions have been linked to basic needs that emerge within specific ecological and economic contexts ( Van de Vliert, 2007 ; Welzel, 2013 ). This value polarity is also relevant for the control of disease threats, as it prioritizes free exploration vs. restrictions of personal impulses and is relevant for containing spread of infectious diseases ( Schaller, 2011 ).

This cultural distinction becomes even more salient when seen within the context of demographic and social structures of the two countries. Romania has a public health care system that underperforms in many respects ( Fărcăşanu, 2010 ; Ungureanu et al., 2017 ; Horodnic et al., 2018 ; Precupeţu and Popa, 2020 ). Therefore, individuals in Romania may feel more at risk given the lack of trust and acknowledged problems with the public health system. In contrast, Italy has a highly functional health care system. At the same time, Italy has a high share of elderly, with the percentage of people over 65 years being 22.1% (compared to 17.58% in Romania) (“ Romania Demographics Profile, 2020 ). This likely has led to a greater casualty rates in Italy, as the elderly are the most vulnerable segment of the population ( Hulíková Tesárková, 2020 ). Furthermore, Italy is characterized by extended families ( Caserta et al., 2021 ), which facilitates contacts between young and old people, therefore accelerating likely transmission of the virus.

Italy was the first country in Europe, together with Germany, where the virus began to spread, starting from the end of January. In Italy the spread of the epidemic has been particularly rapid. Within 1 month, both the central government and regional governments started to adopt the first restrictive measures, isolating the areas of epidemic outbreak (the so-called red areas) and introducing increasing limits to people’s movements. At the beginning of March, the interruption of all economic activities and complete lockdown for all citizens were decreed by law. Despite this, the progression of the epidemic continued throughout the month of March, reaching 147,577 infected and 18,849 deceased by April 10, 2020 (Source: Italian Ministry of Health). In mid-March the number of new infected stopped growing and at the end of March, the number of deceased began to decline after reaching a peak of nearly 1,000 deaths per day.

At about a month after Italy confirmed its first cases, the virus reached Romania. However, over the first 2 weeks, the COVID-19 epidemic had a relatively slower evolution. The Romanian government started implementing several measures such as banning all public gatherings and international travels, closing schools, restaurants, cafes, shopping malls, limiting or prohibiting the movement of persons for no urgent reason and instituting a national lockdown to enforce these measures. In spite of these actions, the virus continued to spread throughout March and the beginning of April, reaching 5,990 confirmed cases of COVID-19, and 291 deceased. At the end of March, the number of deaths began to start growing, reaching the maximum of 28 deaths per day by the mid of April.

The different timing between the two countries in the development of the epidemic has led, in the case of Romania, to greater awareness on the severity of the effects of the contagion, following the news arriving from Italy. The greater cultural orientation toward survival values together with the lower average income and perceived weaker and less efficient health system ( Popa et al., 2017 ; Druică et al., 2019 ; Cosma et al., 2020 ) may have led to a greater level of attention in the Romanian population, and therefore the adoption of more careful prevention behaviors. Conversely, the Italian population seems to have initially underestimated the risks associated with COVID-19, adopting less rigorous preventive behaviors based on values of self-expression and relying on a health care system that was perceived to be among the most qualified within international comparisons ( Björnberg and Phang, 2019 ; Motta Zanin et al., 2020 ).

The Study Goal

Our study had three major goals: (1) to examine the applicability and effectiveness of the health beliefs model to understand individual’s prevention behavior during an acute public health crisis, (2) using a cultural psychology lens we explicitly test the HBM in two cultural context that vary both in level of threat and the salience of survival values and (3) to examine individual differences within these two contexts, that is identify what demographic groups are particularly diligent in following these behaviors. Overall, our study provides important new insight on the effectiveness of HBM variables for improving health behaviors, which can help with improving communication targets and pathways about COVID-19 in the ongoing pandemic.

Materials and Methods

Sampling methodology.

We collected our data via a combination of open email-based and web-based survey, distributed between March 13 to March 27, 2020 in Romania and from March 18 to April 1st, 2020 in Italy. Invitations were disseminated through Facebook, LinkedIn, WhatsApp, and other social networks, as well as via email networks. The Center of Applied Behavioral Economics, University of Bucharest, and Carlo Bo University of Urbino, Italy jointly conducted the study. The respondents were informed at the beginning of the survey that their participation is voluntary and anonymous and that by completing the questionnaire, they provide consent to participation in this study.

The sampling methodology was based on chain-referral sampling ( Biernacki and Waldorf, 1981 ), by adopting a non-probabilistic snowball process, which is based on contacting one participant via the other ( Browne, 2005 ). This method allows to quickly improve the scope of on-line questionnaires and optimizes the balance between time and costs ( Baltar and Brunet, 2012 ). Differently from the respondent-driven sampling (RDS) ( Heckathorn, 2011a , b ), the respondents have not been traced in the recruitment waves following the initial seeds of respondents, and they did not receive any material compensation or prize for their participation in the research.

The initial seeds of the samples have been chosen by convenience and not randomly, with self-selected participants opting in based on their availability to answer the questionnaire. Participants were asked to pass the questionnaire to their social networks, thus identifying new groups of respondents and exponentially growing the size of the sample. Although convenience sampling is often criticized for not providing representative samples and thus running the risk of biased results due to the non-representative nature of the Internet population and any volunteer effects ( Eysenbach and Wyatt, 2002 ; Schonlau, 2004 ), it is important to define for which subset of a population the conclusions drawn from a convenience sample are assumed to be valid ( Eysenbach, 2004 ) and hence, the interpretation and conclusions need to be discussed with these constraints in mind.

Participants

A total of 1,868 respondents (1,126 individuals from Romania and 742 individuals from Italy) provided valid answers. The average age was 33.89 ( SD : 13.25, Range: 16–82) in Romania, which was significantly higher compared to the average age in the Italian sample: 36.94 ( SD : 15.07, Range: 14–79), t (1442.7) = 4.487, p < 0.001. This age difference is aligned with the overall age distribution of the two countries ( Romania Demographics Profile, 2020 ). Further, significantly more participants in the Italian sample were male (38.14%) compared to the Romania sample (24.51%). A comparable number of individuals were married, with the overall rate being 70% (70.78% in Romania, 68.87% in Italy). The number of individuals with children was somewhat higher in Romania (38.54%) compared to Italy (35.58%). A significantly higher number of respondents were medical students in Romania (14.12%) compared to Italy (7.14%). Although the sample is not fully representative of the characteristics of the population due to the sampling method adopted, the overall sample composition approximates the general population. We include the demographic variables in our models described below, which allows us to statistically control for any demographic differences. Detailed demographics and statistical comparisons between the samples can be found in Table 1 .

Table 1. Descriptive statistics for Romania and Italy.

Measurement

Health beliefs.

Health beliefs were measured with a 24-item Likert-scale ranging from 1 (totally disagree) to 7 (totally agree). The health beliefs scale was previously used to measure the following belief dimensions ( Hartley et al., 2018 ): Perceived susceptibility to the illness (four items, one item was excluded in our study due to differential translations in Romania and Italian), perceived severity of the illness (eight items), perceived benefits of preparing against the illness (three items), perceived barriers to preparation (five items), perceived self-efficacy (four items). The complete list of items is available in the Appendix, while the reliability of the individual measures in Romania and Italy are presented in Table 2 .

Table 2. Reliability of the individual measures in Romania and Italy along with the corresponding 95% confidence intervals.

Health Behavior

To assess participants behavior we asked them about their adoption of 8 commonly recommended prevention behaviors at the time of our study (Washing hands, cleaning surfaces with alcohol regularly, etc.). Participants answered on a 1–7 scale. The reliability of all measures [including ω, GLB as alternatives to αααα ( Trizano-Hermosilla and Alvarado, 2016 )] can be found in Table 2 and correlations between the health belief facets in Table 3 .

Table 3. Correlation of the health belief facets in Romania and Italy.

Demographics

We included the following demographics: age, gender (0 = female, 1 = male), student (0 = no, 1 = yes), medical studies undertaken (0 = no, 1 = yes), in a relationship (0 = no, 1 = yes), parent (0 = no, 1 = yes), higher degree (0 = No, 1 = Yes), and chronic patient (0 = no, 1 = yes).

Statistical Analysis

First, we assessed the equivalence of the health beliefs scale across Romania and Italy, by using confirmatory factor analysis in an attempt to identify a unique, and invariant model in both samples. Considering that the Romanian sample was larger than the Italian sample, first, we identified the best-fitted model in Romania that was then fitted across both samples. We assessed whether the model shows a similar structure across samples, tested for metric equivalence (similarity of loadings) and scalar invariance (similarity of intercepts) ( Fischer and Karl, 2019 ).

Second, to test whether endorsement differed across behaviors and countries we fitted a General Linear Model in which endorsement was predicted by behavior, country, their interaction (to test for differential effectiveness across the two sample locations), and a random effect for participants.

Third, we tested the effect of demographics and health beliefs on prevention behaviors by using a multi-group path model, in which each behavior was predicted by the observed health belief variables and the demographics. We subsequently constrained all regression paths to be equal for Romania and Italy to increase the parsimony of the model and allow for easier interpretation ( Fischer and Karl, 2019 ). A separate model in which we used the full latent model is reported in the Supplementary Material on the OSF. Overall, the results were comparable, with the major differences being that the path between latent perceived benefits and disinfecting surfaces did no longer significantly differ between countries, but the path between latent perceived barriers and washing hands did vary between countries.

Model Equivalence Across Countries

The model in Romania showed good fit (CFI = 0.916, RMSEA = 0.060 [0.057, 0.064], SRMR = 0.066) after we introduced a covariance between the three severity items “When I think of Coronavirus, my heart starts beating faster” and “I am afraid to think about Coronavirus,” “The thought of getting sick with Coronavirus scares me” (indicating the possible presence of an anxiety factor in the severity measure) and between the self-efficacy items “I know how to adopt a preventative behavior when it comes to getting sick with Coronavirus” and “I am confident that I can properly adopt a preventive behavior regarding Coronavirus disease.”

We subsequently fitted this model across both samples and found good configural fit, as well as metric invariance but not scalar invariance (see Table 4 ). This is a first important outcome from a cultural perspective; individuals in the two samples perceived and interpreted the constructs in a similar manner. Overall, this indicates that the current measurement model of the HBM works sufficiently well to explore the relationship with other variables across countries, but we are not in a position to compare mean differences with this measure, but only relative endorsement of perceptions (e.g., profiles). A conceptual representation of the model is shown in Figure 1 and all item loadings constrained across countries can be found in Supplementary Table 1 .

Table 4. Model fit across levels of equivalence.

Figure 1. Conceptual model of the final CFA structure.

Prevalence of Health Behaviors Across the Two Samples

Overall, we found significant differences based on country [ F (1,14928) = 10, 538.26, MSE = 3.27, p < 0.001], behavior [ F (7,14928) = 22.57, MSE = 3.27, p < 0.001], and their interaction [ F (7,14928) = 19.43, MSE = 3.27, p < 0.001]. In Romania the three most endorsed behaviors were: Avoiding contact with individuals that show respiratory symptoms, not touching one’s face, and calling emergency lines when experiencing fevers or coughs. The least endorsed behaviors in Romania were: Disinfecting surfaces, not taking non-prescribed medicine, and washing hands. In Italy the three most endorsed behaviors were: Covering one’s mouth/nose while sneezing our coughing, washing hands, and avoiding contact with individuals that show respiratory symptoms. The least endorsed behaviors in Italy were: Only using PPE when necessary, Calling emergency lines, and disinfecting surfaces (we show the results for both countries in Figure 2 ).

Figure 2. Self-reported practice of behaviors aimed at reducing the spread of COVID-19. All error bars represent 95% CI corrected for within-subjects comparisons. All behaviors were standardized within participants and normalized across countries to increase the interpretability.

The Effect of Demographics on Prevention Behaviors

We fitted a model in which the health beliefs predicted the individual behaviors, with the paths constrained across countries with a MLM estimator. The model showed excellent fit to the data (CFI = 0.99, RMSEA = 0.031 [0.024, 0.037], SRMR = 0.03). To investigate country differences, we examined the expected χ 2 change for each path if it would be released and estimated separately across countries. We selected the path with the highest expected χ 2 change in the fully constrained model and subsequently adjusted all other p -values using a Bonferroni correction based on the number of previously selected paths. Overall, we released 7 paths. The following paths were released in this order:

(1) Path between covering mouth when sneezing and self-efficacy (χ 2 = 13.994, p adj < 0.001),

(2) Covering mouth when sneezing and perceived benefits (χ 2 = 13.335, p adj < 0.001),

(3) Disinfect surfaces and perceived benefits (χ 2 = 13.222, p adj < 0.001),

(4) Disinfect surfaces and self-efficacy (χ 2 = 9.207, p adj = 0.008),

(5) PPE usage and perceived benefits (χ 2 = 8.965, p adj = 0.015),

(6) Washing hands and age (χ 2 = 8.389, p adj = 0.024), and

(7) Washing hands and parental status (χ 2 = 7.989, p adj = 0.035). We report all constrained and unconstrained paths in Table 5 and show a conceptual representation of the model in Figure 3 .

Table 5. Model Results for the SEM path-model across countries.

Figure 3. Conceptual representation of the path-model with all behaviors entered simultaneously.

Focusing on the demographic effects that were similar across countries, only gender, medical studies background, and relationship status showed significant effects. Male participants (compared to female participants) were less likely to wash their hands B = −0.128[−0.221, −0.035], p = 0.007, not touch their faces B = −0.213[−0.342, −0.085], p < 0.001, to cover their mouth when sneezing B = −0.106[−0.196, −0.015], p = 0.022, not take non-prescribed medicine B = −0.25[−0.384, −0.116], p < 0.001, and disinfect surfaces B = −0.214[−0.344, −0.084], p = 0.001. In contrast, participants in a relationship (compared to single participants) were more likely to not take unprescribed medicine B = 0.159[0.024, 0.294], p = 0.021 and disinfect surfaces 154[0.021, 0.287], p = 0.023. Finally, participants with medical studies background were more likely to avoid individuals with respiratory illnesses B = −0.306[−0.466, −0.146], p < 0.001.

The Effect of Health Beliefs on Prevention Behaviors

Regarding the individual components of HBM we found that perceived self-efficacy was a significant predictor of all behaviors. It was the only part of the model that consistently emerged as a significant predictor for each recommendation. It was also the strongest predictor in absolute terms (examining the size of the unstandardized path coefficients). Concerning differences between samples, self-efficacy was a significantly stronger predictor for covering one’s mouth when sneezing in Italy compared to Romania, but disinfecting surfaces was more strongly associated with self-efficacy in Romania compared to Italy. Perceived benefits also significantly predicted all behaviors in Romania (and all but two of the behaviors in Italy), but the relative strength of the relationship was weaker compared with perceived self-efficacy. Concerning the differences between the two samples, perceived benefits were again more strongly related to covering one’s mouth when sneezing in Italy compared to Romania; whereas benefits were not significant to disinfecting surfaces in Italy and was significantly and substantively correlated with perceived benefits in Romania. Finally, the use of protective equipment only when needed was associated with benefits in Romania, but not in Italy. Perceived barriers and severity significantly correlated with four of the behaviors with about equal strength: washing hands, avoiding individuals with respiratory infections, not touching one’s face and calling emergency lines when feeling ill. In addition, severity was positively associated with disinfecting surfaces, but perceived barriers were not. The only belief in the HBM that did not correlate with any behaviors after controlling for the other beliefs was susceptibility.

Exploration of Mediation Models

As highlighted by a reviewer, the revised HBM includes mediation effects of demographic variables on health behaviors via the main HBM variables ( Glanz et al., 2008 ; Jones et al., 2015 ). In other words, demographic effects such as age or gender should only influence health behavior via central variables within the HBM. We explored these options in our data and provide full results in the Supplementary Material . We set up independent models in each sample. The demographic variables of age, gender and medical background were included as exogeneous variables. The core variables of the HBM (perceived susceptibility to the illness, perceived severity of the illness, perceived benefits, perceived barriers, and perceived self-efficacy) were included as potential mediators. The behavioral items were included as outcomes. A full description of our analytical procedure is also included in the Supplementary Material . The main results from this exploration suggested that: (a) gender effects on washing hands, avoiding individuals with respiratory infections, not touching one’s face and disinfecting surfaces were mediated by perceived severity (with males reporting lower intentions to perform the behavior mediated via reduced severity) and these effects were not statistically different across the two samples; (b) age effects on all behaviors were mediated by perceived benefits in Romania, but (c) not in Italy. Older Romanians were more likely to perform these behaviors and this was mediated via greater perceived benefits. There were also weaker indirect effects of age on all behaviors via self-efficacy, with older individuals more likely to perform behaviors via greater self-efficacy. Finally, individuals with a medical background were more likely to perform these protective behaviors. The relation was mediated via greater self-efficacy, irrespective of sample background. Medical background was also positively related to washing hands, not touching ones face, covering the mouth when sneezing, not taking unprescribed medicine and calling emergency lines via perceived benefits, again irrespective of sample. Therefore, perceived benefits and self-efficacy appear to be better mediators of age and medical background demographics, while perceived severity mediated the effects of gender on preventive behaviors. Full information is provided in the Supplementary Material .

The goal of our study was to use tools from cultural psychology to examine the Health Belief Model during the COVID – 19 pandemic in two samples that are characterized by different levels of infection and differential emphasis of survival vs. self-expression values. First of all, we found that the core variables of the HBM were perceived similarly in the two cultural contexts, but there were baseline differences that preclude direct comparisons between the two samples. This is a first crucial step in any cultural analysis as the outcomes of this analysis determine how results can be interpreted ( Fontaine, 2011 ). In our case, we can safely compare the effectiveness of the model across the two contexts, but we cannot directly compare the base rates.

We found that there was no single behavior that was widely adopted in both samples. At the time of our study, there was still no strong consensus in the literature on specific protective behaviors, beyond increased personal hygiene and covering one’s face when sneezing. Not surprisingly, given the diversity of medical opinion, our participants reported a number of diverse behaviors and there was no clear and consistent pattern across both samples. Romanian people received daily updated news from the media on the progress of the epidemic in China and then in Italy. Given the cultural preoccupation with security, this seems to have stimulated greater adoption of preventive behaviors prior to the start of the epidemic in their country. In turn, the adoption of preventive behaviors may have contributed to slowing the spread of the epidemic, avoiding the rapid increases experienced in Italy. Although we cannot directly compare the individual behavior items, the overall means were much higher in Romania compared to Italy. This may be driven by the combination of a cultural orientation emphasizing security with the news of the negative impact of the pandemic in nearby Italy.

The exploration of individual differences is important within a cultural psychology perspective ( Wang, 2016 ). We found that women overall were more likely to adopt protective behaviors. These patterns are in line with the overall pattern reported in the literature, suggesting that men are more likely to take risks and less likely to seek medical help compared to women ( Byrnes et al., 1999 ; Nam et al., 2010 ). Age influenced health behaviors via perceived benefits and self-efficacy in Romania, but not in Italy. Older individuals are typically more strongly acculturated ( Taras et al., 2010 ), suggesting that cultural dynamics on behaviors via salient health perceptions may more strongly operate in Romania vs. Italy. This is in line with recent evidence of differential norm strength in the context of the pandemic ( Fischer and Karl, 2021 ; Gelfand et al., 2021 ).

Theoretical Implications

We explicitly tested the properties of current HBM instruments across two cultures. Any cultural exploration depends on the validity of the data ( Fontaine, 2011 ; Smith et al., 2013 ; Wang, 2016 ). Our model overall fitted well across both samples and the association between individual items and the overall constructs was comparable. From a cultural perspective, this implies that individuals have comparable conceptualizations of salient health beliefs in these two contexts.

When examining the specific patterns, we found that perceived self-efficacy – that is the belief of being able to successful protect oneself from being infected – was the most consistent and strongest statistical predictor of health behaviors. This supports general findings in the wider psychological literature that self-efficacy is crucial for understanding behavior and behavior change ( Rosenstock et al., 1988 ; Wang and Zhang, 2016 ). The second most consistently associate health belief was perceived benefit. This fits with the larger literature ( Bond et al., 1992 ) and implies that individuals are more likely to adopt preventive behaviors that are seen as beneficial for individuals. Perceived barriers and severity also showed some effects in both samples, but overall were less strongly associated. In contrast, perceived threat may not be sufficient to motivate behavior in the absence of a belief to be able to protect oneself through adopting effective measures. These results align with the findings of Janz and Becker (1984) who researched the effectiveness of health beliefs on the adoption of preventive behaviors in a wide variety of contexts. However, the absence of a threat effect needs to be more thoroughly investigated, including in longitudinal studies.

Concerning cultural differences in the strengths of associations, we found relatively few differences compared to the largely consistent patterns for the HBM variables across the various behaviors. On one hand, the two settings share many cultural features, with the major difference being along the survival vs. self-expression value dimension. For the Italian sample, it seems that salient behaviors (covering one’s mouth) were better predicted by perceived efficacy and benefits; whereas the least endorsed behavioral actions were less well predicted by these HBM variables. These findings align with previous literature showing that how HBM factors relate in terms of weights and predictive power may vary with target behaviors ( Abraham and Sheeran, 2005 ), and that some HBM factors can be more effective than others in explaining adherence to specific behaviors in concrete interventions ( LaBrosse and Albrecht, 2013 ; Jones et al., 2014 ). Our pattern suggests that health belief variables are better predictors of individually focused, but more frequent behaviors in the Italian context. This may align with the self-expression values that are comparatively more salient in Italy – individuals perform those behaviors that can be easily performed and are seen beneficial and easy to perform for the individual. In contrast, in our Romanian sample disinfecting surfaces were among the least endorsed behaviors but were also somewhat better predicted by health beliefs compared to our Italian sample. Given the greater concern with security in Romanian society, the beliefs of the effectiveness of this behavior may have led to this stronger behavioral association.

These patterns suggest that normatively shared beliefs within a population are important for understanding the adoption of health behaviors, which have follow-on effects for the larger social and cultural system ( Daniel et al., 2021 ; Fischer et al., 2021 ). As we have seen in the first stages of the pandemic in Northern Italy, the impact of the pandemic on social and cultural conditions due to extended lockdowns may be substantive.

Looking more broadly at the emerging patterns in different contexts, our findings concur with emerging findings using the HBM in other countries. The HBM dimensions were correlated with preventive behavior in India, however, the infection risk as perceived by the respondents was not the same as actual risk ( Jose et al., 2021 ). Focusing on individual differences, research in Brazil showed gender, income and health status effects on the link between both perceived susceptibility and severity on preventive behavior ( Costa, 2020 , p. 202). An Iranian study on adult population found that after controlling for gender and residence, the strongest predictors of preventive behavior against COVID-19 were perceived barriers, perceived self-efficacy, fatalistic beliefs, and perceived interests ( Shahnazi et al., 2020 ), whereas a second Iranian study conducted with adolescents found that the strongest predictor of COVID preventive behavior was self-efficacy ( Fathian-Dastgerdi et al., 2021 ). A Chinese study found that HBM variables were correlated with preventive behavior but that the magnitude of correlations were small ( Tong et al., 2020 ). In Ethiopia, self-efficacy, perceived benefits, perceived barriers, and perceived susceptibility of COVID-19 as well as cues to action correlated with preventive behaviors ( Tadesse et al., 2020 ; Yehualashet et al., 2021 ). Together with these other studies, our research suggests that HBM is a useful framework, but the variability also implies that cultural dynamics play a role and need greater attention. Possible candidates for further exploration include social axioms (e.g., Tong et al., 2020 ), personality dynamics ( Nowak et al., 2020 ; Fischer et al., 2021 ), and the role of emotions in the cultural shaping of COVID-19 narratives ( Chentsova-Dutton, 2020 ).

Practical and Managerial Implications

A fact that clearly emerges from the study is that the greater awareness of the severity of COVID-19 correlates with more prudent behavior by the population. This has significant implications for information policies regarding the development of a pandemic with serious consequences such as COVID-19. In the case of Italy, some mistakes were made, since communication policies to the population were initially contradictory: on the one hand, people were invited to follow preventive behavior, on the other, they were encouraged not to abandon normal habits due to the risk of a slowdown in several economic sectors (especially travels, restaurants, and retailing) ( De Blasio and Selva, 2021 ). For example, on February 27, the mayor of Milan launched an advertising campaign on social networks entitled “Milan doesn’t stop,” with famous people depicted while drinking in a bar. This means that in the face of a pandemic of proven serious threat, communication by the authorities must be clear and unambiguous, giving priority to the safety of people before safeguarding economic interests. To instill optimism in such situations can be deleterious, and communication should emphasize the risks rather than understate them. Our results suggest that we need different emphasis in the contents of the communication (as relevant within HBM). In particular, the content of health communications may aim to emphasize perceived efficacy especially in contexts where efficacy beliefs are weaker, but communicators may also consider the perceived degree of threat posed by the disease. In addition, the source of health communication should be appropriate to the cultural context (for an example highlighting the role of religious leaders see: Osei-Tutu et al., 2021a ). In Italy, the initial high confidence in the national healthcare system may have led to underestimation of the risks of the pandemic, and this suggests that in the face of diseases with unknown seriousness and harmfulness, it is important to adopt a prudent attitude by emphasizing the potential dangers rather than downplaying them.

Limitations

One clear limitation of our current study is the convenience nature of our sample. A further limitation is the self-reported nature of the behaviors, which might be susceptible to response bias and reference group effects ( Heine et al., 2002 ). The means on all measures were consistently higher in Romania compared to Italy. This pattern may suggest some ceiling effects in the former country compared to the latter and possible reference group effects ( Heine et al., 2002 ). The disease context may influence both behavioral compliance rates and the perceptions of compliance rates which influences self-reports of the behavior. Absent more objective indicators, we cannot disentangle response set and substantive processes. A third limitation is that the countries followed different communication strategies about preventive behavior. This is of theoretical importance because it may trigger action cues which has been discussed as a moderator of HBM. We focus on the direct effects of the HBM in our study, yet these effects might be modulated by specific cues to action, which could be explored in future research. A fourth limitation from a cultural comparative perspective is that we did not include specific measures of cultural values. Unfortunately, the rapidly developing situation during the early stages of the pandemic together with pragmatic constraints on the number of instruments that could be included in an online study, we were unable to include measures of cultural values. Future studies on the HBM including measures of cultural values and norms are highly encouraged. Related to this point, our approach was focused on beliefs by individuals in two specific contexts, which does not allow a differentiation of individual vs. group-level normative processes within the context of these behaviors. Future research clearly needs to start examining the intersection between individual and group-level processes (for one possible example using sample level processes, see Fischer and Karl, 2021 ). Finally, in our current study we focus on cognitive factors as part of the HBM, it is nevertheless likely that emotional and affective responses to COVID-19 shape individuals prevention behavior which could be examined as potential moderators or mediators in future studies ( Daniel et al., 2021 ; Fischer et al., 2021 ).

Despite these limitations, our paper provides a snapshot of the endorsement of health behaviors in the acute context of the COVID – 19 crisis. It is important to gain insights into health behavior at the moment when those behaviors are crucial for containing further spread of the virus. The results imply that self-efficacy is an important contributor but also point to the importance of the perceived severity of the infection at the time of measurement. With only two samples measured at a single time point, it is not possible to disentangle time and context effects, especially considering that Italy and Romania varied in both central cultural values and severity of the pandemic. Future studies with more measurement points over time or a larger number of study sites that vary systematically in cultural orientations and include measures of cultural values and norms would be informative for examining the impact of disease context on the adoption of health behaviors.

Overall, our study shows that the Health Belief Model can be used to understand what beliefs are associated with reporting appropriate health behaviors. At a practical level, this opens up important avenues for potential intervention programs for increasing adaptive health behaviors in early stages of a pandemic. The results show the importance of increasing self-efficacy and perceived benefits in order to convince people to take actions to limit the spread of a new virus. From a cultural psychology perspective, the relative divergence for some of the variables also points to the need to study how individual health belief facets vary across countries and behaviors. We found that core constructs within the HBM were perceived similarly across these two contexts, but that means could not be directly compared. This highlights the importance of examining HBM more carefully across different cultural, social and economic contexts and the need to tailor interventions and communication about preventive measures to the specific context.

Data Availability Statement

The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found below: https://osf.io/k93dr/?view_only=fb66c152ffba45219451b4d03b4ba1e8 .

Ethics Statement

The studies involving human participants were reviewed and approved by the Ethics Committee of the University of Bucharest. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

ED, AS, and FM: data collection. ED, JK, RF, and AS: conceptualization. JK, RF, and ED: writing the original draft. ED, RF, FM, and JK: writing revised drafts. All authors contributed to the article and approved the submitted version.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyg.2021.627575/full#supplementary-material

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Keywords : Health Belief Model, COVID-19, preventive behavior, lockdown, culture, health behavior, measurement invariance

Citation: Karl JA, Fischer R, Druică E, Musso F and Stan A (2022) Testing the Effectiveness of the Health Belief Model in Predicting Preventive Behavior During the COVID-19 Pandemic: The Case of Romania and Italy. Front. Psychol. 12:627575. doi: 10.3389/fpsyg.2021.627575

Received: 09 November 2020; Accepted: 20 December 2021; Published: 12 January 2022.

Reviewed by:

Copyright © 2022 Karl, Fischer, Druică, Musso and Stan. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Elena Druică, [email protected]

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The Health Belief Model: A Qualitative Study to Understand High-risk Sexual Behavior in Chinese Men Who Have Sex With Men

• PMID: 26604043
• DOI: 10.1016/j.jana.2015.10.005

The Health Belief Model (HBM) has been widely used to explain rationales for health risk-taking behaviors. Our qualitative study explored the applicability of the HBM to understand high-risk sexual behavior in Chinese men who have sex with men (MSM) and to elaborate each component of the model. HIV knowledge and perception of HIV prevalence contributed to perceived susceptibility. An attitude of treatment optimism versus hard life in reality affected perceived severity. Perceived barriers included discomfort using condoms and condom availability. Perceived benefits included prevention of HIV and other sexually transmitted illnesses. Sociocultural cues for Chinese MSM were elaborated according to each component. The results demonstrated that the HBM could be applied to Chinese MSM. When used with this group, it provided information to help develop a population- and disease-specific HBM scale. Results of our study also suggested behavioral interventions that could be used with Chinese MSM to increase condom use.

Keywords: China; HIV; health belief; high-risk sexual behavior; men who have sex with men.

Copyright © 2016 Association of Nurses in AIDS Care. All rights reserved.

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• Published: 13 September 2024

A qualitative study on reasons for women’s loss and resumption of Option B plus care in Ethiopia

• Wolde Facha   ORCID: orcid.org/0000-0002-7463-524X 1 ,
• Takele Tadesse 1 ,
• Eskinder Wolka 1 &
• Ayalew Astatkie 2  

Scientific Reports volume  14 , Article number:  21440 ( 2024 ) Cite this article

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• Health care
• Medical research

Loss to follow-up (LTFU) from Option B plus, a lifelong antiretroviral therapy (ART) for pregnant women living with human immunodeficiency virus (HIV), irrespective of their clinical stage and CD4 count, threatens the elimination of vertical transmission of the virus from mothers to their infants. However, evidence on reasons for LTFU and resumption after LTFU to Option B plus care among women has been limited in Ethiopia. Therefore, this study explored why women were LTFU from the service and what made them resume or refuse resumption after LTFU in Ethiopia. An exploratory, descriptive qualitative study using 46 in-depth interviews was employed among purposely selected women who were lost from Option B plus care or resumed care after LTFU, health care providers, and mother support group (MSG) members working in the prevention of mother-to-child transmission unit. A thematic analysis using an inductive approach was used to analyze the data and build subthemes and themes. Open Code Version 4.03 software assists in data management, from open coding to developing themes and sub-themes. We found that low socioeconomic status, poor relationship with husband and/or family, lack of support from partners, family members, or government, HIV-related stigma, and discrimination, lack of awareness on HIV treatment and perceived drug side effects, religious belief, shortage of drug supply, inadequate service access, and fear of confidentiality breach by healthcare workers were major reasons for LTFU. Healthcare workers' dedication to tracing lost women, partner encouragement, and feeling sick prompted women to resume care after LTFU. This study highlighted financial burdens, partner violence, and societal and health service-related factors discouraged compliance to retention among women in Option B plus care in Ethiopia. Women's empowerment and partner engagement were of vital importance to retain them in care and eliminate vertical transmission of the virus among infants born to HIV-positive women.

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Introduction.

Lost to follow-up is a major challenge in the prevention of mother-to-child transmission (PMTCT) of HIV among HIV-exposed infants (HEI). Globally, about 1.5 million children under 15 years old were living with HIV, and 130,000 acquired the virus in 2022 1 . In the African region, an estimated 1.3 million children aged 0–14 were living with HIV at the end of 2022, and 109,000 children were newly infected 2 . Five out of six paediatric HIV infections occurred in sub-Saharan Africa in 2022 3 . Most of these infections are due to mother-to-child transmission (MTCT), accounting for around 90% of all new infections 4 , 5 . Without any intervention, between 15 and 45 percent of infants born to HIV-positive mothers are likely to acquire the virus from their mothers, with half dying before their second birthday without treatment 3 . Almost 70% of new HIV infections were due to mothers not receiving ART or dropping off during pregnancy or breastfeeding 3 .

In Ethiopia, the burden of MTCT of HIV is high, with a pooled prevalence ranging from 5.6% to 11.4% 6 , 7 , 8 , 9 , 10 . Ethiopia adopted the 2013 World Health Organization’s Option B plus recommendations as the preferred strategy for the PMTCT of HIV in 2013 11 , 12 , 13 , 14 . Accordingly, a combination of triple antiretroviral (ARV) drugs was provided for all HIV-infected pregnant and/or breastfeeding women, irrespective of their CD4 count and World Health Organization (WHO) clinical staging 11 , 13 . Besides, the drug type was switched from an EFV-based to a DTG-based regimen to enhance maternal life quality and decrease LTFU from Option B plus care 11 , 15 . The Efavirenz-based regimen consists of Tenofovir (TDF), Lamivudine (3TC), and Efavirenz (EFV), while the DTG-based regimen consists of TDF, 3TC, and DTG 13 , 15 , 16 . The change in regimen was due to better tolerability and rapid viral suppression, thereby retaining women in care and achieving MTCT of HIV targets 17 , 18 .

The trend of women accessing ART for PMTCT services increases, and new HIV infections decrease over time 3 , 19 , 20 . However, the effectiveness of Option B plus depends not only on service coverage but also on drug adherence and retention in care 4 , 15 , 21 . In this regard, quantitative studies conducted in Ethiopia showed that the prevalence of LTFU from Option B plus ranged from 4.2% to 18.2% 22 , 23 , 24 . Besides, the overall incidence of LTFU ranged from 9 to 9.4 per 1000 person-months of observation 25 , 26 , which is a challenge for the success of the program.

Qualitative studies also revealed that the main reasons for LTFU among women were maternal educational status, drug side effects, lack of partner and family support, lack of HIV status disclosure, poverty, discordant HIV test results, religious belief, stigma, and discrimination, long distance to the health facility, and history of poor adherence to ART 27 , 28 , 29 , 30 , 31 , 32 . Reasons for resumption to care were a decline in health status, a desire to have an uninfected child, and support from others 30 , 33 . Unless the above risk factors for LTFU are managed, the national plan to eliminate the MTCT of HIV by 2025 will not be achieved 34 .

Currently, because of its fewer side effects and better tolerability, a Dolutegravir (DTG)-based regimen is given as a preferred first-line regimen to pregnant and/or breastfeeding women to reduce the risk of LTFU 13 , 16 . The goal is to reduce new HIV transmissions and achieve Sustainable Development Goal (SDG) 3.3 of ending Acquired Immunodeficiency Syndrome (AIDS) as a public health threat by 2030 35 , 36 , 37 . As mentioned above, there is rich information on the prevalence and risk factors of LTFU among women on Option B plus care before the DTG-based regimen was implemented. Besides, the previous qualitative studies addressed the reasons for LTFU from providers’ and/or women’s perspectives rather than including mother support group (MSG) members. However, there was a lack of evidence that explored the reasons for LTFU and resumption of care after LTFU from the perspectives of MSG members, lost women, and healthcare workers (HCWs) providing care to women. Therefore, this study aimed to explore the reasons why women LTFU and resumed Option B plus care after the implementation of a DTG-based regimen in Ethiopia.

Materials and methods

Study design and setting.

An exploratory, descriptive qualitative study 38 was conducted between June and October 2023. This study was conducted in two regions of Ethiopia: Central Ethiopia and South Ethiopia. These neighbouring regions were formed on August 19, 2023, after the disintegration of the Southern Nations, Nationalities, and Peoples' Region after a successful referendum 39 . The authors included these nearby regions to get an adequate sample size and cover a wider geographic area. In these regions, 140 health facilities (49 hospitals and 91 health centers) provided PMTCT and ART services to 28,885 patients at the time of the study, of whom 1,236 were pregnant or breastfeeding women (675 in South Ethiopia and 561 in Central Ethiopia).

Participants and data collection

Study participants were women who were lost from PMTCT care or resumed PMTCT care after LTFU, MSG members, and HCWs provided PMTCT care. Mother support group members were HIV-positive women working in the PMTCT unit to share experiences and provide counselling services on breastfeeding, retention, and adherence, and to trace women when they lost Option B plus care 11 , 40 . Healthcare workers were nurses or midwives working in the PMTCT unit to deliver services to women enrolled in Option B plus care.

Purposive criterion sampling was employed to select study participants from twenty-one facilities (nine health centers and twelve hospitals) providing PMTCT service. A total of 46 participants were included in the study. The interview included 15 women (eleven lost and four resumed care after LTFU), 14 providers, and 17 MSG members. Healthcare workers and MSG members were chosen based on the length of time they spent engaging with women on Option B plus care; the higher the work experience, the more they were selected to get adequate information about the study participants. Including the study participants in each group continued until data saturation.

The principal investigator, with the help of HCWs and MSG members, identified lost women from the PMTCT registration books and appointment cards. A woman's status was recorded as LTFU if she missed the last clinic appointment for at least 28 days without documented death or transfer out to another facility 15 . Providers contacted women based on their addresses recorded during enrolment in Option B plus care, either via phone (if functional) or by conducting home visits for those unable to be reached. Informed written consent was obtained, and the research assistants conducted in-depth interviews at women’s homes or health facilities based on their preferences. After an interview, eleven women who lost care were counselled to resume PMTCT care, but nine returned to care and two refused to resume care. Besides, the principal investigator, HCWs, and MSG members identified women who resumed care after LTFU, called them via phone to visit the health facility at their convenience, and conducted the interview after obtaining consent. The research team covered transportation costs and provided adherence counselling to women post-interview. A woman resumed care if she came back to PMTCT care on her own or healthcare workers’ efforts after LTFU.

One-on-one, in-depth interviews were conducted with eligible MSG members and HCWs at respective health facilities. A semi-structured interview guide translated into the local language (Amharic) was used to collect data. The guide comprises the following constructs: why women are lost to follow-up from PMTCT care, what made them resume caring after LTFU, and why they did not resume Option B plus care after LTFU with probing questions (Supplementary File 1 ). The interview was conducted for 18 to 37 min with each participant, and the duration was communicated to study participants before the interview. The interview was audio-taped, and field notes were taken during the interviews.

Data management and analysis

Thematic analysis was used to analyze the data. The research assistants transcribed the interviews verbatim within 48 h of data collection and translated them from the local language (Amharic) to English for analysis. The principal investigator read the translated document several times to get a general sense of the content. An inductive approach was applied to allow the conceptual clustering of ideas and patterns to emerge. The authors preferred an inductive approach to analyze data since there were no pre-determined categories. The core meaning of the phrases and sentences relevant to the research aim was searched. Codes were assigned to the phrases and sentences in the transcript, which were later used to develop themes and subthemes. The subthemes were substantiated by quotes from the interviews. The interviews developed two themes: reasons for LTFU and the reasons for resumption after LTFU. The findings were triangulated from healthcare workers, MSG members, and client responses. Open code software version 4.03 was used to assist in data management, from open coding to the development themes and sub-themes.

Background characteristics of the study participants

We successfully interviewed 46 participants (14 providers, 15 women, and 17 MSG members) until data saturation. The mean (± standard deviation [SD]) of age was 25.53 (± 0.99) years for women, 32.5 (± 1.05) years for MSG members, and 32.2 (± 1.05) years for care providers. Three out of fifteen women did not disclose their HIV status to their partner, and 5/15 women’s partners were discordant. The mean (± SD) service years in the PMTCT unit were 10.3 (± 1.3) for MSG members and 3.29 (± 0.42) for care providers (Supplementary File 2 ).

Reasons for LTFU

Women who started ART to prevent MTCT of HIV were lost from care due to different reasons. Societal and individual-related factors and health facility-related factors were the two main dimensions that made women LTFU. The societal and individual-related factors were socioeconomic status, relations with husbands or families, lack of support, HIV-related stigma and discrimination, lack of awareness and perceived antiretroviral (ARV) side effects, and religious belief. Health facility-related factors such as lack of confidentiality, drug supply shortages, and inadequate service access led to women's loss from Option B plus care (Supplementary File 3 ).

Societal and individual-related factors

Socioeconomic status.

Lack of money to buy food was a major identified problem for women’s LTFU. Women who did not have adequate food to eat became undernourished, which significantly increased the risk of LTFU. Besides, they did not want to swallow ARV drugs with an empty stomach and thus did not visit health facilities to collect their drugs.

“My life is miserable. I have nothing to eat at my home. How would I take the drug on an empty stomach? Let the disease kill me rather than die due to hunger. This is why I stopped to take the medicine and LTFU.” (W-02, 30-year-old woman, divorced, daily labourer)

Women also disappeared from PMTCT care due to a lack of money to cover transportation costs to reach health facilities.

I need a lot of money to pay for transportation that I can’t afford. Sometimes I came to the hospital borrowing money for transportation. It is challenging to attend a follow-up schedule regularly to collect ART medications.” (W-11, 26-year-old woman, married, housewife)

Relationships with husbands and/or families

Fear of violence and divorce by sexual partners were identified as major reasons for the LTFU of women from PMTCT care. Due to fear of partner violence and divorce, women did not want to be seen by their partners while visiting health facilities for Option B plus care and swallowing ARV drugs. As a result, they missed clinic appointments, did not swallow the drugs, and consequently lost care.

“Due to discordant test results, my husband divorced me. Then I went to my mother's home with my child. I haven’t returned to take the drug since then and have lost PMTCT care.” (W-03, 25-year-old woman, divorced, commercial sex worker)

Women did not disclose their HIV status to their discordant sexual partners and family members due to fear of stigma and discrimination. As a result, they did not swallow drugs in front of others and were unable to collect the drugs from health facilities.

“I know a mother who picked up her drugs on market day as if she came to the market to buy goods. No one knows her status. She hides the drug and swallows it when her husband sleeps.” (P-05, 29-year-old provider, female, 3 years of experience in the PMTCT unit) “I don't want to be seen at the ART unit. I have no reason to convince the discordant husband to visit a health facility after delivery. My husband kills me if he knows that I am living with HIV. This is why I discontinued the care.” (W-12, 18-year-old woman, married, housewife)

Women who lack partner support in caring for children at home during visits to health facilities find it difficult to adhere to clinic visits. Besides, women who did not get financial and psychological support from their partners faced difficulties in retaining care.

“Taking care of children is not business for my husband. How could I leave my two children alone at home? Or can I bring them biting with my teeth?” (W-05, 24-year-old woman, divorced, daily labourer) “ I didn't get any financial or psychological support from my husband. This made me drop PMTCT care.” (W-15, 34-year-old woman, married, daily labourer) Lack of support

Women living with HIV also had complaints of lack of support from the government, non-governmental organizations (NGOs), and HIV-related associations in cash and in kind. As a result, they were disappointed to remain in care.

"Previously, we got financial and material support from NGOs. Besides, the government arranged places for material production and goods sale to improve our economic status. However, now we didn't get any support from anywhere. This made our lives hectic to retain PMTCT care.” (W-06, 29-year-old woman, married, daily labourer)

HIV-related stigma and discrimination

Fear of stigma and discrimination by sexual partners, family members, and the community were mentioned as reasons for LTFU. Gossip, isolation, and rejection from societal activities were the dominant stigma experiences the women encountered. As a result, they did not want to be seen by others who knew them while collecting ARV drugs from health facilities, and consequently, they were lost from care and treatment.

“Despite getting PMTCT service at the nearby facility, some women come to our hospital traveling long distances. They don't want to be seen by others while taking ARV drugs there due to fear of stigma and discrimination by the community.” (P-10, 34-year-old provider, female, 2 years of experience in the PMTCT unit) “I am a daily labourer and bake ‘injera’ (a favourite food in Ethiopia) at someone's house to run my life. If the owner knew my status, I am sure she would not allow me to continue the job. In that case, what would I give my child to eat?” (W-12, 18-year-old woman, married, housewife) “My family did not know that I was living with the virus. If they knew it, I am sure they would not allow me to contact them during any events. Thus, I am afraid of telling them that I had the virus in my blood.” (W-05, 24-year-old woman, divorced, daily labourer)

Lack of awareness and perceived ARV side effects

Sometimes women went to another area for different reasons without taking ARV drugs with them. As per the Ethiopian national treatment guidelines 13 , they could get the drugs temporarily from any nearby facility that delivers PMTCT service. However, those who did not know that they could get the drugs from other nearby PMTCT facilities lost their care until their return. Others were lost, considering that ARV drugs harm the health status of their babies.

“One mother refused to retain in care after the delivery of a congenitally malformed baby (no hands at birth). She said, 'This abnormal child was born due to the drug I was taking for HIV. I delivered two healthy children before taking this medication. I don't want to re-use the drug that made me give birth to a malformed baby." (P-14, 32-year-old provider, female, 4 years of experience in the PMTCT unit)

When they did not encounter any health problems, women were lost from care, considering that they had become healthy and not in need of ART. Some of them also believe that having HIV is a result of sin, not a disease. Besides, some women believed that it was not possible to have a discordant test result with their partner.

“I didn't commit any sexual practice other than with my husband. His test result is negative. So, from where did I get the virus? I don't want to take the drug again.” (W-02, 30-year-old woman, divorced, daily labourer)

Religious belief

Some study participants mentioned religious belief as a reason for LTFU and a barrier to resumption after LTFU. Women discontinued Option B plus care due to their religious faith and refused to resume care as they were cured by the Holy Water and prayer by religious leaders.

“I went to Holy Water and was there for two months. My health status resumed due to prayer by monks and priests there. Despite not taking the drugs during my stay, God cured me of this evil disease with Holy Water. Now I am healthy, and there is no need to take the medicine again.” (W-09, 25-year-old woman, married, daily labourer)

Some women believed that God cured them and made their children free of the virus despite not taking ART for themselves and not giving ARV prophylaxis for their infants.

“Don't raise this issue again (when MSG asked to resume PMTCT care). I don't want to use the medicine. I am cured of the disease by the word of God, and my child is too. My God did not lie in His word.” (MSG-16, 32-year-old MSG, married, 16 years of service experience “Don't come to my home again. I don't have the virus now. I have been praying for it, and God cured me.” (W-03, 25-year-old woman, divorced, commercial sex worker)

Health facility-related factors

Shortage of drug supply.

Women were not provided with all HIV-related services free of charge and were required to pay for therapeutic and prophylactic drugs for themselves and their infants. Most facilities face a shortage of prophylactic drugs, primarily cotrimoxazole and nevirapine syrups, for infants and women, and other drugs used to treat opportunistic infections. As a result, women lost their PMTCT care when told to buy prophylactic syrups for infants and therapeutic drugs to treat opportunistic infections for themselves.

“Lack of cotrimoxazole syrup is one of the major reasons for women to miss PMTCT clinic visits. In our facility, it was out of stock for the last three months. Women can't afford its cost due to their economic problems.” (MSG-03, 34-year-old provider, married, 12 years of service experience)

Inadequate service access

Most women travelled long distances to reach health facilities to get PMTCT service due to the absence of a PMTCT site in their area. Due to a lack of transportation access and/or cost, they were forced to miss clinic visits for PMTCT care.

“In this district, there were only two PMTCT sites. Women travelled long distances to get the service. To reach our facility, they must travel half a day or pay more than three hundred Ethiopian birr for a motorbike that some cannot afford. Thus, women lost the service due to inadequate service access.” (P-06, 30-year-old provider, male, 2 years of experience in the PMTCT unit)

In almost all facilities, PMTCT service was not given on weekends and holidays, despite women's interest in being served at these times. When ARV drugs were stocked out at their homes, they did not get the drugs if facilities were not providing services on weekends and holidays. When appointment date was passed, they lost care due to fear of health workers’ reactions.

Lack of confidentiality

Despite maintaining ethical principles to retain women in care, breaches of confidentiality by HCWs were one of the reasons for LTFU by women. Women were afraid of meeting someone they knew or that their privacy would not be respected. As a result, they lost from PMTCT care.

“I don’t want to visit the facility. All my information was distributed to the community by a HCW who counselled me at the antenatal clinic.” (W-09, 25-year-old woman, married, daily labourer)

Reasons for resumption after LTFU

Healthcare workers' commitment to searching for lost women, partners’ encouragement, and women’s health status were key reasons for resuming women's Option B plus services after LTFU.

Healthcare workers’ commitment

The majority of lost women resumed Option B plus care after LTFU when healthcare workers called them via phone or conducted home visits for those who could not be reached by phone call.

“We went to a woman’s home, who started ART during delivery and lost for four months, travelling about 90 kilometers. She just cried when she saw us. She said, 'As long as you sacrificed your time traveling such a long distance to return me and save my life, I will never disappear from care today onward.' Then, she returned immediately and was linked to the ART unit after completing her PMTCT program.” (P-13, 32-year-old provider, male, 5 years of experience in the PMTCT unit) “We have an appointment date registry for every woman. We waited for them for seven days after they failed to arrive on the scheduled appointment date. From the 8th day onward, we called them via phone if it was available and functional. If we didn't find them via phone, we conducted home visits and returned them to care.” (P-02, 24-year-old provider, female, 3 years of experience in the PMTCT unit)

Partner encouragement

Women who got their partners' encouragement did not drop out of PMTCT care. Besides, most women returned to care and restarted their ARV drugs due to partner encouragement.

“I did not disclose my HIV status to my husband, which was diagnosed during the antenatal period. I lost my care after the delivery of a male baby. When my husband knew my status, rather than disagreeing, he encouraged me to resume the care to live healthily and to prevent the transmission of HIV to our baby. This was why I resumed care after LTFU.” (W-14, 28-year-old woman, divorced, daily labourer)

Women’s health status

Some women returned to Option B plus care on their own when they felt sick and wanted to stay healthy.

“When I felt healthy, I was away from care for about eight months. Later on, when I sought medical care for the illness, doctors gave me medicine and linked me to this unit (the PMTCT unit). I returned because of sickness.” (W-06, 29-year-old woman, married, daily labourer)

This qualitative study assessed the reasons why women left the service and why they resumed care after LTFU. The study aimed to enhance program implementation by providing insights into reasons for LTFU and facilitators for resumption from women's, health professionals', and MSG members' perspectives. We found that financial problems, partner violence, lack of support, HIV-related stigma and discrimination, lack of awareness, religious belief, shortage of drug supply, poor access to health services, and fear of confidentiality breaches by healthcare providers were major reasons for LTFU from PMTCT care. Healthcare workers’ commitment, partner encouragement, and feeling sick made women resume PMTCT care after LTFU.

In this study, fear of partner violence and divorce were identified as major reasons that made women discontinue the PMTCT service. Men are the primary decision-makers regarding healthcare service utilization, and the lack of male involvement in the continuity of PMTCT care decreases maternal health service utilization, including PMTCT services 41 , 42 . In addition, economic dependence on men threatened women not to adhere to clinic appointments without their partner’s willingness due to fear of violence and divorce 28 . Thus, strengthening couple counselling and testing 13 , male involvement in maternal health services, and women empowerment strategies like promoting education, property ownership, and authority sharing to reach decisions on health service utilization were crucial to retaining women in PMTCT care. Besides, legal authorities and community and religious leaders should be involved in preventing domestic violence and raising awareness about the negative effects of divorce on child health.

Financial constraints to cover daily expenses were major reasons expressed by women for LTFU from PMTCT care. Consistent with other studies, this study revealed that a lack of money to cover transportation costs resulted in poor adherence to ART and subsequent loss of PMTCT care 27 , 29 , 43 . As evidenced by other studies, lack of food resulting from financial problems was a major reason for LTFU in the study area 30 . As a result, women prefer death to living with hunger due to food scarcity, which led them to LTFU. Besides, women of poor economic status spent more time on jobs to get money to cover day-to-day expenses than thinking of appointment dates. Thus, governments and organizations working on HIV prevention programs should strengthen economic empowerment programs like arranging loans to start businesses and creating job opportunities for women living with HIV.

Despite continuous information dissemination via different media, fear of stigma and discrimination was a frequently reported reason for LTFU among women in PMTCT care. Consistent with other studies conducted in Ethiopia and other African countries, our study identified that fear of stigma and discrimination by partners, family, and community members are significant risk factors for LTFU 27 , 28 , 29 , 31 . As a result, women did not usually disclose their HIV status to their partners 28 , 32 so that they could not get financial and psychological support. This highlights the need to intensify interventions by different stakeholders to reduce HIV-related stigma and discrimination in the study area. Women's associations, community-based organizations, and religious, community, and political leaders should continuously work on advocacy and awareness creation to combat HIV-related stigma and discrimination.

Our study revealed that a lack of support for women made them discontinue life-saving ARV drugs. In developing countries like Ethiopia, most women living with HIV have low socio-economic status to run their lives, and thus they need support. However, as claimed by the majority of study participants, the government and organizations working on HIV programs were decreasing support from time to time. This was in line with qualitative studies such that lack of support by family members or partners 27 was identified as a barrier to adherence to and retention in PMTCT care 27 , 28 , 29 , 30 , 32 . Organizations working on HIV programs need to design strategies so that poor women get support from partners, family members, the community, religious leaders, and the government to stay in PMTCT care. Moreover, some women thought incentives and support must be given to retain them in Option B plus care. Thus, HCWs should inform women during counselling sessions that they should not link getting PMTCT care to incentives or support.

Women infected with HIV want to be healthy and have HIV-free infants, which could be achieved by proper utilization of recommended therapy as per the protocol 27 , 43 . However, women’s religious beliefs were found to interfere with adherence to the recommended treatment protocol, made them LTFU, and refused resumption after LTFU. Although religious belief did not oppose the use of ARV drugs at any time, women did not take the medicine when they went to Holy Water and prayer. As evidenced by previous studies, lost women perceived that they were cured of the disease with the help of God and refused to resume PMTCT care 27 , 30 . This finding suggests the need for sustained community sensitization about HIV and its treatment, engaging religious leaders. They need to inform women on ART that taking ARV drugs does not contradict religious preaching, and they should not discontinue the drug at any religious engagement.

Once on ART, women should not regress from care and treatment due to problems related to the facility. Unlike the study conducted in Malawi, which reported a shortage of drugs as not a cause of LTFU 29 , in the study area there was a shortage of drugs and supplies to give appropriate care to women and their infants and to retain them in care. They did not get all services related to HIV free of charge and were requested to pay for them, including the cotrimoxazole syrup given to their infants. The finding was consistent with the study conducted in Malawi, where the irregular availability of cotrimoxazole syrup was mentioned as a risk factor for LTFU 32 .

On some occasions, there may also be a shortage of ARV prophylaxis (Nevirapine and Zidovudine syrups) at some facilities for their infants that they couldn’t get from private pharmacies. Services related to PMTCT care were expected to be free of charge for mothers and their infants throughout the care. Ensuring an adequate supply of prophylactic and therapeutic drugs should be considered to prevent the MTCT of HIV and control the spread of the disease among communities via appropriate resource allocation. Facilities should have an adequate supply of ARV prophylaxis and should not request that women pay for diagnostic services. Besides, they always need to provide cotrimoxazole syrup free of charge for HIV-exposed infants.

Lack of awareness of a continuum of PMTCT care among women is a major challenge to retaining them in care. Women who experienced malpractice against standard care practice and had misconceptions about the disease were at higher risk for LTFU. Those women who forgot to take ARV drugs due to different reasons (maybe due to poor counselling) did not get the benefits of ART. Improved counselling and appropriate patient-provider interaction increase women’s engagement in care and reduce the risk of LTFU 28 , 44 . Thus, proper counselling on adherence, malpractice, and misconceptions should be strengthened by healthcare providers in PMTCT units to create optimal awareness for retention.

Maintaining clients’ confidentiality is the backbone of achieving HIV-related treatment goals. However, some women disappear from PMTCT care due to a lack of confidentiality by HCWs delivering the service. Although not large, women claimed a lack of privacy during counselling, and disclosing their HIV status in the community was practiced by some healthcare professionals. The finding was consistent with the study conducted in developing countries, including Ethiopia, where lack of privacy and fear regarding breaches of confidentiality by healthcare workers were identified as risk factors for LTFU 31 , 32 , 44 . Thus, HCWs should deliver appropriate counselling services and maintain clients’ confidentiality to develop trust among women.

The validity of the findings of this study was strengthened by the triangulating data collected from women, MSG members, and HCWs delivering PMTCT service. Besides, the study included women from the community who had already been lost from care during the study, which minimized the risk of recall bias. However, we recognized the following limitations. First, the study did not explore the husband’s perspective to validate the findings from women and HCWs. Second, the study may have different reasons for LTFU for women who were unreached or unwilling to participate compared to those who agreed to be interviewed. Thus, further studies are advised to include the husband’s perception to validate their concern and to address all women who have lost care.

Conclusions

Financial constraints to cover transportation costs, fear of partner divorce and violence, HIV-related stigma and discrimination, lack of psychological support, religious belief, shortage of drug supply, inadequate service access, and breach of confidentiality by HCWs were major reasons for women’s lost. Healthcare workers’ commitment to searching for lost women, partners’ encouragement to resume care, and women’s desire to live healthily were explored as reasons for resumption after LTFU. Women empowerment, partner engagement, involving community and religious leaders, awareness creation on the effect of HIV-related stigma and discrimination for the community, and service delivery as per the protocol were of vital importance to retain women on care and resume care after LTFU. Besides, HCWs should address false beliefs related to the disease during counseling sessions to retain women in care.

Data availability

All data generated or analysed during this study are included in this article and its Supplementary Information files.

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Acknowledgements

The authors acknowledge the staff of the South Ethiopia and Central Ethiopia Regional Health Bureaus for their technical and logistic support. Moreover, the authors sincerely thank the research assistants who translated and transcribed the interview. The authors would also like to thank the study participants who were involved in the study.

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W.F. was involved in the study's conception, design, execution, data acquisition, analysis, interpretation, and manuscript drafting. T.T., E.W., and A.A. were involved in the project concept, guidance, and critical review of the article. All the authors have reviewed and approved the final manuscript and agreed to publish it in scientific reports.

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Facha, W., Tadesse, T., Wolka, E. et al. A qualitative study on reasons for women’s loss and resumption of Option B plus care in Ethiopia. Sci Rep 14 , 21440 (2024). https://doi.org/10.1038/s41598-024-71252-2

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Supporting recovery, healing and wellbeing with Aboriginal communities of the southeast coast of Australia: a practice-based study of an Aboriginal community-controlled health organisation’s response to cumulative disasters

• Lynne Keevers 1 ,
• Maria Mackay 2 ,
• Sue-Anne Cutmore 4 ,
• Kristine Falzon 3 ,
• Summer May Finlay 4 ,
• Samantha Lukey 5 ,
• Julaine Allan 6 ,
• Chris Degeling 4 ,
• Ruth Everingham 7 ,
• Mim Fox 4 ,
• Padmini Pai 7 &
• Katarzyna Olcon 4  

BMC Health Services Research volume  24 , Article number:  1068 ( 2024 ) Cite this article

Metrics details

The recent crises of bushfires, floods, and the COVID-19 pandemic on the southeast coast of Australia were unprecedented in their extent and intensity. Few studies have investigated responses to cumulative disasters in First Nations communities, despite acknowledgement that these crises disproportionately impact First Nations people. This study was conducted by Aboriginal and non-Aboriginal researchers in partnership with Waminda, South Coast Women’s Health and Wellbeing Aboriginal Corporation, an Aboriginal Community Controlled Health Organisation (ACCHO). It investigated the collective experiences of people affected by cumulative disasters to identify the practices that support healing, and recovery for Aboriginal communities. The study addresses a knowledge gap of how Waminda, designs, manages and delivers responses to address complex health and social issues in the context of cumulative disasters.

Underpinned by practice theory this study employed Indigenous-informed, narrative inquiry. Culturally-appropriate, multiple interpretive methods were used to collect data including: observations; yarns with Aboriginal community members, yarns with Waminda practitioners, management and board members; interviews-to-the-double, visual images and documentation. The data were collated and analysed using the phases of reflexive thematic analysis.

The paper articulates a suite of culturally safe and place-based practices that enhance social, emotional and spiritual well-being following cumulative disasters. These practice bundles include: adopting a Country-centred conception of local communities; being community-led; viewing care as a collective, relational, sociomaterial accomplishment and having fluid boundaries. These practice bundles ‘hang together’ through organising practices including the Waminda Model of Care, staff wellbeing framework and emergency management plan which orient action and manage risks. The paper demonstrates the need for disaster responses to be community-led and culturally situated. ACCHOs are shown to play a crucial role, and their local responses to immediate community needs are grounded in contextual knowledge and use existing resources rather than relying on mainstream system-wide interventions.

Conclusions

The paper suggests crafting responses that focus on assisting communities (re)gain their sense of belonging, hope for the future, control over their lives and their capacities to care for and to be cared for by Country, are key to both enhancing healing, health and well-being and harnessing the strengths of communities.

Peer Review reports

Introduction

The recent climate-related crises of bushfires, floods, and the COVID-19 pandemic on the southeast coast of Australia were unprecedented in their extent and intensity. The 2019–2020 bushfires burnt 5.4 million hectares and killed an estimated 800 million animals [ 1 , 2 ]. Much of the National Parks in the region were burnt. Plants, birds, animals, insects, and people were killed, and habitats, homes and infrastructure destroyed in rural and regional communities. These communities were in the early stages of bushfire response and recovery when floods, the COVID-19 pandemic and restrictions on movement hit.

Few studies have investigated responses to cumulative disasters in Aboriginal and Torres Strait Islander communities, despite acknowledgement that these crises disproportionately impact Aboriginal people as residents, as communities and as traditional custodians of Country [ 3 ]. The roles of Aboriginal communities in disaster planning, response and recovery have previously been overlooked [ 3 , 4 ].

Accordingly, in this study, an interdisciplinary team of Aboriginal and non-Aboriginal researchers investigate the collective stories of people affected by cumulative disasters to identify the practices they experienced as helpful in healing, health and wellbeing for Aboriginal communities and Country.

The research is conducted in partnership with Waminda, South Coast Women’s Health and Wellbeing Aboriginal Corporation. Waminda is a women-led Aboriginal Community Controlled Health Organisation which raises the health, well-being and spiritual status of Aboriginal and Torres Strait Islander women and their families in Southeast New South Wales, Australia on Yuin Country. For 39 years Waminda has been providing culturally safe and holistic services within the Shoalhaven region and outreach services from Wollongong to Wallaga Lake. Waminda offers the opportunity to belong and receive quality health and well-being support using a tailored, strength-based approach [ 5 ]. Waminda is recognised in Australia and internationally as a centre of excellence for Aboriginal and Torres Strait Islander Health and as a leader in ensuring culture is the central focus in enhancing social, spiritual, and emotional well-being [ 6 ].

This study addresses a knowledge gap of how Waminda, designs, manages and delivers responses to address complex health and social issues in the context of cumulative disasters. It demonstrates the need for disaster responses to be community-led and culturally situated. ACCHOs are shown to play a crucial role, and their local responses to immediate community needs are grounded in contextual knowledge and use existing resources rather than relying on mainstream system-wide interventions.

This paper articulates culturally-safe, place-based practices that assist communities (re)gain their sense of belonging, hope for the future, control over their lives and their capacities to care for and to be cared for by Country. These are key indicators of health, well-being, and inclusive communities [ 7 ] and thereby, central to enhancing healing and recovery.

Specifically, the paper addresses the following research question. What do the collective narratives of Aboriginal people affected by cumulative disasters tell us about the practices that support social and emotional well-being, healing, and recovery?

To achieve these aims we adopt Gee and colleagues’ [ 8 ] p 0.55 definition of social and emotional well-being (SEWB) as a ‘multidimensional concept of health that includes mental health, but which also encompasses domains of health and well-being such as connection to land or ‘country’, culture, spirituality, ancestry, family, and community’. The importance of the social, cultural, historical, and political determinants in shaping Aboriginal and Torres Strait Islander SEWB [ 9 ] is foregrounded in this paper.

This paper recognises that naming First Nations people is complex and varied. Aboriginal peoples is a broad term for the custodians of the lands within which this research was conducted. The term Aboriginal peoples and/or communities is used in this context. Aboriginal and Torres Strait Islander peoples is also used when referring to Australian First Nations peoples. First Nations peoples encompass the diversity of Aboriginal and Torres Strait Islander cultures and identities and is also used in an international context. Before invasion there was no collective term for the diverse cultural and language groups of this Country [ 10 ].

Taking guidance from Waminda, and the research participants, Country is capitalised in this study as it is not only a common noun but also a proper noun. As discussed by Rose [ 11 ] p. 7) ‘people talk about Country in the same way that they would talk about a person: they speak to Country, sing to Country, visit Country, worry about Country, feel sorry for Country, and long for Country. People say that Country knows, hears, smells, takes notice, cares, and is sorry or happy. Country is a living entity with a yesterday, today, and tomorrow, with a consciousness and a will toward life’.

Before discussing our research methods, analysis of the data and findings, we present a review of the literature focused on the question- What is the evidence about practices that support or hinder healing post cumulative disasters for First Nations’ communities and the environments to which they belong? We review, in the context of colonisation, the impacts of cumulative disaster on First Nations communities, the contributions of First Nations knowledges to disaster management and the roles of ACCHOs in disaster risk reduction, response, recovery and mitigating cumulative traumas.

Cumulative disasters and First Nations communities

The cumulative disasters experienced over recent years have posed a threat to Aboriginal heritage and cultural practices creating challenges for community recovery [ 12 ]. Cumulative disasters contribute to a reduction in economic and social resources and a depletion of community resilience which, according to Anderson [ 13 ], is detrimental to collective SEWB. Further, the increase in social disadvantage can result in a deterioration of relational supports, consequently impacting mental and emotional health [ 14 , 15 ]. First Nations peoples have expressed grief and loss over disasters’ impact on Country [ 14 ], grieving for both human and non-human kin [ 16 ]. Ballard and colleagues’ [ 14 ] study found a continuation of suffering in community, in relation to the overlapping losses and the damage Country continues to experience.

Since colonisation, First Nations peoples in Australia have experienced a loss of cultural, social, spiritual, and political rights, been dispossessed of their Country, and denied their identities [ 17 ]. The ongoing impacts of colonisation have forced many First Nations peoples to the margins, with the consequence of being amongst the most at-risk populations for poor health and well-being outcomes anywhere in the world [ 18 ]. As Williamson and colleagues [ 16 ] argue, this situation has also resulted in Aboriginal and Torres Strait Islander peoples having extensive experience of the impacts of trauma and, thereby, much to teach regarding resilience, resistance, recovery and strengths in relation to climate-related crises.

Relatedly, localised First Nations knowledges are significant in disaster risk reduction, response, and recovery, with mutual collaboration amongst community identified as a key practice in responding to disasters [ 19 ]. Ali and colleagues [ 18 ] argue approaches must be locally led by First Nations peoples using community development principles and situated on Country. However, instead of First Nations knowledges being utilised, climate-related disasters have compounded First Nations people’s experiences of marginalisation [ 20 ]. Rawson’s [ 21 ] study situated in Aotearoa/New Zealand shows that seeking assistance from health services or emergency response agencies is often problematic for First Nations peoples due to institutional racism, discrimination and dealing with the ‘system’ [ 21 ] p. 84. Williamson and colleagues [ 22 ] concur, arguing that without specific attention to the structural issues that perpetuate racism First Nations peoples will continue to be marginalised and excluded from disaster risk reduction, response, and recovery. There is a need to recognise the importance of self-determination in disaster response and recovery, cease the continued marginalisation of First Nations’ voices and work collaboratively to bring their voices to the centre of decision-making [ 22 ]. For example, caring for Country is an intimate cultural responsibility for First Nations people [ 18 ], making up the human and non-human networks of kinship connections [ 4 ]. This care has been found to be beneficial to First Nations people’s SEWB [ 23 ] as healing through spiritual and cultural practices is tied to Country [ 3 ]. The view of land as spiritual and interconnected highlights the significance of First Nations peoples’ decisions to remain on Country despite experiencing consecutive disasters [ 22 ].

Accordingly, Weir and colleagues [ 24 ] argue that Country must be considered the priority in risk reduction, response, and protection as such an approach will also ensure the protection of human life and property as they are inherently connected to Country. While disaster risk reduction specifically associated with bushfires should be a focal point for risk management [ 24 ], there are risks to First Nations people when sharing cultural knowledge in relation to caring for Country. Fire management expertise as it relates to cultural burning is an example. This cultural practice is often perceived by non-Indigenous stakeholders as purely fire management rather than directly related to care of Country [ 3 ].

First Nations people’s relationship with Country is political in colonised lands such as Australia [ 22 ]. This politics incorporates the legal rights over land and the importance of Country, shaping First Nations people’s cultural and social lives. Though laws in Australia have changed to enable the management of some areas of Country, most First Nations peoples have been consigned to the margins in managing their homelands [ 16 ]. First Nations peoples are often excluded from decision-making, with regulatory bodies focussing on caring for townships over Country [ 25 ].

Health services responses: the role of ACCHOs

ACCHOs are sites where Aboriginal people are centrally involved in decision-making as they are governed by a community-member board that primarily employs Aboriginal staff [ 26 ]. In Australia, ACCHOs are situated in communities providing holistic primary health care to their Aboriginal communities [ 26 ]. Disaster management and recovery literature demonstrates ACCHOs are central in enabling localised, timely responses to disasters as they possess local knowledge to provide culturally safe approaches to disaster management in their communities [ 26 ]. Cullen and colleagues [ 27 ] assert partnering with community is key to identifying firstly, what is needed, and secondly, the ability to respond to those needs. For example, during disaster management ACCHOs have led responses to basic needs such as access to food security, acquiring stable housing and supporting SEWB [ 26 ].

In the initial phases of disaster management, Hadlos and colleagues [ 19 ] review of the literature found ACCHO’s responses utilised the resources and efforts within community with minimal reliance on external services. McCalman and colleagues [ 26 ] study found the community valued the nimble and holistic responses of ACCHOs to the COVID 19 pandemic and that this responsiveness reduced health and well-being risks to individuals and communities alike. Importantly, Williamson [ 3 ] claims ACCHO’s were not established or funded to account for disaster management and these additional responsibilities have made agency resource constraints visible.

Despite evidence of the impact disasters have on humans and non-human kin the authors could find few studies of consecutive disasters within First Nations’ communities [ 28 ]. Further, the authors could find no literature exploring the practices that support holistic well-being, healing, and recovery for First Nations peoples from cumulative disasters. Although, practice theory has informed and been informed by First Nations research in such areas as: racism in Finland and Australia [ 29 ] financial education in Canada [ 30 ] and Aboriginal and Torres Strait Islander young people and learning [ 31 ] the authors could find no literature providing a First Nation’s lens on practice theory in relation to disasters. Accordingly, this study uses an Indigenous-informed approach to practice theory to investigate responses that support Aboriginal communities to heal and articulates the connections between practices enacted by Waminda staff, participants, and communities to enhance mental, physical, emotional, social, and spiritual well-being.

Research sites, methodology and methods

This study focuses specifically on Waminda’s SEWB practices with service recipients, staff, and their communities in the context of the 2019–2020 bushfires, floods, and the COVID-19 pandemic. The SEWB team works across services and programs, collaborating to support people’s decision-making, healthcare needs, cultural knowledges, and cultural safety. The SEWB programs assist clients in having access to the specialist physical and psychological care they need in a timely manner, and with a focus on flexible service delivery. This context of cumulative disasters demanded an expansion of Waminda’s service footprint to include Aboriginal communities in towns and villages along 300 km of the south coast. Accordingly, this study, includes as research participants Waminda staff, service recipients and community members from the distributed Aboriginal communities of the Illawarra, Shoalhaven and far south-coast regions impacted by the cumulative disasters.

This study was approved by the Aboriginal Health and Medical Research Council Human Research Ethics Committee (no. 1779/21) and the Ethics Committee of The University of Wollongong & ISLHD Health and Medical Human Research Ethics Committee (no. 2021/ETH00110). No ethical issues were identified in the study. Eleven authors identify as female and one as male with backgrounds in social work, public health, nursing, Aboriginal and Torres Strait Islander healthcare and occupational therapy. This interdisciplinary team is well suited to conduct the study as most have extensive experience in collaborative research using qualitative methods, four team members have First Nations cultural knowledges, nine have PhDs and five live in the communities directly impacted by the bushfires and floods. The lead author has expertise in applying practice theory to research and guided the conceptual framework of the study.

Methodology

Underpinned by practice theory [ 32 ] this Indigenous-informed, narrative inquiry [ 33 ] was co-designed with Waminda. Healthcare settings and organisations are turning to practice theory to understand health services responses and service user experience [ 32 ]. Reviews of mental health and psychological interventions have emphasised the need for practice-based evidence from everyday clinical and organisational settings to complement the evidence-base obtained from randomised controlled trials [ 34 ].

In practice theory, the primary unit of analysis is practice, described by Schatzki [ 35 ] as the complex interactions of sayings, doings and relatings between people, other beings, and material artefacts. Accordingly, a practice-based approach for this study focuses on the situated, embodied, spatially and temporally extended ways that staff and community members involved with Waminda work to support recovery in local communities amid environmental and public health crises. This approach involves working with Waminda and their communities to identify from their collective narratives [ 36 ] the practices, relations and the spiritual and material arrangements that enhance recovery, well-being and healing for people, kin, communities, sea, and land [ 37 ].

The researchers’ community-engaged, participatory standpoint aims to learn with and from Waminda and the communities they serve. Indigenous-informed narrative inquiry is a methodology that is inclusive of multiple stakeholders and involves individual and collective exploration of experiences and critical reflection on practices [ 33 ]. Such an approach is particularly suited to this project as it stresses the importance of context and culture. Story and the act of storytelling are important in many First Nations people’s communities [ 38 ] and well suited to research with Waminda, which involves local Aboriginal communities as participants in the study. The methodology emphasises oral communication, relationship and co-creation between researchers and participants [ 38 ]. Storytelling is an ideal method for integrating the role of other-than-human elements such as Country, animals, water, wind and fire into data collection and analysis [ 39 ].

Participant recruitment and selection

Purposive sampling was used to recruit participants who were: (1) Waminda staff, management, or board members (2) South coast Aboriginal community members over the age of 18 years who were impacted by the 2019–2020 bushfires, floods, and the COVID-19 pandemic. All participants are de-identified and pseudonyms are used. Aboriginal community members, Waminda staff, management and board members were recruited via email, flyers, announcements at meetings and gatherings at Waminda between May 2021 and April 2022. The Participant Information Sheets (PIS) were made available, the researchers talked through the PIS and answered any questions that potential participants had. Informed written consent was obtained from participants prior to data collection.

Data collection methods

Capturing practice requires a toolkit approach, asserts Nicolini [ 40 ]. Accordingly, culturally-appropriate, multiple interpretive data collection methods were utilised, including:

Written ethnographic accounts of observations of a range of Waminda programs, workshops, and everyday interactions (approximately 14 h of observations) [See supplementary file A for observation protocol].

Transcripts of yarns with 38 Aboriginal people (Female = 33, Male = 5, Age = 25yrs-78yrs) living in 7 communities impacted by cumulative disasters. Our conversational yarning approach uses four types of yarning, adapted from Bessarab and Ng’andu [ 41 ] - the social yarn, the research yarn, the healing yarn, and the collaborative yarn. Yarns ranged from 37 to 150 min [See supplementary file B for Yarn guide].

Transcripts of yarns conducted with 32 Waminda practitioners, managers, and board members (Female = 30, Male = 2, Age = 24yrs- 61yrs). Yarns ranged from 32 to 143 min [See supplementary file C for yarn interview guide].

Transcripts of interviews-to-the double with 6 female practitioners from Waminda’s SEWB programs. The interview-to-the-double [ 42 ] is a technique that asks interviewees to imagine they have a double (the interviewer) who will replace them in their job. The interviewee is then asked to provide the necessary detailed instructions which will ensure that the ‘double;’ will not be unmasked. This technique is useful for verbally eliciting and articulating practice in a situated context when direct observation is impossible or undesirable. They ranged from 50 to 61 min. [See supplementary file D for interview-to-the double guide].

Transcripts of two collaborative yarns that involved SEWB staff, board members, Waminda managers and research team members, sense-making, co-analysing and reflexively discussing early research findings to explain or make visible practices and new understandings [ 41 ].

Translation of early analysis of the data into visual images by research participants.

Documentation and artefacts including Waminda’s model of care, Balaang Healing framework, staff wellbeing framework, emergency management plans, Annual Reports, and photographs of the bushfire and COVID responses.

SC, LK, MM and SF collected the data and participants identified themselves to these four authors. Two of these researchers knew some of the research participants prior to conducting the research. All yarns and interviews-to-the double were audio recorded and professionally transcribed.

Data analysis

To identify the practices that support SEWB, healing and recovery in the narratives of Waminda staff and community members, we ‘zoomed in’ on the doings , sayings , relatings , spiritual and material arrangements discussed in the data. We also ‘zoomed out’ to the broader organisational, social, and political context and arrangements [ 43 ]. The data were deidentified prior to analysis. The data were collated and analysed using the phases of reflexive thematic analysis outlined by Braun & Clarke [ 44 ] by LK, MM, SC and RE. The researchers initially: (1) familiarised themselves with the data; (2) coded the data using words from the texts; (3) inductively developed more ‘abstract’ codes to develop the themes; (4) reviewed the themes; and (5) refined and named the themes [ 45 ]. This early identification and analysis of themes and practices was corroborated in sense-making, collaborative yarns conducted with managers, board members and practitioners. We incorporated member checking, co-analysis, and validation by inviting research participants to review and comment on their transcripts and our early interpretations of the data [ 46 ].

In this section, we analyse the practices enacted by Waminda that were co-emergent and co-constitutive of their responses to the environmental and public health crises. The data analysis identified five dominant practice bundles [ 35 ] in the Waminda responses. Drawing on Schatzki [ 35 ] practice bundles refer to sets of practices and spiritual and material arrangements that work together and are interconnected in more or less dense and persistent ways [ 47 ]. The practices are not discrete, they are entangled, bundled together such that each practice bundle is comprised of multiple practices. These practice bundles and some of the practices that make them up are:

Adopting a country-centred conception of local communities.

Connecting to Country spiritually, physically, affectively, and emotionally.

Complex view of bushfire as a resource for healing.

Caring for Country after the bushfires- a practice for healing.

Community-led

Deep listening.

Response-ability.

Networking.

Fluidity of boundaries.

Willingness to change roles and transform spaces.

Expanding boundaries and the Waminda footprint.

Caring: a sophisticated, collective, socio-material accomplishment.

Sociomateriality of care practices.

Hanging in there, staying with the struggle.

Enabling women to be active in their own care.

Organising practices: orientating situated actions and managing risks.

Enacting the Model of Care and emergency management plan.

Co-ordinating and enabling the practice bundles to ‘hang’ together.

These practice bundles work together to form a texture of practices that harness the strengths of Aboriginal communities in disaster responses and recovery. The practice bundles and the practices which constitute them were translated into visual images (Fig.  1 ) by some research participants, led by Aunty Lorraine Brown and Aunty Narelle Thomas, renowned artists from the Coomaditchie United Aboriginal Corporation. Figure  1 beautifully shows how these practice bundles and themes are entangled, overlap and not easily separable.

Strengths of our communities- Lorraine Brown & Narelle Thomas

Aunty Lorraine Brown and Aunty Narelle Thomas explain:

The flower shapes, handprints and footprints represent community and the strength that brings community together in times of tragedies, loss, destruction and a fight against sickness [COVID pandemic], fires and floods. People working together to console, to care, to listen, to repair and to find the overpowering strength to continue on. The lines connect these communities together- the bold colours reflect- east coast saltwater people, communities and Country.

Adopting a country-centred conception of local communities

Waminda adopts a Country-centred conception of community connections and local communities that encompass the land, other-than-humans, humans, and the entangled relations amongst them. This ontological standpoint is threaded through all the practice bundles discussed in this paper. This inseparability of Country and community means practices such as connecting to Country, caring for Country after the bushfires and adopting a complex view of bushfire are key resources for healing body, mind, spirit, and heart’s pain.

Connecting to country spiritually, physically, affectively, and emotionally

The entanglement of personal and Country well-being is evident in Dawn’s, an Aboriginal health practitioner, description of travelling down to Mogo after the fires.

That trip down the coast was the saddest trip that I’ve ever had in all my life. And I’ve been travelling down there since I was a kid. To see that much of the bush burned out. It was so so sad. And when I came to Mogo and seen the way it was burned and how it was affected, that first time I really cried. And to go down there now, it’s so refreshing. I really love the drive now because everything’s regenerating and the trees are all growing so it makes me feel good again, so good.

The centrality of connecting to Country for healing, recovery and holistic well-being is reinforced by Aunty Margaret, an Elder and Waminda board member, who comments:

People are very connected to the ocean. I think they’re not going to fully recover until COVID goes and it stops disrupting everything because they really haven’t been able to recover because COVID came just after the bushfires. But their connection to the water and that, they get … how could you say it? … like a sense of belonging, when they go to the water to collect their food and to fish and to do all of that stuff. That’s all a normal part of our culture, to be connected to the water and live from the water.

Aunty Margaret’s words demonstrate the centrality of practices involving the ocean for enhancing well-being after the bushfires and how COVID-19 movement restrictions made such gatherings and intermingling with the sea impossible for some communities. Simultaneously, for those communities who were able to continue to be nourished and sustained by the ocean, these cultural practices involving water were key to mitigating the isolation, uncertainties and restrictions that were part of the COVID-19 pandemic.

Complex view of bushfire as a resource for healing

Manaaki, a case worker, describing his experience of the bushfires, illustrates the tensions, complexities and nuanced view of fire underpinning the Waminda response:

It was like the apocalypse. It was confronting living in bush smoke every day. Having, you know, ashes landing in your backyard, just awake all night with the worry of maybe the house might get burnt down, you know, and watering the roof. I think seeing injured and dead animals from it too was pretty hectic… Yeah, I think also understanding the necessary sort of process of it [fire] for healing Country… how fire relates to birthing and renewal, sort of like that phoenix concept… The germinator of seeds in Country here. Yeah, it was like the whole country was getting smoked and sort of like a ceremonial state but the level it went to was not good for the trees and not good for Country. There is a lot of healing that needs to come about. Yeah, a lot of animals were lost, a lot of homes were lost. Yeah, I sort of balance it with – I balance the grief and loss with that philosophy of the renewal of life.

This stance of holding in tension the terrible, regenerative, and ceremonial potentials of fire is embodied in Waminda practising smoking ceremonies as a means of coming together for healing in the midst of their bushfire response. Sharmaine, a manager, and member of Waminda’s cultural committee explains.

So, when we came back from the bushfires and come back into work, and there was that feeling of loss, and there was that feeling of grief … So, yeah, we thought, “Well, what do we need to do? We need to come together. We need to come to a place where that healing, we need that cleansing, we need a smoking”. So, that’s where the smoking actually come from, and that’s what the cultural committee agrees to have with all staff [both Aboriginal and non-Aboriginal], because it affected all staff.

Caring for country after the bushfires- a practice for healing

A common practice evident in community yarns is the healing power of caring for Country and learning to care for Country after the bushfires. Meryn’s, (community member) narrative is representative:

So, we did wildlife care and the wild feeds. Also, people were putting bread out, and so we were going around collecting the bread, because it’s not actually good for them. We put fruit out instead. So, we did that around Watos with the boys, with the guidance of Maria and Jamie down the road telling us… And we got educated … on our walk we’d take a little thing of seeds, and you sprinkle it on the front yards of everyone down where it was all black, for the kangaroos and that. I think it’s made all of us respect the land we live on and what it gives us. Not just our house, but everything around us, to watching it being black to seeing how quick it grew. Like, the green was, it come back really quickly, didn’t it? The kids learnt so much about the animals and feeding them, putting water out, which they still do now. They all made the bird feeders, and how you can’t paint them because you don’t want them to get sick from the paint… it’s all got to be oiled. We learnt all that from other Elders teaching us. People sharing their knowledge. As young people, you don’t really know… I never, ever looked at the ground, the trees, how beautiful everything was, until that fire.

Here Meryn describes how this small community came together to care for the land and kin after Country was devastated by the fires. Neighbours, both Aboriginal and non-Aboriginal, who hadn’t had much contact prior to the fire were guided by those with experience in local wildlife and land care, enabling this young Aboriginal family to learn and to begin to recover together. Meryn goes on to describe how these practices were critical to the recovery, health, and well-being of her children:

Looking after Country feeds us and the kids. The green trees and how healthy it is, only helps their health. Without that, kids like… how nasty and dark and gloomy and yuck the ground were for them. They wanted to see how… and they went down and said, oh look, it’s growing, Mum, there’s flowers! They just started to see… it’s all black, and then there’s one green plant and then more… and they want to take photos of that. And we are also so grateful to still see there’s kangaroos bouncing around again.

Perhaps the COVID-19 movement restrictions allowed these children and their community to see and notice these first green shoots, the first flowers. Perhaps if they were able to travel to school and work each day, this learning and care would not have unfolded. The small shoots of renewal may have gone unnoticed as they require slow time, close looking, touching, and smelling, an intense local attention to be seen.

Zooming out to broader context: discounting, denying and not valuing Aboriginal ways of knowing, being and doing

This bundle of practices that shape and are shaped by Waminda’s Country-centred conception of local communities challenge dominant fire risk reduction, response, and recovery discourses which position ‘the bush’ and its inhabitants at the bottom of the hierarchy for protection after human life and property.

In a collaborative yarn Aleesha and Sharmaine, managers, discuss the discounting of Aboriginal ways of knowing, being and doing embedded in such discourse.

Aleesha: I think the other part of the bushfire was the fact, the thing that made it complex, well what hurt more is that as Aboriginal people, we’ve been ignored for that long, we wouldn’t be in the place that we are in if it wasn’t for the impact of colonisation, being ignored and not listened to our traditional practices from day dot… So, when I think of the fires, I think of the ignorance. I think of how we’ve got practices that have worked for hundreds of thousands of years, but they just get pushed aside, and then we’re watching our Country, all this devastation and all that harm, because we’re ignored.

Sharmaine: And I think too, it goes back to, it’s always at the cost of something, when white people don’t listen, and it’s always at the cost of our sufferings, our environment, our Country, our land, us as people.

Within this colonised context, the data illustrates how this bundle of practices that enact a Country-centred view of local communities contributes to people’s capacity to care for and be cared by Country and strengthens their sense of belonging to their communities. Such practices, thereby, create conditions of possibility for healing and enhancing well-being for children, adults, communities, and Country.

Being led by community, listening to local people, recognising the importance of local knowledge, and trusting that the community knows what is required and what matters most to them is a dominant practice bundle evident in the data.

The following quote by Tanya, a case worker, represents this orientation to responding to disasters, which was reiterated by almost all of the Waminda staff participants.

And the work we do is driven by, it’s led by community. And I think that’s a really strong message… We are led by community and the need comes from community and that leads us. So those decisions were made by community, and we just acted upon the needs of the community.

Being community-led requires practices different from those generally enacted by emergency services, large non-government organisations and the government. Below we discuss three of the practices that make up this practice bundle: deep listening, response-ability, and networking, that the data analysis suggests work together to enable a community-led response.

Deep listening

Deep listening is central to being community-led and a key relational practice in the narratives. John, a member of the maintenance crew, turned first responder in the bushfires explains:

I think if anyone is looking to put themselves in a position to help anyone, the most important thing is to just sit there and listen. Leave your phone in the car. Grab a bit of pen and paper, then write it all down and feel that - be connected to it. Listen to the pain. You shouldn’t say anything. If you’re going to listen, you should only probably talk when asked… We could have sat in each community for hours on end. You’ve just got to get down there and have an understanding of what they was going through and the only way to do that is sit front and centre and to listen.

John’s comments encompass deep listening, listening that is respectful, that is felt and does not involve filling the silence but pays quiet attention to what is both said and not said.

Deep listening, as the foundation to being able to be community-led in the midst of disaster responses, is evident in Bridget’s, a mental health practitioner’s advice:

Listen, listen to community. No service has all the answers for community, like community, has their own answers. They will know what’s needed. They’re like the experts in their own lives and their own stories. Problems can be incurred when decisions about what is needed, is out of sync with what’s actually being asked for.

The practice of deep listening, of sitting and holding people’s suffering at the centre of attention, is crucial but not sufficient if responses are to be community-led and ‘in-sync’ with what is needed. Determining how to quickly cobble together the resources to deliver what is needed demands what Donna Haraway [ 48 ] describes as response-ability.

Response-ability

Each day as the climate-related crises unfolded, Waminda had to cultivate the capacity to respond and engage with the unexpected. Being response-able is central to effective responses, as it answers the trust of the held-out hand, demonstrates listening and remembering and, thereby, enables community-led responses. John explains:

If you’re going to do something about it or your actions, you know, there’s no point in saying “oh yeah I’m gunna”, get it, get it down there. Get it off the trucks. I think that’s what it was all about, just being present in the moment and listening and relaying that back… So, I’d ring up and say, “June we need this” and by the time we’ d get back that night we were able to access it. We were able to go purchase it. Jade and my old Brett, our finance team just had everything sorted for us. It was a collective. It wasn’t just us but the team, everyone to help and the whole organisation involved, community too. Waminda listened and Waminda actioned it.

Here response-ability is a collective knowing and doing that requires an ecology of practices to be enacted just in time to ensure communities can access the supplies, the medical attention, and the people to listen to their stories. Indeed, all the arrangements they need to sustain themselves and live with the anxiety, stress, and grief that disasters provoke. Continually cultivating response-ability ensured Waminda could meet the obligations and responsibilities that ‘turning up’ entails.

Building, extending, maintaining, and using networks across the southeast coast is a prerequisite for being community-led. The networks Waminda relied upon during the environmental and public health crises were not a contact list stored on a computer, but multigenerational webs, nodes and pathways tied together with sticky threads of connection.

Karena, a well-being support practitioner, and member of the cultural committee, explains:

We identified who the key people were in the communities who we could reach out to- to speak to them about what support the community may need that we could provide and ensure particularly for that far-south coast that it got to everyone and knowing that that’s our mob as well. We needed to be there to be able to support them.

Waminda used these key contacts and relationships as nodes, and they in turn distributed what was needed throughout their communities, creating an interlaced web in which communication travelled along many lines multi-directionally. Aunty Phyliss, a community member and Elder, described how the process worked during the COVID pandemic.

We got really good hampers from Waminda, which was really essential, and Makala would drop them all off for us… what she brought up really went around a wider community… community of people that missed out, to the people in lockdown, families with COVID. Yep, we were like drop-off point for a whole network around here, Albion Park, Unanderra, Dapto, Shellharbour….

But these networks are hard won and not easy. Sharmaine explains:

I’ll be honest, that can be challenging for us too at times. I mean, when I think about the bushfires, that was really hard, making sure that we’re having contact with those, certain contacts in community, because not all community get along, so therefore, we’ve got to make sure that we’re actually talking to everyone so that we’re not leaving anyone out. A mainstream service, they can’t do that, they can’t guide that. It’s hard enough for us to do that, let alone a mainstream service.

This bundle of practices that we call ‘community-led’ can be traced out to the institutional context within which Waminda’s responses emerged.

Zooming out to broader context: lack of institutional listening and responsiveness

Amid the bushfires and Covid-19, almost all Aboriginal community members report an absence of listening by those with decision-making power, including some health department officials and emergency services personnel and politicians. Community were denied not only a voice but also an audience. Lora, maintenance crew turned first responder, explains:

They never lost their voice. From Batemans Bay all the way down to the Inlet no one was really listening apart from I think Waminda and a few other people. They were asking you know but like our government went down, it was a big thing with Scomo [nickname of former prime minister], but it was more for the 6 o’clock news.

Yasmin, a young single mother with two children with disabilities, describes what happened when she got a text letting her know that she and her children had contracted COVID:

I got a text message to say that, I was positive. So, I rang them [the state health service] but that was it… I thought about it, like what happens if I need to call an ambulance right now? What do I do? What if they need to take me to hospital? What do I do? I’ve got two kids inside… they’re both positive for COVID, we all had it, like what do you do? They didn’t get back to me, no one listened… There was no, they didn’t even send me phone numbers to say if you need help with food, nothing. There was nothing.

The lack of responsiveness evident in Yasmin’s narrative was a common experience among research participants. Such a lack of response is dangerous, given the responsibility the state health services were accorded in providing information and guidance during the pandemic. A member of the Waminda executive, June, describes the struggles experienced trying to secure timely responses from the health system when COVID-19 first began spreading in the Aboriginal community.

Yesterday, there was a positive case in one of our clients. NSW Health just didn’t know what to do about that. We rang them and said, “Well what’s going to be our response? She’s at home with her three-year-old, like what are you going to do? Who’s going to ring her? “Oh yeah she’s on the list”. “When are you going to ring her?“… The day before we’d literally had 30 people on the Zoom, 30 big white bureaucrats talking about their response in the Aboriginal community, and they can’t go out to one woman and a three-year-old and support her with what she’s got to do and she’s positive and sick. They are trying to work out what they’re going to do while we’re doing it and they’re not listening.

It is clear from participants that while in principle primary and tertiary health services are funded to provide a service to all members of the community, in practice this was not occurring. Participants highlighted a lack of responsiveness to Aboriginal and Torres Strait Islander people in a way that meets their needs.

In this context where response-ability must be ongoing, not in the abstract but in practice, participants agreed it is difficult to overestimate the value of responses that are community-led and place local people and their knowledges at the centre of decision-making. Such practices contribute to people (re)gaining a sense of control over their life, hope for the future and ensure people experience recognition and representation.

Fluidity of boundaries

Engaging collaboratively, practising mutual respect, being response-able and privileging the expertise of the local community is also entangled with another practice bundle evident in the yarns and observations - deliberately blurring and creating fluid boundaries between workers, community members, board members and their work roles. Most workers identify as being of the community rather than simply providing services to or for the community.

Dianne, a manager, and member of the cultural committee, explains:

Because they’re us and we’re them. That’s the difference. I think that’s a big difference with Waminda. As a service, we never ever separate ourselves from community, because we are community.

Willingness to change roles and transform spaces

In responding to the bushfires Waminda’s staff had to quickly change their work roles. June, a member of the executive team, explains:

We don’t ever get people to do anything we wouldn’t do ourselves. I deliberately, and all the executive too, we were doing trips as well just so that it wasn’t like, “Okay. Well, good luck and let us know how you go when you get back.” We were just packing boxes and doing all that stuff to say, “This is what our whole response has to be because it’s sort of family”.

The building that is usually home to the SEWB and case management team was transformed into a warehouse and packing space. The maintenance crew became first responders. Michelle, member of the Beehive team, describes how their roles and work were transformed, an experience echoed by the almost all Waminda staff participants:

I remember the day that we heard about how badly the Aboriginal communities had been affected, we made a plan. We got everybody doing something, running around collecting stuff, purchasing stuff, putting the boxes together, putting the meals together, getting vouchers to help support people, trying to source generators. And we sent our maintenance team out there with all those resources for people, there were clothes, there were tents, there were sleeping bags, there were things for people who’d lost their homes… And we were the first on the ground for that community [Mogo], and in fact, in some instances it was weeks after we’d made first contact and provided them with help and assistance, that they actually got a little bit of support or even saw anyone from any of the other mainstream services. We were in constant contact with the maintenance teams to see how they’re going. We were constantly monitoring the fire situation, making sure our teams were safe.

Expanding boundaries and the Waminda footprint

This bushfire response required Waminda to expand its service footprint and boundaries quickly. Michelle’s comment is representative of Waminda staff participants views:

Community, when push comes to shove, they’ll absolutely, just respond. There’s no question of whether you’re overstepping your boundary, you know how AMSs [Aboriginal Medical Services] are supposed to only work from here to here, and the next AMS is responsible for this to this, there was none of that. There were people in need in community who weren’t getting the help from mainstream services, and it was either us or no-one. There wasn’t a question of whether or not we should. You just don’t leave your kin to suffer.

Zooming out to broader context: exclusionary boundary-making practices

This expansion of boundaries occurred when some other ACCHOs directly impacted by the bushfire, could not meet the overwhelming and urgent needs of community. Further, many Aboriginal community members experienced mainstream services as hostile, discriminatory and unwilling to assist. Trevor, an Aboriginal community member in the Dalmeny yarn and volunteer at the evacuation and recovery centres, explains:

The first shift I did at Batemans Bay, I was sitting there watching black fellas come in, get their number, told to sit down, and wait. White fellas come in, get a number, push through, go, and talk to someone, here is your hotel. Then, and I’m shaking, I’m so angry about this, I overhear shit like “that family over there is Aboriginal so just watch them because they’re from Mogo and they said they lost their house but Mogo’s fine so they’re just scamming”. Because it was two or three days for them on their little system to catch up to say that Mogo had been hit, and so for days black fellas are coming in from Mogo and they’re being ridiculed, they’re being made out to be liars, they’re being made out that they’re ripping the system off and they’re being sent away in shame with nothing.

Restricting service responses to within the boundaries determined by an inaccurate data system unable to keep pace with the spread and impacts of the mega fires produced care-less, culturally unsafe, discriminatory responses that were threaded through with racist attitudes and practices.

Caring: a sophisticated, collective, sociomaterial accomplishment

Caring for humans and other-than-human kin is at the heart of healing in climate-related disasters and a crucial practice bundle evident in the data. At Waminda, care is not a transaction, a quality, or a dyadic relationship between the carer and those being cared for. It is caring as an ongoing, sophisticated, collective, sociomaterial accomplishment.

Bridget, a mental health practitioner comments:

There’s that idea of collective care, which is culturally embedded and based on the very, if you like, vital and personal nature of the work, people are people. It’s humanising, actually. It’s a humanising way of providing care, as opposed to some of the mainstream approaches you could argue, would be more dehumanising in their approach.

This type of caring, that contains the germs of partial healing even in the face of devastation and destruction, is made up of a texture of practices including taking anticipatory action, hanging in there, staying with the struggle and creating opportunities for women to look after their own bodies and get healthier and happier with the Waminda family. Perhaps the aspects of care practices that were most dominant in the data are the powerful role of sociomaterial arrangements and enabling women to be active in their own care.

Sociomateriality of care practices

Throughout the narratives and yarns, care practices concerning both the bushfires and COVID-19 involved lots of ‘stuff’. Care was carried and enacted with/in generators, clear eyes, care-packs, bandages, food and drink, mobile phones, and social media. Natalie, an Aboriginal Health Worker, explains how she and three other young women from the palliative care team put together care packs for families during the COVID-19 lockdown, when the children were required to be home schooled:

So, this room was just lined up with boxes. There was like 20 or 30 boxes going out every few days to different families and we were listening to the families about what they needed as, depending on how many kids they had and the ages and how many adults were in the house, making sure that they had things appropriate in the box suitable for that family. So, they weren’t all just the same, each box was sort of tailored for the family… We done the food as well, craft and the activity packs for kids, basically having things set up at home because of the lockdown… Then the maintenance team would come and pick them up or anyone that was able to chuck them in their car would come pick them up from here and then drop them off or we’d put them in the big bus and then drive around and drop them off. And during that time as well we were still continuing the food hampers and all the supplies for the bushfires.

Kerry, a counsellor elaborated:

We had people’s names on the box, we wrapped it in gift paper with a ribbon. It definitely felt, it felt important for us, it was a genuine gesture. It wasn’t a stock standard gesture.

Here care matters in all senses of the word. Caring rests on understanding relationships as a response to another on their terms and in their specific circumstances.

Women active in their own care

The sociomateriality of care is also evident in the following quote from an interview-to-the-double with Bella, a diabetes educator. It reflects the everyday way in which Waminda practises care:

It’s about the ladies wearing the CGM, the continuous glucose monitor, and so learning about their glycaemic control and their patterns even when they’re asleep and the reasons why it might be high, and they can see in real time what their blood glucose levels are doing. So, it’s not me saying oh, you can’t eat that because… It’s more self-determination, so they might go, oh wow, I just had some pasta for dinner and my sugars went up to 16 and they stayed up all night long; maybe pasta’s not such a great option for me.

The entanglement of technology with care practices was also used to promote bodily autonomy in the bushfire and COVID-19 crises, as Annie, a midwife explains:

I suppose from a clinical perspective, thinking about trying to provide clinical services within the main hub and then out in community when the fires and COVID are happening, it’s pretty hard to navigate how to get past all the risk. We were able to provide telehealth services, facetime on phones and iPads and organising just over-the-phone advice. What I’ve seen is that it’s given the women that we look after their body autonomy as well. So, we educate them about how to look after themselves and their bodies during pregnancies, get them to feel their babies, and get them to do their own checks at home when they think that they might be unwell and unable to come in.

Zooming out to broader context: patriarchal, white colonial society

Waminda’s care practices are enacted in the context of a patriarchal white-settler colony, its ongoing immigrations, and struggles over recognition for Aboriginal and Torres Strait Islander peoples. Mainstream service providers and government departments have and continue to cause harm to Aboriginal and Torres Strait Islander peoples. The service system often looks for a deficit, which in turn generates a deficit. This patriarchal, colonial deficit lens tends to regard Aboriginality and culture as a risk, entrenching more harm by casting what is a strength as a deficit.

The following extract from a collaborative yarn with Waminda staff analyses the practice of using iPads and Facetime to teach pregnant women how to monitor their bodies during the bushfires and the pandemic:

Luz: Working in the child protection space, there are that many women who were seen as not receiving antenatal care, because they were scared to go out during COVID, but then they came under the attention of child protection services, or even had their children removed as a result of not having antenatal care.

Sharmaine: … and a big part of that, is because we’re Waminda, and it’s matriarchal. So that’s a really big thing, women active in their own care, it’s women’s self-determination.

Aleesha: And it goes back to sovereignty never ceded, and that includes our own personal bodies.

In this context, caring creates affective relations that enhance a sense of control over one’s body, hope for the future, and belonging to a community in which care matters. Such practices are, in the words of Sara, a community member from Ulladulla,

so helpful for mental health. That’s the big thing – mental health… they work on how you feel about yourself and how you can connect with each other.

Using organising practices to orientate situated actions and manage risks

In this section, we discuss the key organising practices, including Waminda’s Model of Care (incorporates the Balaang Healing framework and the staff well-being framework), and the emergency management plan (for visual representations and details of these models and frameworks see Waminda, Annual report 2022–2023 [ 5 ] p. 6–8) that coordinate and enable the bundles of practices discussed in this paper to ‘hang together’ to form a holistic Waminda response, thereby, enhancing healing, recovery and wellbeing.

These organising practices, which have culture and the recognition of the impacts of colonisation sedimented throughout, were organically and dynamically integrated into the ways of doing, being and valuing during the environmental and public health crises. Tayla, an Aboriginal health worker’s, comment is representative:

Everything we do talks to our Model of Care within Waminda. It’s embedded. Waminda’s Model of Care is embedded to me as Tayla, as Aboriginal health worker, as Infection Control Officer, as all my hats that I hold, Waminda’s Model of Care is embedded.

In Tayla’s words, the Model of Care is embodied in her practice. A mental practitioner and leader of the SEWB team discussing their response to the bushfires and then COVID concurs:

Our way of being, of working collaboratively actually embodies the healing framework. Everything we’ve been doing was in line with the healing framework… But it wasn’t like, any of us got out the healing framework and went off each bit and said somebody signs. It was this natural progression.

In this way the Model of Care oriented Waminda’s response to crises but was not used as a step-by-step guide that predetermined how to proceed.

June, in her role as emergency response coordinator in the bushfires, discusses the emergency management plan and the staff well-being framework:

We’ve had to have in place for accreditation, and just because it’s good practice, that sort of emergency management plan, but you can never ever imagine using it. So, when it actually did happen there was some things that did just really click in from having to do that for all these years… So, my home became, like a little SES, because I had shit everywhere and everything all laid out on the table and everyone’s phone numbers and everyone’s contact details, their next of kin and the maps. The TV was going the whole time and the radio and the phone with alerts and then just hooking up trying to think who was affected by what. Just getting my head around really quickly with IT about contacting staff all at once through our text messages and stuff… So having that staff well-being framework and actually doing it, like making 130 calls four times a day.

The relations between Waminda’s organising models, frameworks and plans and the bundles of practices that made up the Waminda response to the crises are complex and interconnected. The Model of Care and the emergency management plan are best understood not as a pre-existing series of sequenced steps that prescribe practice but as conceptual, affective, and culturally-situated resources for action. Accordingly, the practice bundles articulated in this paper were not explicitly determined by Waminda’s models and plans but in situ by local interactions with staff, communities, and Country. The Model of Care and the emergency management plan are artefacts inseparable from the practices within which they are enacted. Planning and articulating the Model of Care is a form of culturally-situated practice. Using plans in this way to orient action enabled Waminda to improvise, take risks and manage them responsively:

It was really high risk… we had to make calculated decisions all of the time. And some of the decisions might’ve been too risky but I suppose we were within our capacity of knowing what we had to do… We knew that it was high risk, and we knew that we had to be quite calculated about it. We would look at where the fire fronts were and where they were going and sometimes, they had to avert and not go to places. John was quite incredible, and he would ring me and say, “June I think if we stop at Mogo on the way home that’s not going to give us enough time to get through X” and I’m like, “Okay well you can’t go there today. You’ve got to come back”.

Discussion: implications and contributions

In summary, we used a practice-based approach to investigate the collective stories of people affected by consecutive environmental and public health disasters to identify the practices they experience as helpful in supporting healing, health and wellbeing for Aboriginal people, their communities and Country.

The bundles of practices articulated in this paper and enacted by Waminda during the bushfire crisis created a form of community deployment that was simultaneously sophisticated, strategic, organic, care-filled and healing. Waminda’s practices were marked by a continuous ‘yes’ response, finding ways to meet the emerging care needs of Aboriginal communities for urgent and comprehensive support. These needs included access to timely communications and accurate information, water, food, clothing, prescription medications, temporary shelter, physical and mental first aid, and ways of connecting to family and community. The COVID-19 health crisis demanded other unexpected, emergent responses for and with service users, staff, and community members.

We do not claim that the articulation of practices enacted by Waminda are generalisable to all other organisations as both a limitation and strength of this study is that it is small-scale and contextually located. However, there are implications from this study that may be of interest to other ACCHOs, First Nations peoples, other regional and rural communities, and policymakers.

The paper contributes a suite of culturally safe and place-based practices that enhanced emotional, spiritual, social, and embodied well-being following cumulative disasters. These practice bundles include: adopting a Country-centred conception of local communities; being community-led; viewing care as a collective, relational sociomaterial accomplishment and having fluid boundaries. These practice bundles ‘hang together’ through organising practices including the Model of Care, the staff wellbeing framework and the emergency management plan which orientate action and manage risks. This texture of interdependent practices are able to be adapted by health services in other rural and regional locations in response to pandemic conditions or other disasters. The paper suggests that crafting responses and implementing practices that focus specifically on assisting communities (re)gain their sense of belonging, hope for the future, control over their lives and their capacities to care for and to be cared for by Country, are key to enhancing healing, recovery, and well-being.

The paper makes a second contribution by demonstrating the need for disaster responses to be community-led and culturally situated. ACCHOs are shown to play a crucial role, and their local responses to immediate community needs are grounded in contextual knowledge and use existing resources rather than relying on mainstream system-wide interventions. ACCHOs, and other community-based organisations contribute to the fabric of a robust civil society which is essential for recovery and mitigates the mental health struggles common following disasters. The study demonstrates that Waminda’s multigenerational, dense, horizontal networks enable such distributed, local responses and do not rely on top-down, centralised directives. Such practices are built on the strengths of local communities, culture, and Country in alliance with community organisations and members to enable recovery, healing, health and well-being. This paper joins calls [ 3 , 26 , 49 ] to recognise and fund the significant work of ACCHOs and other community-based organisations in disaster response and recovery.

The paper makes a third contribution by articulating the value of adopting a Country-centred conception of local communities. It points to the need to disengage from ongoing colonising frames of knowledge and practices that view settler relationships with Australian landscapes through ideas of ‘wilderness’. These reinscribe First Nations’ geographies as empty and available to settler priorities for conservation or colonisation [ 50 , 51 ]. Such material-discursive practices are underpinned by assumptions of the separation of humans from nature and prioritise people and their built environment over Country for protection.

The significant finding of the discriminatory and racist responses towards Aboriginal people at evacuation and recovery centres evident in this study echoes research by Williamson [ 3 ]. The experiences of Aboriginal communities attest to the urgent need that Cadag [ 52 ] advocates to decolonise disaster risk, reduction, response and recovery practices, policymaking, and research. The colonised context, which this study shows, results in a deficit discourse of First Peoples, is sedimented, according to Sherwood [ 53 ], in the training of health professionals and imported into policies to describe First Nations people’s health. The findings of this study demonstrate that the failure of mainstream healthcare systems and disaster response and recovery agencies to enact culturally-safe care with First Nations Australians is where the deficit manifests.

Learning from Country, valuing, protecting, and caring for Country, and connecting to Country through, for example, growing and catching food are critical practices that contribute to healing, health, social and emotional well-being following cumulative disasters.

The paper makes a fourth contribution by empirically demonstrating care as a knowledgeable doing, as collective, emergent, sociomaterial practices accomplished in ongoing, adaptive, open-ended responses to care needs [ 32 , 54 ]. This relational view of care as practised is enacted within Waminda’s model of care and healing framework. It offers an alternative to the view of care currently prevalent in the health and human services sector, which casts care as a transaction to be costed and delivered to an individual. Waminda’s care practices and approach to healing provide a practical example of Quinn and colleagues [ 55 ] theoretical paper that advocates dialogue between First Nations peoples’ healing and disaster recovery fields.

Finally, this paper makes a methodological contribution as to the authors’ knowledge this is the first study to present a First Nation’s ontological approach to practice theory in the context of disasters. The paper illustrates how Indigenous-informed, narrative inquiry, underpinned by practice theory, enabled a focus on doings, sayings and relatings, spiritual and sociomaterial arrangements at the local level. We were then able to trace these practices out to Waminda’s key organising practices that coordinate and ensure the practice bundles, work together. Our analysis could then zoom out [ 43 ] to show that responses and response-ability are always situated and enacted in social, political, economic, and historical contexts. They are produced through dynamic and contested political processes and relations at the local level. For example, the care-filled relations, sense of belonging and connections generated through the Waminda responses are inseparable from the exclusionary, racist practices of some of the evacuation and recovery centres. Our paper suggests that yarning and storytelling will be among our most valuable practices for coming to imagine and to know what works and what is to be done [ 56 ]. This is significant as we face the immense challenges of climate-related crises in all their political, economic, ecological, and cultural diversity.

Given the projected increases in extreme weather events due to climate change, there is a pressing need for health services to become better equipped to address healing, recovery, and well-being in settings of cumulative disasters, especially with diverse and vulnerable populations living in rural and regional communities.

The organising practices of Waminda are an affective, political, and ethical call to learn to respond – to act care-fully, when outcomes cannot be guaranteed. A risky, committed, becoming involved in one another’s lives, in diverse, passionate, practical, touching, meaningful ways. The capacity to quickly bring together and distribute resources, is built on many years of experience and commitment to servicing and standing with their communities. Perhaps, Waminda’s response-ability offered a glimpse of safety and hope in the face of devastation– ways of responsibly imagining and affecting multiple traumas and injustices locally [ 57 ]. Waminda and their communities work together, ‘push back’ and struggle over justice that is yet-to-come so that Aboriginal women, their families, and their Country may live healthy, flourishing lives.

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly due to potential that transcripts of yarns and interviews with participants may lead to their identification but are available from the corresponding author on reasonable request and with permission of Waminda.

Abbreviations

Aboriginal Community Controlled Health Organisations

Corona Virus Disease, 2019

Social and Emotional Well-Being

Illawarra Shoalhaven Local Health District

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Acknowledgements

The authors would like to acknowledge the participants in this research. All the Aboriginal and non-Aboriginal participants generously shared their experiences from the bushfires, floods, and COVID-19 pandemic.

This research was funded by the National Health and Medical Research Council through the Medical Research Future Fund, grant number APP2005659.

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Sue-Anne Cutmore, Summer May Finlay, Chris Degeling, Mim Fox & Katarzyna Olcon

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L.K, M.M. and S.L. wrote the main manuscript text, L.K. S.C. M.M. and S.F. collected the data, L.K., M.M. and S.C. analysed the data. L.K., M.M., S.C., S.L., K.F., S.F., C.D., R.E., J.A., M.F., P.P and K.O. reviewed the manuscript.

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The health belief model’s ability to predict COVID-19 preventive behavior: A systematic review

Amare zewdie.

1 Department of Public Health, College of Medicine and Health Science, Wolkite University, Wolkite, Ethiopia

Ayenew Mose

2 Department of Midwifery, College of Medicine and Health Science, Wolkite University, Wolkite, Ethiopia

Tadesse Sahle

3 Department of Nursing, College of Medicine and Health Science, Wolkite University, Wolkite, Ethiopia

Jemal Bedewi

Molla gashu, natnael kebede.

4 Department of Health Promotion, School of Public health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia

5 Department of Public Health, College of Medicine and Health Science, Weldia University, Weldia, Ethiopia

Associated Data

Supplemental material, sj-docx-1-smo-10.1177_20503121221113668 for The health belief model’s ability to predict COVID-19 preventive behavior: A systematic review by Amare Zewdie, Ayenew Mose, Tadesse Sahle, Jemal Bedewi, Molla Gashu, Natnael Kebede and Ali Yimer in SAGE Open Medicine

Supplemental material, sj-docx-2-smo-10.1177_20503121221113668 for The health belief model’s ability to predict COVID-19 preventive behavior: A systematic review by Amare Zewdie, Ayenew Mose, Tadesse Sahle, Jemal Bedewi, Molla Gashu, Natnael Kebede and Ali Yimer in SAGE Open Medicine

The health belief model specifies that individuals’ perceptions about particular behavior can predict the performance of respective behavior. So far, the model has been used to explain why people did not follow COVID-19 preventive behavior. Although we are using it, to our best knowledge, its predictive ability in COVID-19 preventive behavior is unexplored. So, this review aimed to assess the model’s predictive ability and identify the most frequently related construct.

A systematic review was conducted to examine the predictive ability of health belief model in COVID-19 preventive behavior using research done all over the world. Preferred reporting items for systematic review and meta-analysis guidelines were used. Comprehensive literature was searched using databases such as PubMed, Google scholar, and African Online Journal to retrieve related articles. Descriptive analyses such as the proportion of studies that better explained COVID-19 prevention behavior and the significance ratio of each construct of the model were made.

Overall, 1552 articles were retrieved using a search strategy and finally 32 articles fulfilling the inclusion criteria undergo the review. We found that in the majority (87.5%) of the studies health belief model has a good predictive ability of COVID-19-related behavior. Overall the explained variance for health belief model ranged from 6.5% to 90.1%. The perceived benefit was the most frequently significant predictor; highest significance ratio (96.7%) followed by self-efficacy, cues to action perceived barrier, susceptibility, and severity in decreasing order.

Conclusion:

Health belief model has a good predictive ability of COVID-19-related behavior in the majority of reviewed studies. The perceived benefit was the most frequently significant predictor of COVID-19-related behavior. Professionals who are in need can effectively use health belief model in planning and designing interventions to prevent and control the pandemic.

Introduction

The 2019 novel coronavirus disease is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and spread to several countries. On 30 January 2020, the World Health Organization’s (WHO) 1 Emergency Committee considered it a global health emergency and declared it to be a pandemic in March 2020. 2 It was first identified as clusters of pneumonia cases that have been reported for unknown reasons in Wuhan, Hubei Province, China. 3 The COVID-19 pandemic has negatively affected economic growth, sense of security, healthcare system, trade relations, tourism, employment, education, and global interactions of many countries across the globe. 4

WHO has recommended several health-promotive behaviors for the prevention of the COVID-19 pandemic. Facemask wearing, social distancing, hand washing with soap and water, use of alcohol-based hand sanitizer, self-isolation, avoiding spending time in crowded places, and taking the vaccine was the most highly advocated behavior to prevent and control the pandemic. These preventive behavior are investigated and framed as interventions by different theoretical molds in different parts of the world. 5 – 7

Different scholars such as sociologists, psychologists, and behavioral and public health experts have proposed a variety of theories and models to explain the factors affecting people’s health behavior, among these the prominent was the health belief model (HBM). HBM was introduced by Rosenstock and is a general conceptual framework and theoretical guideline for health behaviors in public health research. It consists of constructs, namely the perceived susceptibility, perceived severity, perceived benefits, perceived barriers, self-efficacy, cues to action, and preventive health behaviors. Despite the subsequent development of alternate models, the HBM is still widely used in health campaigns and taught in academic settings. 8 , 9

Systematic review and meta-analysis are combined and summarized sources of evidence for actual practice. They settle controversies arising from apparently conflicting individual studies and can answer questions not addressed by the individual studies. Systematic review and meta-analyses adopt “a replicable, scientific, transparent and detailed process that aims to minimize bias through exhaustive literature searches by providing an audit trail of the reviewers’ decisions, procedures, and conclusions. 10 , 11 Those qualities of systematic review and meta-analyses put them at the top of the evidence hierarchy and increase their importance for policy formulation and decision-making. 12

Review of the model

The HBM specifies that individuals’ perceptions of six variables can predict their behavior. 8 First, the model argues people will be more motivated to act in healthy ways if they believe they are susceptible to a particular negative health outcome. Second, the model predicts that the stronger people’s perception of the severity of the negative health outcome, the more they will be motivated to act to avoid that outcome. Susceptibility and severity concern the individual’s perception of the threat to a negative health outcome. Third, the individual must perceive that the target behavior will provide strong positive benefits. Fourth, the model argues that if people perceive there are strong barriers that prevent them from adopting the preventive behavior, they will be unlikely to do so. Fifth, the model also assumes individuals should perceive as they are capable of performing that particular behavior. Finally, HBM includes a cue to action whereby the individual is spurred to adopt the preventive behavior by some additional elements 13 – 15 ( Figure 1 ). HBM has been used to explain a variety of health problems; from preventive behavior to complex sick role behaviors. 16 The model’s ability to explain and predict a variety of behaviors associated with positive health outcomes has been successfully investigated several times. 17 The model has also been used to develop many successful health communication interventions by framing messages to the HBM variables to change health behaviors. 18 The ability of each component of the HBM in predicting a variety of health behaviors is quite different. Additionally, the model’s ability in explaining people’s behavior to newly emerging health problems is unstudied. 19

Conceptual framework of the health belief model.

As COVID-19 pandemic emerged and propagated across the world scholars from different departments investigated the reason why people did not follow COVID-19 preventive behavior using the important framework, the HBM. Several interventions are also being implemented to prevent this pandemic, which is framed using the HBM. Despite we use the HBM for explaining COVID-19 behavior and designing of COVID prevention program; to our best knowledge, issue related to its predictive ability and most frequently associated construct to COVID-19 behavior is unexplored. So this systematic review aims to assess predictive ability and identify the most frequently related construct of the model to COVID-19 preventive behavior.

Significance of the study

The result of the review would be beneficial in planning and implementing an intervention to improve COVID-19 preventive behavior. Since it evaluates the effectiveness of the HBM in explaining COVID-19 preventive behavior, it can help program designers confidently use the model in COVID-19 prevention programs. Since the review identifies the most frequently associated construct of the model to COVID-19 preventive behavior, therefore it contributes evidence inputs for preparing messages and materials for outreach and media campaigns by considering the identified important construct to prevent and control COVID-19. In addition, it may ignite a new insight for further studies that might be conducted on a related topic.

Study design and setting

A systematic review was conducted to examine the predictive ability of HBM in COVID-19 preventive behavior and identify the most frequently associated construct of the model to COVID-19 preventive behavior using research done all over the world on COVID-19 preventive behavior incorporating HBM as a framework. Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines were used for this review ( supplementary table 1 ). PRISMA is a protocol consisting of checklists that guide the conduct and reporting of systematic reviews and meta-analyses, which increase the transparency and accuracy of reviews in medicine and other fields. 20

Search strategies and sources of information

We have checked the PROSPERO database ( http://www.library.ucsf.edu/ ) and the resources on COVID-END (COVID-END) whether published or ongoing projects exist related to the topic to avoid any further duplication. Thus, the findings revealed that there were no ongoing or published articles in the area of this topic. Then this systematic review was registered in the PROSPERO database with Id no of CRD42022311171. Comprehensive literature was searched in databases such as PubMed, Google scholar, and African Online Journal to retrieve related articles from 28 December 2021 to 7 January 2022. Gray literature was searched using Google. Search terms were formulated using PICO guidelines through the online databases. Medical Subject Headings (MeSH) and key terms had been developed using different Boolean operators “AND” and “OR.” The following search term was used: “COVID-19” OR “SARS-CoV-2” OR “coronavirus” OR “coronavirus disease” AND “health belief model.”

Eligibility criteria

In this systematic review, we included studies that meet the following criteria. First, a study must be done on COVID-19 preventive behavior using HBM. Second, no restriction was made regarding country, population group, race, gender, and publication date. Study which employ a qualitative method and not report explaining ability such as variance explained, study with data extracted, duplicate, abstract-only papers, articles without available full text, conference, editorial, author response theses, case reports, case series, and systematic review studies are excluded at each respective stage of screening.

Outcome measurements

This review has two main outcomes. The primary outcome was the proportion of variance of COVID-19 prevention behavior explained by the HBM. It is defined as the variance of COVID-19 prevention behavior which is explained by the HBM framework that they are employed in their research article starting from the drafting of the conceptual framework up to the fitting of the analysis model. Therefore, all included studies were reporting the proportion of variance explained by the model they are fitted as analysis output. Thus, a higher percentage of explained variance indicates a great explaining ability of the model in COVID-19 preventive behavior. It also means that you make better predictions. 21 The secondary outcome was factors associated with coronavirus disease 2019 (COVID-19) preventive behavior (constructs of HBM). Construct that are frequently associated with the behavior are considered as an important factor that needs focus while we design interventions to improve COVID-19 prevention behavior.

Data extraction

All studies obtained from all databases were exported to Endnote version X8 software to remove duplicate studies. Then after, all studies were exported to a Microsoft Excel spreadsheet. Four authors (A.Z., A.M., T.S., and M.G.) independently extracted all the important data using a standardized data extraction form which was adapted from the Joanna Briggs Institute (JBI) data extraction format for the first outcome. 22 For the first outcome (proportion of variance) the data extraction format included (primary author, year of publication, country, sample size, analysis model fitted, and proportion of variance explained. Another three authors (J.B., N.K., and A.Y.) extracted data for the second outcome (associated factors of COVID-19 preventive behavior (constructs of HBM)) using table format which shows the effect size of each construct on COVID-19 prevention behavior with the level of significance. In case of disagreement, all the authors were met and discussed the issue and resolve it.

Quality assessment

To assess the quality of each study included in this systematic review, the modified Newcastle Ottawa Quality Assessment Scale for cross-sectional studies was used ( Supplementary Table 2 ). 23 Three authors (A.Z., A.M., and T.S.) have assessed the quality of each study (i.e. methodological quality, sample selection, sample size, comparability and the outcome, and statistical analysis of the study). In the case of disagreement between authors; another four authors (M.G., J.B., N.K., and A.Y.) were involved and discussed and resolved the disagreement.

Statistical analysis

Selected articles were entered into Microsoft Excel spreadsheet format for analysis. For the primary objective (outcome) descriptive analyses such as the proportion of studies that better explained COVID-19 prevention behavior were made. For the second objective (outcome) frequency of each construct of the HBM for which it significantly predicts (significance ratio) COVID-19 prevention behavior were made considering all included studies. Then, verification of the most frequently associated (predictor) was given for possible use in the practical setting.

Patient and public involvement

In this review, neither patient nor the public was involved in the study design, conduct, reporting, or dissemination plans of our research.

Overall, 1552 articles were retrieved using a search strategy about COVID-19 prevention behavior and HBM worldwide. Duplicates (257) were removed and 1295 articles remained. After reviewing ( n  = 683) articles were excluded by title, and ( n  = 394) articles were excluded by reading abstracts. Therefore, 218 full-text articles were accessed and assessed for inclusion criteria, resulting in the further exclusion of 186 articles primarily due to listed reasons ( Figure 2 ). As a result, 32 studies fulfilled the inclusion criteria to undergo the final systematic review. Concerning the country in which the studies were done, the included studies relatively cover all segments of the globe despite Iran, the United States, and China having 7, 4, and 4 articles included countries, respectively. Of the total included studies 11(34%) of them utilized HBM for explaining COVID-19 vaccine acceptance and intention. The remaining 21 studies use HBM for explaining adherence and intention to practice COVID-19 prevention measures separately as well as in groups as prevention precaution ( Table 1 ).

Flow chart of study selection for systematic review on predicting ability of the health belief model in COVID-19 preventive behavior.

Study characteristics, proportion variance, and type of COVID-19 related behavior explained in included studies in the systematic review 2022.

HLoR: hierarchical logistic regression; MLR: multiple linear regression; HLR: hierarchical linear regression; MLMA: multilevel modeling analyses; SEM: structural equation modeling.

Predicting ability of HBM in COVID-related behavior

Regarding the predictive ability of the HBM, in the majority 28 (87.5%) of the studies, HBM has a good predictive ability ( R 2  > 25%) of COVID-19-related behavior. 24 – 27 , 30 – 42 , 44 – 46 , 48 – 55 From this nearly half (43.7%) of the studies, HBM had explained 50% and above variance of COVID-19-related behavior and intention. Overall, the explained variance for HBM ranged from 6.5% to 90.1% ( Table 1 ).

Frequency of statistically significant association of HBM constructs with COVID-19 preventive behavior

Knowing how frequently a certain factor predicts certain behavior is important to consider that factor when we plan to change the respective behavior. Included studies in this review incorporate those six key constructs of HBM in their analysis model as a predictor of respective behavior. Considering this, perceived susceptibility was significantly associated with COVID-19-related behavior in 19(59.4%) studies and it was the only construct that is not missed in all studies. From these, in three studies it was considered in combination with perceived severity as a perceived threat. Similarly, perceived severity significantly predicted COVID-19-related behavior in 12 (40%) of studies. In two studies it was not considered as a predictor.

Regarding perceived benefit, it was significantly associated with COVID-19-related behavior in 29(96.7%) of studies even if it was not included in two studies as a model construct. It is the most frequently significant predictor of COVID-19-related behavior and intention in this review since it was not significant only in a single study (higher significance ratio). Likewise perceived barrier significantly predicted COVID-19-related behavior in 16 (64%) of the studies and it was not considered as a model construct in 7 studies.

Concerning self-efficacy, it was a significant predictor of COVID-19-related behavior in 14(87.5%) studies. Although it was missed in half of 16 included studies as a model construct, it is the second most frequently associated construct of HBM with COVID-19-related behavior. Similarly, cues to action were significantly associated with COVID-19-related behavior in 13 (72.2%) studies and it was not considered as a model construct in nearly half 14 studies ( Table 2 ).

Significance ratio of HBM constructs with COVID-19-related behavior of each included studies in the systematic review 2022.

b: unstandardized coefficient; β: standardized coefficient; NI: not included; Ps; Perceived susceptibility; –means nonsignificant.

Psychological theories significantly contribute to the planning and design of effective public health and health promotion interventions. 16 This is particularly true in the current environment where public health officials need insights into effective COVID-19 responses, which has severely impacted many aspects of individuals’ lives across the globe. 56 There is also increasing evidence that protective behaviors are culturally molded, requiring a focused examination of perceptions and behaviors using verified and practically supported frameworks. 57 One of the important frameworks was HBM which we have been using for many health-related behaviors including COVID-19-related behavior and intention. In this review, we have focused on this important framework (HBM) to assess its predictive ability and how frequently its construct predicts the current COVID pandemic-related behavior in studies done all over the world.

We found that in the majority (87.5%) of the studies HBM has a good predictive ability of COVID-19-related behavior. From this, in half of the studies, HBM had explained 50% and above variance of COVID-19-related behavior and intention. The finding is consistent with a systematic review done on evaluating the effectiveness of the HBM in improving adherence by reviewing interventional studies. In that review, the majority (83%) of the HBM-based intervention studies achieved statistically significant improvements in adherence. 58 Overall, the explained variance for HBM ranged from 6.5% to 90.1%, which was comparable to a systematic review and meta-analysis on the effectiveness of HBM for mammography screening; the explained variance for HBM ranged from 25% to 89%. 59 This finding implies HBM had a significant predictive ability of COVID-19 preventive behavior and indicates the use of the model in designing an intervention to prevent and control the pandemic.

In this review, we have also examined the significant ratio of each six constructs of HBM with COVID-19 preventive behavior. The reason why we focus on the significance ratio of each construct is that knowing how frequently a certain variable or construct predicts certain behavior is important to consider the variable while we plan to change the respective behavior. Communication messages, as well as educational appeals, should target the factor that is frequently linked to the behavior. Concerning this perceived benefit was significantly associated with COVID-19 related behavior in almost all (96.7%) of studies. It was the most frequently significant predictor (highest significance ratio) of COVID-19-related behavior and intention. This finding was compliment with a systematic review and meta-analysis done on the effectiveness of HBM and the theory of planned behavior for mammography screening, in which the components of cues to action and perceived benefits were the variables most strongly associated with participation in mammography screening. 59 However, the significance ratio in the current review is slightly lower than a critical review on HBM-related investigations published during the period 1974–1984; in which the significance ratio of perceived benefit was 78%. 17 The possible discrepancy may be due to; the critical review was done for many different health behaviors which may lower the significance level of perceived benefit. In another way in the current review, perceived benefits (perceived importance of those COVID-19 prevention precautions) have great ability of predicting COVID-19 preventive behavior. This finding implies COVID-19 prevention behavior change intervention should address benefits of the prevention measures.

Self-efficacy, cues to action, perceived barrier, perceived susceptibility, and severity have 87.5%, 72.2%, 64%, 59.4%, and 40% significance ratios in this systematic review, respectively. This indicates self-efficacy was the second most frequent significant predictor of COVID-19-related behavior whereas perceived severity was the last significant predictor. This finding is compliment with a critical review of HBM-related investigations published during the period 1974–1984. 17 The finding implies COVID-19 behavior change intervention should target self-efficacy, important cues to action, individual perception of barriers, disease vulnerability, and severity in order of significance.

Restriction of our search strategy to the English language may limit our sample studies included in our review. Furthermore, variations in effect size that are reported by included primary studies restrict us from doing a meta-analysis to estimate pooled effect size rather we have focused on evaluating predicting ability of the HBM and identifying the most frequently associated construct of the model to COVID-19 preventive behavior.

HBM has a good predictive ability of COVID-19-related behavior in the majority of reviewed studies. This implies that HBM can explain COVID-19 preventive behavior by using its important components or constructs which increase its use in planning and designing an intervention to prevent and control the COVID-19 pandemic. To target our focus to the most frequently significant construct, we have evaluated the significance ratio of all constructs of HBM in the reviewed articles. Concerning this, perceived benefit was the most frequently significant predictor (highest significance ratio) of COVID-19-related behavior and intention. Self-efficacy, cues to action, perceived barrier, perceived susceptibility, and severity were the remaining significant predictor of COVID-19-related behavior in decreasing order of significance ratio. Public health professionals and health promotion experts should consider those constructs of HBM in order of significance while they plan and design behavior change interventions.

Supplemental Material

Acknowledgments.

We would like to thank all authors of the primary studies which are included in this systematic review.

Authors’ contributions: A.Z. conceived the idea and participated in data extraction, analysis, and draft writing. A.M., T.S. M.G., J.B., N.K., and A.Y. participated in the analysis, preparation of the manuscript, and revision. All authors read and approved the final version of the manuscript to be considered for publication.

Availability of data and materials: The data set analyzed during the current study is available from the cross-pondering author on reasonable request.

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.

Institutional review board statement: This systematic review used and analyzed information obtained from pre-existing studies

Supplemental material: Supplemental material for this article is available online.

Structured Defense Model Against DNP3-Based Critical Infrastructure Attacks

• Research Article-Computer Engineering and Computer Science
• Published: 14 September 2024

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• Erdal Ozdogan   ORCID: orcid.org/0000-0002-3339-0493 1  

Critical infrastructures encompass the essential systems required to operate various sectors, including energy, water, communication, finance, health, and transportation. The sophistication and organization of attacks on these infrastructures are escalating. A frequently targeted protocol within these critical infrastructures is the Distributed Network Protocol 3 (DNP3). This study developed a Machine Learning-supported Intrusion Detection System to identify attacks on DNP3 networks. The research utilized a current and balanced dataset containing DNP3 traffic from critical infrastructures. A model incorporating two defense lines, reflecting the structure of the attacks, was proposed. The initial detection of reconnaissance attacks is designed to prevent subsequent attacks. Reconnaissance attacks are identified in the first defense line using Extreme Gradient Boosting. In contrast, attacks on critical infrastructures are classified as the second defense line, with the support of artificial neural networks. In the study’s first phase, the model achieved high accuracy in detecting reconnaissance attacks. In the second phase, the model achieved approximately 99% accuracy in detecting attacks and around 98% average success in classification. The model achieved 96% accuracy in evaluating unknown attack detection capability.

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Ozdogan, E. Structured Defense Model Against DNP3-Based Critical Infrastructure Attacks. Arab J Sci Eng (2024). https://doi.org/10.1007/s13369-024-09577-3

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