Abstract COVID-19 pandemic has affected over 100 countries in a matter of weeks. People's response toward social distancing in the emerging pandemic is uncertain. In this study, we evaluated the influence of information (formal and informal) sources on situational awareness of the public for adopting health-protective behaviors such as social distancing. For this purpose, a questionnaire-based survey was conducted. The hypothesis proposed suggests that adoption of social distancing practices is an outcome of situational awareness which is achieved by the information sources. Results suggest that information sources, formal (P = .001) and informal (P = 0.007) were found to be significantly related to perceived understanding. Findings also indicate that social distancing is significantly influenced by situational awareness, P = .000. It can, therefore, be concluded that an increase in situational awareness in times of public health crisis using formal information sources can significantly increase the adoption of protective health behavior and in turn contain the spread of infectious diseases. 4 were reported. The WHO officials also raised serious concerns that Pakistan might emerge as the next epicenter of this pandemic. 5 In Pakistan, the first case of COVID-19 was travelassociated; infected individuals returned from Iran on 26 February 2020. 6 As the first case surfaced, the Ministry of Health began implementing the COVID-19 control framework which included isolation of suspects and quarantining of infected individuals. However, the situation worsened gradually and on 17 March, total cases rose to 237. 7 In response to the looming fears of an emerging epidemic, officials took additional steps to control COVID-19 community transmission. Important measures that were taken included quarantine, urging the healthy public to self-isolate and practice social distancing strategies to avoid COVID-19 infection. 8 Formal (newspapers, press releases, and educational messages) and informal sources (social media, online reviews, views of family and peers) of information play a role in improving situational awareness in times of public health emergencies. [9] [10] [11] [12] [13] Retaining situational awareness comprises of perception which relies on these information sources. 10 Effective and timely management of infections is greatly dependent on social distancing behavior; perception plays a vital role in the adoption of protective behavioral response. [14] [15] [16] In this study, we have used situational awareness theory (SAT) in conjunction with the theory of planned behavior (TPB). The Endsley model describes SA at three levels: perception which makes the base of SA; perceived information, that is, comprehension is the second level, and projection is the third level. 17 This theory has been used by researchers for gaining improved awareness for the management of emergencies in health care. 17-20 TBP does not take into account effect of social awareness on infectious diseases. 21, 22 Therefore, where this theory has been used for existing behavior change theoretical frameworks, which have been adapted for prediction of healthrelated behavior change in chronic and noncommunicable diseases, there is a lack of a comprehensive evidence-based model of protective behavior against infectious disease threat.
The SAT has been used earlier during the severe acute respiratory syndrome (SARS) epidemic by research groups for reporting public perception of SARS outside the affected region.
Studies carried out in the initial phase of outbreak reported lower SA, that is, 9%-30%; however, as information became widespread, later studies reported greater awareness among masses. The hypothesis proposed in this study has been devised after careful consideration of previously reported literature ( Figure 1 ). [23] [24] [25] 2 | METHODS
A questionnaire-based survey was carried; for details of the questionnaire see Table S1 . For the measurement of responses 5-point Likert scale was used. Age, sex, location, and education were the demographic characteristics of the study population. An open-ended question was also added at the end of the questionnaire to record the general opinion of participants on COVID-19.
The designed questionnaire was then reviewed by two PhD students and two molecular virologists, in terms of construct items, understanding the ability and contextual relevance after a few changes as suggested after the pilot test, an online link was generated for response collection. A total of 210 responses was received.
Collected responses were screened, and both multivariate and univariate outliers were detected and deleted. 26 Also, skewness and kurtosis analysis were performed; a reflective measurement model requires three tests, that is, internal consistency, convergent, and discriminant validity. 27 The internal consistency was validated using composite reliability (CR), threshold value: 0.70.
Fornell and Larcker 27 and Henseler et al, 28, 29 were used for the assessment of discriminant validity using a multitrait-multimethod matrix. Specifically, heterotrait-monotrait ratio (HTMT) value, 0.85, is considered a threshold to ensure discriminant validity (Table 1 ).
The structural model was measured using path coefficient, determination coefficient (R 2 ), effect size (F 2 ), and the predictive relevance (Q 2 ). 30 The structural model involves two basic preliminary assessments of R 2 and path coefficient 31 ; according to the hypothesized relationship and is assessed by 5000 bootstrapping resampling technique.
F 2 values of 0.02, 0.15, and 0.35 manifest small, medium, and large effects, respectively. 32 Q 2 was evaluated using Stone-Geisser test. 33 The predictive relevance is explained as "measure of how well-observed values are reconstructed by the model and its parameter estimates." 34 Q 2 is established through blindfolding, and a value greater than zero signifies that the model has predictive relevance.
Partial least squares (PLS) was used to test the study model. PLS is a well-established technique with path analytics modeling and is used for testing causal models through both reflective and formative constructs. [35] [36] [37] [38] The model proposed here was tested by Smart PLS Version 2.M to perform analysis in two stages using structural equation modeling: the measurement model (first-order confirmatory factor analysis) and structural model assessment ( Table 2 ).
We analyzed sentiments for 82 responses against the open-ended question. The sentiment analysis becomes a dominant information source in people's daily life which helps in decision-making. 39 We used a manual approach to assign a specific category to each opinion based on its inherent meaning (semantics). Degree of prediction (so that a review belongs to a certain category) was measured by assigning labels
The proposed health care protective model. This figure represents the hypothesis on which the survey was conducted. It shows that formal and informal sources of information play a significant role in developing awareness which, in turn, impacts the adoption of social distancing behavior manually: A, B, and C for regular, comparative, and suggestive reviews, respectively. 40 This method resembles the closed card sorting method. 41 3 | RESULTS Table 2 indicates that all variables have values lower than the threshold, that is, 0.70 and therefore CR has adequate loadings to satisfy internal consistency reliability. Hence, convergent validity evaluation ensures that items put together explain 50% construct.
We used the average variance explained (AVE) threshold value, 0.50, as suggested by Rasoolimanesh et al. 30 All values are greater than 0.50 to justify the convergent validity of the items. Results of this study reveal that the studied variable fall within threshold range indicating that the constructs used in the survey were constructive. Therefore, this study proposes a theoretical model that incorporates the influence of information sources on COVID-19 awareness and its impact on distancing behavior (Figure 1 ).
In essence, the study fully satisfies all necessary tests to ensure fit and satisfactory measurement model, as identified above.
The R 2 value of the obtained responses fell in a weak category for perceived understanding (0.095) and social distancing (0.116), respectively. Specifically, exogenous variables identified in this study explain 10% and 12% variances. To assess a reliable path coefficient, bootstrapping and percentile bootstrap confidence interval (95%) were used. Accordingly, the path coefficient relationship between information dimensions and perceived understanding performance was also tested.
It was found that formal and informal information sources significantly affect perceived understanding. Formal information has a statistically significant effect on perceived understanding (β = .183; t = 3.067, P = .001). Informal information is also significantly associated with perceived understanding (β = .234; t = 2.440; P = .007) ( Table 3 ). Statistical analysis also shows that perceived understanding (β = .340; t = 4.794; P = .000) is significantly related to the adoption of social distancing (Figure 3 ). These results lead to the acceptance of the proposed hypothesis.
Once the basic requirements of the inner model were fulfilled; F 2 and Q 2 were analyzed to determine the effect of an exogenous variable on the endogenous variable and predictive relevance of the whole model. In this study, it is identified that formal and informal information has a small effect, that is, 0.037 and 0.060, while perceived understanding has a medium effect, that is, 131. For this study, the model has predictive relevance because it recorded a Q 2 value of 0.028 and 0.067 for perceived understanding and social distancing, respectively, which are greater than zero. 
A hypothetical model that evaluated the effect of formal and informal sources of information on situational awareness (perceived understanding) and ultimately adoption of protective behavior (social distancing) was studied. Results obtained suggest that both When comparing the trust of the general public on information sources, it was revealed that trust in the formal sources is slightly higher in comparison with informal sources. Moreover, another outcome of this study, that is, situational awareness affects the adoption of social distancing behavior which is also consistent with the previously reported surveys conducted to evaluate the effect of formal information sources on the adoption of HPB during A/H1N1 influenza pandemic 2009. 9 Rubin and his colleagues reported that information from media sources increased the adoption of hygiene behavior which led to increased tissue and sanitizer use among British masses during the endemic swine flu. 42 The model developed in this study suggested that social distancing is not linked with formal messages. This outcome supports the fact that social distancing is adopted when a perceived health threat is high. 22 Another outcome suggests that when friends and peers behave responsibly, a person also adopts protective behavior. However, mixed signals from peers and friends led to the declined utility In South Asia, Pakistan is the first country to experience a high severity of CVOID-19 infection. Our study concludes that at the time of such a public health crisis formal information sources (formal and informal) play a significant role in increasing awareness among masses and cognitively influence the adoption of social distancing practices.
The world is facing serious COVID-19 pandemic; this necessitates situational awareness for the adoption of health care protective practices. We believe that the variables studied have 