# Motivation and emotion/Book/2023/Protection motivation theory and COVID-19

* Multimedia presentation (3 min)

## Overview

* Case study
* Figure 1. Public health message advising protective behaviours to combat the spread of COVID-19.
* Avery refuses to wear a face mask, Olivia is sceptical about receiving a COVID-19 vaccination, Logan is protesting against government pandemic mandates, and Kai is occasionally breaking lockdown restrictions to socialise with friends.
* Contrastingly, Dannie refuses to leave home, Robin is frequently hand washing, and Casey is eager to receive a third vaccination.
* Stanley works for the Australian Government in the Department of Health and has been tasked with developing a new campaign aimed at promoting and improving healthy COVID-19 behaviours. However, with such a wide spectrum of behaviours adopted across society, Stanley is initially unsure how to create a campaign that will maximise engagement with protective behaviours.
* After considering current research applying protection motivation theory to COVID-19, Stanley begins to identify key motivating factors contributing to safe, and unsafe, COVID-19 related behaviours. This case study demonstrates how psychological theory, particularly protection motivation theory, can have real-world applications.
An individual may choose to wear a face mask, receive a vaccination, use a seatbelt, or brush teeth twice daily; alternatively, one may choose to smoke, consume a high-sugar diet, not wear sunscreen, or ride a bike without a helmet. Why does an individual choose to engage in protective healthy behaviours in one situation, and maladaptive or unhealthy behaviours in another? Understanding the motivation underlying risky, and risk-averse, behaviours is of particular benefit to those in a position to positively influence behaviour, especially those in the health sector.
Protection motivation theory (PMT) is one psychological framework used to explain motivating factors underlying an individual’s responses to potentially threatening, or fear evoking, situations (Norman et al., 2005). PMT can identify the likelihood of engaging with protective responses, help predict health-related behavioural changes, and inform the design of strategies aimed at fostering healthy behaviours.
Considering the global health crisis presented by the pandemic, PMT can aid in the management of COVID-19. A breadth of research has rapidly emerged applying PMT to COVID-19 related behaviours, predominantly face mask wearing, adherence to lockdown restrictions, and intention to be vaccinated. These learnings can be used to create, shape and inform beneficial public messaging (see Figure 1), rules and guidelines that foster and promote healthy COVID-19 responses.
* Focus questions
* What is protection motivation theory (PMT)?
* How does PMT explain and predict COVID-19 health-related behaviours?
* How can PMT be used to manage COVID-19?

## What is protection motivation theory?

Protection motivation theory (PMT) is a psychological model used to understand, explain and predict engagement with protective behaviours (Norman et al., 2005). Developed by Rogers (1975) and later revised by Rogers (1983), the model is frequently used to assess responses to fear appeals (Norman et al., 2005). Further, the model can explain motivation underlying a variety of health-related behaviours. PMT can help explain an individual’s decision to smoke despite known health risks, or to get vaccinated and prevent disease. PMT can also explain broader societal patterns of behaviour, such as those that occurred in response to public messaging and health recommendations during the COVID-19 pandemic. There are several key PMT factors (see Figure 2) that explain protection motivation, these include:[factual?]
[Add wiki bullet-points]
- Perceived severity
- Perceived vulnerability
- Maladaptive rewards
- Self-efficacy
- Response efficacy
- Response cost
These factors are separated into two cognitive categories, threat appraisal and coping appraisal. PMT involves comparing threat appraisal and coping appraisal to assess the likelihood of adopting protective or maladaptive behaviours (Norman et al., 2005).

### Threat appraisal

Threat appraisal refers to the level of threat an individual feels from a particular health risk. This appraisal involves an individual’s subjective evaluation of a threat’s perceived severity, and an individual’s perceived vulnerability to the specific threat (Norman et al., 2005). Car accidents, skin cancer, and disease are examples of health risks that may be appraised with high perceived severity and individual vulnerability.
Risks are often compared to rewards achieved by ignoring the threat and engaging with maladaptive behaviours (Norman et al., 2005). While smoking poses health risks, it also produces addictive dopamine rewards, and although highly processed foods negatively impact internal organs, these foods often offer palatable rewards. In these instances rewards for maladaptive behaviours may be greater than the threat’s perceived severity or individual’s perceived vulnerability. Ultimately, threats with a high degree of perceived severity and perceived vulnerability increase the likelihood of adopting protective behaviours, while unhealthy behaviours that produce rewards, increase the likelihood of adopting maladaptive behaviours (Norman et al., 2005).

### Coping appraisal

Coping appraisal refers to assessing coping strategies that may protect against a potential threat. This appraisal involves an individual’s subjective evaluation of response efficacy, how effective a protective behaviour will be in minimising a threat; and evaluation of self-efficacy, the individual’s self-belief in ability to maintain a protective behaviour (Norman et al., 2005). Wearing a seatbelt, applying sunscreen, and hand-washing hygiene are all examples of effective and manageable coping strategies that can protect against health risks.
Coping strategies are compared to response cost, which refers to how challenging, undesirable or difficult a healthy behaviour is to perform (Norman et al., 2005). The response cost for ceasing to smoke may involve challenges of overcoming nicotine addiction, while the response cost of opting for a healthier diet may involve the difficulty of learning and adjusting to new eating habits. Protective behaviours an individual believes will be effective and achievable are likely to be performed, while protective behaviours that require substantial effort or persistence are less likely to be performed.
* Case study
* During the COVID-19 pandemic, public health recommendations encouraged mask wearing, working from home, and vaccination uptake. Julie (83-years-old) has a high threat appraisal of the pandemic, viewing COVID-19 as a severe illness, and feels vulnerable due to her age and immunocompromised system. Julie also has a high coping appraisal, believing that avoiding crowded situations and wearing a mask whenever leaving the house, are manageable behaviours that will effectively protect against COVID-19 infection. Thus, Julie is motivated to engage with protective behaviours of staying home and mask wearing. Contrastingly, Taylor (26-years-old) has a mild threat appraisal, believing that while coronavirus is severe for some, her age makes her less vulnerable to serious symptoms. Taylor believes in the response efficacy of mask wearing, however, the concern of looking awkward in social settings with non-mask wearing friends, means Taylor views the response cost of mask wearing to be too high. Thus, PMT explains two different COVID-19 responses.

## What is COVID-19?

First identified in December 2019 in Wuhan China, COVID-19 is a respiratory virus that rapidly spread internationally (Sun et al., 2020). On 11th March 2020, COVID-19 was declared by the World Health Organisation a global pandemic. The illness, caused by SARS-Cov-2, is a highly contagious airborne disease that can be transmitted through contact with infected surfaces or direct close contact with infected individuals (Lotfi, et al., 2020). The virus lives in liquid droplets that can be transferred via saliva, breath and nasal secretions (Lotfi, et al., 2020). Key symptoms are shown in Figure 3 and include coughing, fever, sore throat, muscle aches, fatigue and loss of smell or taste (Sun et al., 2020). The virulence and contagious nature of COVID-19 has changed as variants of the virus have evolved and caused waves of outbreaks. Forty nations experienced infection to over 70% of the population (Barber et al., 2022), and between April, 2020 and October, 2021 worldwide infection rates reached 17 million new cases a day (Barber et al., 2022).
In response to this global health crisis, governments around the world formulated restrictions and rules aimed at reducing the spread of COVID-19. Many nations closed borders, enforced stay-at-home lockdowns, encouraged or mandated mask wearing, introduced social distancing, promoted hand hygiene and recommended COVID-19 vaccinations (Edwards & Ott, 2021). While these guidelines were intended to promote protective behaviours against a global health risk, adherence has had varying levels of efficacy.

## How does PMT explain and predict COVID-19 health related behaviours?

In order to manage COVID-19 effectively, understanding motivational factors influencing engagement with healthy, or unhealthy, behaviours is key. Throughout the pandemic adherence to protective behaviours, directed by governments and medical professionals, has varied. In March 2020, an American survey found 93.1% of 9009 participants were engaging with increased handwashing, 89% were avoiding social situations, and 60% were cancelling domestic travel (Nelson et al., 2020). In Indonesia, a survey of 508 adults revealed 60% of participants intended to follow government health protocols (Noorrizki et al., 2020). While these results suggest tendencies to adopt protective behaviours against coronavirus infection, a London survey of 681 adults found 92.8% of participants did not follow social distancing rules, with 48.6% revealing this disregard for social distancing was purposeful (Hills & Eraso, 2021). Further, Shewasinad Yehalashet et al.’s (2021) cross-sectional study in Ethiopia, found among 683 adults, with a median age of 38-years, only 44.1% displayed protective COVID-19 behaviours. Moreover, nations across Europe have experienced protests, see Figure 4, against government COVID-19 policies (Neumayer et al., 2023), a pattern of behaviour observed globally with Canada’s Trucker Freedom Convoy and Australia’s Convoy to Canberra. With such varying coping responses to the threat of the pandemic, PMT factors can help explain engagement with key COVID-19 protective behaviours.

### Mask wearing

Face mask (see Figure 5) wearing is a protective behaviour capable of reducing influenza-like illness transmission by over 80% (MacIntyre et al., 2008) and COVID-19 transmission by 79% within households, when worn before symptoms develop (Wang et al., 2020). Considering PMT, high perceived severity of COVID-19 illness, strong belief in face masks as a preventative response, and elevated self-efficacy, all contribute to reducing scepticism towards mask wearing (Kowalski et al., 2022). This is supported by Ding et al. (2022) who sampled 3148 adults in China and found that higher perceived severity and vulnerability to viral transmission, and increased response efficacy and self-efficacy towards mask wearing, raised an individual’s willingness to purchase N95 masks. Importantly, participants in this study were selected from multiple provinces, increasing generalisability. Nudelman et al’s. (2023) 6-week, longitudinal, cross sectional study across Israel, Germany and India, found response efficacy is the most significant PMT factor motivating adherence to COVID-19 guidelines, including mask wearing. While there is some variation, the literature primarily suggests an individual’s belief about the severity of coronavirus, belief about the protective value of face masks, and belief in one’s own ability to action mask wearing, are the key motivating factors for mask wearing behaviour.

### Lockdown restrictions

Lockdown restrictions, such as staying at home and restricting time spent in social gatherings, are protective behaviours that have been encouraged and mandated throughout the pandemic. Strict lockdown policies were implemented around the globe and restricted leaving the home to essential purposes only (Murphy et al., 2020). An Australian survey by Murphy et al. (2020) found only 21.2% of people complied fully with stay-at-home restrictions, with older individuals demonstrating greater compliance. This implies perceived individual vulnerability to coronavirus is a motivating protective factor for stay-at-home behaviour. Sand and Bristle’s (2022) international study across 27 countries, with 40,282 participants, also found perceived individual vulnerability was a key motivating factor for stay-at-home behaviour. Contrastingly, a study in Japan, found individual vulnerability had no effect on adherence to lockdown restrictions, rather perceived severity and self-efficacy fostered protection motivation (Okuhara et al., 2020). Perhaps this suggests cultural variations in threat and coping appraisal, or perhaps as Okuhara et al. (2020) note, the study may have been limited by convenient sampling, and self-reported data. Interestingly, compliance decreases the longer a lockdown continues (Murphy et al., 2020), [grammar?] this suggests that maintaining stay-at-home behaviours over time is difficult. Perhaps this is due to a gradual increase in response cost, with pandemic fatigue. Literature has found conflicting results on PMT factors motivating stay-at-home behaviour. Age and underlying health risks that make an individual more vulnerable to coronavirus increase lockdown compliance, while pandemic fatigue decreases protection motivation.

### Vaccination

Vaccinations against COVID-19 are protective behaviours embraced worldwide, with clinical trials showing the Pfizer-BioNTech vaccine is 95% effective in preventing COVID-19 (Polack, et al., 2020). Literature applying PMT to vaccine uptake shows perceived severity (Eberhardt and Ling, 2021; Eberhardt and Ling, 2023; Wang et al., 2021), and response efficacy (Huang et al., 2021) significantly increases intention to be vaccinated, and is associated with lower levels of vaccination scepticism (Kowalski et al., 2022). By this, the more one perceives COVID-19 as a serious threat, and the greater an individual’s belief in a vaccine as an effective protective measure, the greater the motivation to receive a vaccination. Moreover, cross-culturally, self-efficacy has also been identified as a predictor of intention to be vaccinated. Huang et al.’s (2021) online survey of 929 Taiwanese university students revealed those with greater perceived knowledge about COVID-19 had increased self-efficacy, and greater intention to be vaccinated. Additionally, Eberhardt and Ling (2023) found a positive correlation between vaccination intention and self-efficacy, as measured by an amended influenza PMT Likert scale questionnaire. Increasing self-efficacy is key in motivating vaccination uptake and this can be achieved by continuing to ensure vaccinations are easily accessible and the vaccination process is simple. Another common theme in the literature, [Rewrite to improve clarity] highlights individuals may avoid vaccination due to rewards for this maladaptive behaviour (Kowalski et al., 2023; Eberhardt and Ling, 2023). This could include avoiding any potential long-term side effects from a vaccination, or as noted by Eberhardt and Ling (2023) saving time and money. To increase engagement with vaccinations it is important to highlight the severity of coronavirus, emphasise the benefits of vaccination, increase an individual’s confidence in receiving a vaccine, and minimise rewards for vaccination avoidance.
Figure 6. Summary of research identifying PMT factors that explain COVID-19 behaviours :
| | Perceived severity | Perceived vulnerability | Maladaptive rewards | Response efficacy | Self-efficacy | Response cost |
| Mask wearing | (Kowalski et al., 2022) (Ding et al., 2022) | (Ding et al., 2022) | | (Kowalski et al., 2022) (Ding et al., 2022) (Nudelman et al., 2023) | (Kowalski et al., 2022) (Ding et al., 2022) | |
| Lockdown restrictions | (Okuhara et al., 2020) | (Murphy et al., 2020) (Sand and Bristle, 2022) | | | (Okuhara et al., 2020) | (Murphy et al., 2020) |
| Vaccination | (Eberhardt and Ling, 2021) (Eberhardt and Ling, 2023) (Kowalski et al., 2022) | | (Kowalski et al., 2023) (Eberhardt and Ling, 2023) | (Huang et al., 2021) (Kowalski et al., 2022) | (Huang et al., 2021) (Eberhardt and Ling, 2023) |
Quiz
1
Which PMT factors encourage protective behaviours such as vaccination?
Maladaptive response rewards
Response cost
Perceived severity and self-efficacy
Intention
2
What is one reason an individual may choose to engage in maladaptive behaviour?
Perceived severity
Response cost
High self-efficacy
High response efficacy
3
Why is PMT important for managing COVID-19 behaviours?
PMT can explain why individuals choose particular health related behaviours.
PMT can predict broader societal behavioural patterns.
Understanding motivational factors can improve public messaging and health guidelines.
All of the above. :

## How can PMT be used to manage COVID-19?

Literature applying PMT to pandemic protective behaviours (see Figure 6) can help manage COVID-19 by shaping and informing public health messaging, policies, and future guidelines. Sand and Bristle (2022) note balancing fear messaging with hopeful messaging, is crucial for the uptake of protective behaviours. Moreover, understanding the impact perceived severity and self-efficacy have on decision making, can aid in delivering tailored information that focuses on the seriousness of the risk presented by coronavirus, while also emphasising the manageable nature of many COVID-19 protective behaviours. Conveying the message that all individuals are capable of successfully engaging in healthy COVID-19 behaviours is a vital component of fostering protection motivation.
Minimising misinformation in the media (Sand and Bristle, 2022) and challenging the validity of COVID-19 conspiracy theories (Eberhardt and Ling, 2021; ), may improve coping appraisals. Using reputable evidence to highlight the safety, potency and protective value of receiving COVID-19 vaccinations and wearing masks, can contribute to the uptake of these protective behaviours.
Murphy et al. (2020) suggests health messaging could benefit from promoting a sense of duty towards protecting those more susceptible to COVID-19 in order to increase stay-at-home behaviours. To reduce the response cost that can create pandemic fatigue, shorter periods of restrictions relating to lockdowns and travel, may yield greater compliance. While fostering total protection motivation across society is challenging, the implications of PMT research can provide insight into how COVID-19 might be managed most effectively.

## Conclusion

Protection motivation theory is a psychological framework that helps to understand factors that motivate protective, or maladaptive, behaviours (Norman, et al., 2005). The theory involves comparing a threat appraisal, an assessment of a threats[grammar?] level of severity and an individual’s vulnerability, with a coping appraisal, an assessment of the efficacy of potential protective responses.
PMT can predict and explain COVID-19 responses, revealing that perceived severity and self-efficacy are the strongest motivational factors influencing protective behaviours. Response efficacy is a key factor in mask wearing and intention to be vaccinated, while perceived vulnerability also encourages stay-at-home behaviour. Contrastingly, the ongoing response cost caused by maintaining lockdown adherence, and the perceived rewards for not receiving a vaccination, tend to be strong motivators for adopting risky, or maladaptive, COVID-19 behaviours.
PMT learnings can be used to manage COVID-19. Public health messaging may benefit from emphasising the severity of coronavirus, while instilling confidence in the simple protective behaviours that aid in protection against the virus. Fostering hope, promoting self-belief in healthy behaviours, and ensuring protective options such as masks and vaccinations are easily accessible, can improve self-efficacy. To increase response efficacy, it is important to minimise and discredit misinformation about the coronavirus, and present empirical evim dence for the effectiveness of recommended health behaviours. Utilising restrictions, such as lockdowns, for shorter time periods may better maintain adherence. Ultimately, PMT is a key psychological theory that can aid in the management of COVID-19 by providing insight into the motivational factors of healthy behaviour.