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Factors influencing nursing students’ participatory behaviour during COVID-19

      Abstract

      Background

      Because nursing students are important human resources for future public health, their participatory behaviours related to preventive health during a pandemic were explored.

      Aim

      This study examines the impact of nursing students’ risk communication, anxiety, and their perception of risk on their participatory behaviour during COVID-19.

      Methods

      Data were collected from 180 South Korean nursing students in six provinces via an online survey and were analysed using independent t-test, ANOVA, Pearson's correlation coefficient, and multiple regression. The SPSS WIN 25.0 program was employed.

      Findings

      Perceiving information to influence oneself was a significant predictor of each participatory behaviour. Risk communication was not identified as a factor influencing health-related participatory behaviour. However, the influence of information is a concept derived from risk communication.

      Discussion

      Risk communication for behaviour change needs to be designed so that communication targets recognise the impact of risk. Promoting pro-social behaviour in the nursing curriculum is important because it will make the students more sensitive to information that can have a dangerous impact on others.

      Conclusion

      It is important to create health-related risk communications by considering the perspective of perception of influence.

      Keywords

      Summary of relevance
      Problem or issue
      There are few studies on COVID-19-related behavioural patterns of nursing students.
      What is already known
      In some cases, fear-inducing messages are used to ensure public preventive health behaviour.
      What this paper adds
      Perceiving information to influence oneself affected each kind of participatory behaviour among nursing students. Risk communication, anxiety, and perception of influence of information on others were not identified as factors influencing health-related participatory behaviour.

      1. Introduction

      The South Korean government has shared real-time risk communication so that the public can actively participate in preventive health activities in response to the highly contagious viral disease COVID-19. Systems in many areas of Korea have changed, and nursing education also faces new challenges. Lectures are mostly non-face-to-face, and clinical practice is also limited in part or in its entirety depending on hospital situations (
      • Lee E.
      Affecting factors the Academic burnout in Nursing Students of Non-face-to-face class in COVID-19 situation.
      ). Nursing students, as well as nurses, have close contact with patients, raising the risk of infectious diseases (
      • Kim O.
      • Oh J.H.
      • Lee K.H.
      The convergence study on anxiety, knowledge, infection possibility, preventive possibility and preventive behavior level of MERS in nursing students.
      ). Nursing students may be more vulnerable to infection because they are less skilled than nurses (
      • Jeong M.H.
      Survey of exposure to blood and body fluids, knowledge, awareness and performance on standard precautions of infection control in nursing students.
      ). Nevertheless, few studies have identified factors influencing nursing college students' participation in preventive health behaviours in ongoing pandemic condition.
      Future nursing education is important to foster nurses who can cope with prolonged or new pandemics. Above all, this can be achieved through curriculum design that reflects students' characteristics (
      • Kim S.J.
      A study on the development of a Korean health risk communication model based on the relational themes of emotion: Focusing on the relationship between motivation system and emotions.
      ). Therefore, this study has attempted to understand the effects of risk communication, anxiety, and information impact recognition on participatory behaviours such as preventive health behaviours in nursing students in pandemic situations (Fig. 1).

      2. Background/literature

      In a highly contagious pandemic, it is very important for the public to participate in public health principles. The principles emphasised by the South Korean government include wearing masks, washing hands and avoiding public places and so on (
      • Chang J.
      • Shim J.C.
      Testing the links between health belief model, optimistic bias, and behavioral intention: the case study of foot and mouth disease, mad cow disease, and H1N1 flu.
      ;
      • Lee M.
      • You M.
      Psychological and behavioral responses in South Korea during the early stages of coronavirus disease 2019 (COVID-19).
      ). In addition, sharing health information can be considered to be a participatory behaviour in public health because it is intended to protect oneself and others (
      • Park H.
      • Kim S.
      • Yang J.
      The effects of exposure to MERS information and issue involvement on perceived information influence, disease prevention and information sharing.
      ). Accordingly, in this study, individuals' preventive health behaviours, information sharing, and intentions to participate in public health guidelines were defined as participatory behaviours, one of pro-social behaviours.
      Meanwhile, the South Korean government has used risk communication mainly through mass media or social network systems to resolve the pandemic by inducing public participation (
      • Chang J.
      • Shim J.C.
      Testing the links between health belief model, optimistic bias, and behavioral intention: the case study of foot and mouth disease, mad cow disease, and H1N1 flu.
      ;
      • Lee M.
      • You M.
      Psychological and behavioral responses in South Korea during the early stages of coronavirus disease 2019 (COVID-19).
      ). Risk communication is the process of providing information to the public during natural disasters or other uncertainties (
      • Sheppard B.H.
      • Janoske M.
      • Liu B.F.
      Understanding risk communication theory: A guide for emergency managers and communicators.
      ;
      • Sopory P.
      • Day A.M.
      • Novak J.M.
      • Eckert S.
      • Wilkins L.
      • Padgett D.R.
      • et al.
      Communicating uncertainty during public health emergency events: A systematic review.
      ;
      • Spiegelhalter D.
      • Gage J.
      What can education learn from real-world communication of and uncertainty?.
      ). This risk communication has expanded to epidemic issues, highlighting its role in public health (
      • Infanti J.J.
      • Sixsmith J.
      • Barry M.
      A literature review on effective risk communication for the prevention and control of communicable diseases in Europe.
      ). A risk communication approach that appeals to public fear is often used to inspire the public to undertake protective activities (
      • Witte K.
      • Allen M.
      A meta-analysis of fear appeals: implications for effective public health campaigns.
      ). However, the dissemination of risk-related information must be combined with a well established strategy to protect the public from risks (
      • Janssen E.
      • Ruiter R.A.C.
      • Waters E.A.
      Combining risk communication strategies to simultaneously convey the risks of four diseases associated with physical inactivity to socio-demographically diverse populations.
      ;
      • Peters G.J.
      • Ruiter R.A.
      • Kok G.
      Threatening communication: a critical re-analysis and a revised meta-analytic test of fear appeal theory.
      ).
      Sometimes campaign messages have different consequences from their original intentions because message acceptance relies on the psychological and cognitive processing of the recipient beyond the message producer's control (
      • Cho H.
      • Salmon C.T.
      Unintended effects of health communication campaigns.
      ;
      • Kim H.K.
      • Yoon Y.M.
      An experimental study on the factors affecting persuasiveness of health messages in AIDS campaign.
      ). People behave differently depending on the perception bias of information acquired (
      • Davison W.P.
      The third-person effect in communication.
      ), which can be called “perception of the influence of information” (
      • Park H.
      • Kim S.
      • Yang J.
      The effects of exposure to MERS information and issue involvement on perceived information influence, disease prevention and information sharing.
      ). That is, people tend to have different participatory behaviours depending on their beliefs or attitudes, or whether the risk communication-related issues affect themselves or third parties (
      • Chang J.
      • Shim J.C.
      Testing the links between health belief model, optimistic bias, and behavioral intention: the case study of foot and mouth disease, mad cow disease, and H1N1 flu.
      ;
      • Lang A.
      • Yegiyan N.S.
      Understanding the interactive effects of emotional appeal and claim strength in health messages.
      ;
      • Shen L.
      • Dillard J.P.
      The influence of behavioral inhibition /approach systems and message framing on the processing of persuasive health messages.
      ). Especially, the public tends to accept that socially undesirable messages will have a greater influence on third parties (
      • Andsager J.L.
      • White H.A.
      Self versus others: Media, messages, and the third-person effect.
      ), and that desirable messages will have a greater impact on themselves (
      • Hoorens V.
      • Ruiter S.
      The optimal impact phenomenon: beyond the third person effect.
      ;
      • Perloff R.M.
      Third-person effect research: a critical review and synthesis.
      ). However, since the latter findings were somewhat inconsistent (
      • Golan G.
      • Day A.
      The first-person effect and its behavioral consequences: a new trend in the twenty-five year history of third person effect research.
      ), and as a clue to understanding the public (
      • Dillard J.P.
      • Peck E.
      Affect and persuasion: emotional responses to public service announcements.
      ;
      • Kim S.J.
      A study on the development of a Korean health risk communication model based on the relational themes of emotion: Focusing on the relationship between motivation system and emotions.
      ), it is necessary to clarify the emotions and perceptions associated with their risk responses.
      Previous COVID-19-related studies dealt with psychological issues, such as depression, anxiety, and stress among health care workers; scarcity of health care workers or mainly focused on health care workers during pandemics (
      • Bohlken J.
      • Schömig F.
      • Lemke M.R.
      • Pumberger M.
      • Riedel-Heller S.G.
      COVID-19 pandemic: stress experience of healthcare workers a short current review.
      ). Prior studies on risk communication focused primarily on infectious disease-related emergencies, as shown in a systematic literature review study,
      • Miller A.N.
      • Sellnow T.
      • Neuberger L.
      • Todd A.
      • Freihaut R.
      • Noyes J.
      • et al.
      A systematic review of literature on effectiveness of training in emergency risk communication.
      , which suggested that risk communication strategies for health-related professionals should focus on designing messages for specific audience needs via synthesised findings. However, few studies examined the relationship between a pandemic and risk communication or participatory behavior. Specifically, in case of a prolonged pandemic, nursing students must take additional interest in their growth as they will eventually become an integral part of the healthcare manpower (
      • Kim O.
      • Oh J.H.
      • Lee K.H.
      The convergence study on anxiety, knowledge, infection possibility, preventive possibility and preventive behavior level of MERS in nursing students.
      ).

      3. Methodology

      1. Study design, setting, and sample

      This was a cross-sectional online survey. A total of 180 Bachelor of Nursing students were invited from the Seoul, Gyeonggi-do, Gangwon-do, Chungcheong-do, Gyeongsang-do, and Jeonra-do provinces. The selection criteria for the subjects were nursing students who had online access, and those who were taking a leave of absence or had already graduated were excluded. We determined that a sample size of 210 was required to detect a statistically significant medium effect in a multiple regression model with 14 predictors at a 0.05 significance level. Power analysis was conducted using G* power version 3.1.3 (Institute for Experimental Psychology, Heinrich-Heine University, Dusseldorf, Germany).

      3.2 Ethics

      The Institutional Review Board of the author's University approved this study. The study's purpose was explained to participants, and they were assured that their personal identification information will remain confidential. They were free to withdraw from the study any time, without penalty.

      3.3 Study instruments

      3.3.1 Demographic characteristics

      Participants were asked to disclose their demographic and communication-related characteristics, including age, gender, school year, satisfaction with major, duration of clinical practice experience, respiratory system disease prevention education experience, and area of residence.

      3.3.2 Risk communication

      We used the seven-item scale developed by
      • Sung H.J.
      The influence of cultural biases on risk perception, risk communication perception and participatory behavior intention- comparison of two risk issues; AI (Avian Influenza) infection and Radioactive Waste [Unpublished master’s thesis].
      to evaluate the risk communication awareness about Avian Influenza (AI) infection and radiation waste issues. The contents of AI infection and radioactive waste were modified to adapt to COVID-19 (“I think the COVID-19 risk communication so far has had a good overall outcome”). Questionnaires were adopted through the content validity of five experts and consisted of three sub-domains: organisational, public, and communication levels. Each item used a five-point Likert scale (5 = “not at all”; 1 = “strongly agree”–meaning that the perception of risk communication is higher). Cronbach's alpha was 0.91 in the study by
      • Sung H.J.
      The influence of cultural biases on risk perception, risk communication perception and participatory behavior intention- comparison of two risk issues; AI (Avian Influenza) infection and Radioactive Waste [Unpublished master’s thesis].
      and 0.89 in this study.

      3.3.3 Anxiety

      The Korean version of the anxiety tool developed by
      • Spielberger C.D.
      • Gorsuch R.L.
      • Lushene R.E.
      STAI manual for the state-trait anxiety inventory (“Self-evaluation questionnaire”).
      and translated by
      • Kim J.
      • Shin D.
      A study based on the standardization of the STAI for Korea.
      was used. This comprised 20 questions and used a four-point Likert scale (from 1 = “not at all” to 4 = “always”). The higher the score, the higher the anxiety. Cronbach's alpha was 0.72 in the study by
      • Kim O.
      • Oh J.H.
      • Lee K.H.
      The convergence study on anxiety, knowledge, infection possibility, preventive possibility and preventive behavior level of MERS in nursing students.
      and 0.89 in this study.

      3.3.4 Perception of influence of information

      Perception of influence of information refers to the extent to which perception of oneself and others is affected by risk information (
      • Park H.
      • Kim S.
      • Yang J.
      The effects of exposure to MERS information and issue involvement on perceived information influence, disease prevention and information sharing.
      ). We used the six-item scale developed by
      • Park H.
      • Kim S.
      • Yang J.
      The effects of exposure to MERS information and issue involvement on perceived information influence, disease prevention and information sharing.
      to evaluate the perception of influence of information related to MERS. The content was modified to adapt to COVID-19 using the content validity of five experts. There were six items consisting of two subdomains: the influence of information on oneself and the influence of information on others ("Information about COVID-19 has influenced my (others') thoughts on the threat of COVID-19″). A seven-point Likert scale was employed. Higher scores reflected higher perception of influence. The domain with a high perception score of influence was more dominant. Thus, if the perception of influence on oneself reflects a higher score than the influence on others, the risk information would affect the individual more significantly than it would affect others. Cronbach's alpha was 0.90 and 0.84 in the study by
      • Park H.
      • Kim S.
      • Yang J.
      The effects of exposure to MERS information and issue involvement on perceived information influence, disease prevention and information sharing.
      and 0.84 and 0.85 in this study.

      3.3.5 Participatory behaviour

      Participatory behaviour in this study is a collective term for three concepts attempted to investigate the level of participation in public health activities related to COVID 19: Preventive health behaviour, information sharing behaviour, and participatory behaviour intentions. Tools to measure three concepts are as follows.
      Preventive health behaviour employed tools developed by
      • Park H.
      • Kim S.
      • Yang J.
      The effects of exposure to MERS information and issue involvement on perceived information influence, disease prevention and information sharing.
      . A total of seven questions regarding behaviour, such as washing one's hands more often than usual and the use of hand sanitiser/disinfectant. Response options were configured to allow answers to the proposed behaviour in the “yes” or “no” form. The number of affirmative answers was summed. The higher the number, the higher the preventive behaviour. Kuder–Richardson Formula 20 was 0.70 in this study.
      Information sharing behaviour was measured using a single question used by
      • Park H.
      • Kim S.
      • Yang J.
      The effects of exposure to MERS information and issue involvement on perceived information influence, disease prevention and information sharing.
      : “how often have you been sharing or communicating news and information about COVID-19 with others?” (This communication included conversations, phone calls, texts, e-mails, link sharing, scrapping, tweeting/retweeting, and more.) A five-point Likert scale was employed with options ranging from 1 (“not at all”) to 5 (“very frequently”). The higher the score, the higher the information sharing behaviour.
      Participatory behaviour intention was measured using five questions developed by
      • Sung H.J.
      The influence of cultural biases on risk perception, risk communication perception and participatory behavior intention- comparison of two risk issues; AI (Avian Influenza) infection and Radioactive Waste [Unpublished master’s thesis].
      . The contents therein were modified to adapt to COVID-19 using the content validity of five experts. This comprised five questions and used a five-point Likert scale with options ranging from 1 (“not at all”) to 5 (“strongly agree”). The higher the score, the higher the participatory behaviour intention. Cronbach's alpha was 0.78 in the study by
      • Sung H.J.
      The influence of cultural biases on risk perception, risk communication perception and participatory behavior intention- comparison of two risk issues; AI (Avian Influenza) infection and Radioactive Waste [Unpublished master’s thesis].
      and 0.76 in this study.

      3.4 Data collection

      From April 16 to 30, 2020, Data were collected using online surveys (www.surveymonkey.com), a safety measure to limit the risk of COVID-19 transmission. Three trained research assistants recruited survey participants to the nursing student's online community. A link to the questionnaire was sent via mobile phone or e-mail to those who provided prior consent to participate. The collected data was processed to make it impossible to identify personal information. The coded data was stored on the author's computer and could only be accessed using a password.

      3.5 Statistical analysis

      Data were analysed using the SPSS version 25.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were used to examine participants’ sociodemographic characteristics. Independent t-tests and one-way ANOVA were used to examine the differences in the means of preventive health behaviour, information sharing behaviour, and participatory behaviour intention according to participants’ general characteristics. The Scheffe test was performed as a post-comparison tool, and correlation between the main variables was determined using the Pearson's correlation coefficient. Multiple linear regression analysis (Enter method) was adopted to identify predictors of preventive health behaviour, information sharing behaviour, and participatory behaviour intention. Using the P-P Chart and histogram analysis, the assumption of normal distribution for multiple linear regression analysis was verified and met. To evaluate multicollinearity, the variance inflation factor was assessed and the acceptable level was met. Dummy variables were created for categorical variables. Statistical significance was established at p < .05, and all tests were two-tailed.

      4. Results

      Out of 210 completed questionnaires, 30 were excluded due to incomplete information; data from 180 were analysed.
      Table 1 shows the demographic characteristics of the participants and differences in participatory behaviours according to sociodemographic characteristics. Most participants (94.4%) were female, and the mean age was 21.1 years. The preventive health behaviour score was higher for the female group (p < .001).
      Table 1Differences in participatory behaviour by demographic characteristics (n = 180).
      VariablesCategoriesn (%) or

      mean± SD
      Preventive  health behaviourInformation sharing behaviourParticipatory behaviour intention
      mean (SD)t/F pmean (SD)t/F pmean (SD)t/F p
      Age (In years)21.1 ± 2.1
      GenderMale10 (5.6)5.20 ± 1.03-3.59 <.00
      p < .001,
      2.90 ± 1.20-1.50 .1373.62 ± 0.60-1.26 .210
      Female170 (94.4)6.28 ± 0.923.34 ± 0.873.85 ± 0.56
      Year (school)119 (10.6)6.37 ± 0.90.86 .4643.05 ± 1.031.17 .3243.60 ± 0.572.53 .059
      239 (21.7)6.31 ± 0.923.31 ± 0.863.76 ± 0.56
      349 (27.2)6.04 ± 1.083.22 ± 0.873.81 ± 0.55
      473 (40.6)6.25 ± 0.893.44 ± 0.903.95 ± 0.55
      Satisfaction with majorNone19 (10.6)6.37 ± 0.90.97 .4093.05 ± 1.032.39 .0713.60±0.572.68 .049
      p < .05.
      Low5 (2.8)5.60 ± 0.553.20 ± 0.843.64 ± 0.82
      Moderate80 (44.4)6.18 ± 0.963.51 ± 0.873.95 ± 0.57
      High76 (42.2)6.26 ± 0.973.51 ± 0.873.95 ± 0.57
      Duration of clinical practice (yrs.)None99 (55.0)6.20 ± 0.97.05 .9523.23 ± 0.921.02 .3643.75 ± 0.562.95 .055
      < 125 (13.9)6.20 ± 1.153.32 ± 0,853.86 ± 0.47
      1≤-< 256 (31.1)6.25 ± 0.843.45 ± 0.893.98 ± 0.57
      Engage in learning for infection preventionNone64 (35.6)6.27 ± 0.93.51 .6103.16 ± 0.98-1.73 .0863.73 ± 0.58-1.93 .055
      Yes116 (64.4)6.19 ± 0.973.40 ± 0.843.89 ± 0.54
      Major residential areas in the last 3 monthsSeoul- Kyeonggi43 (23.9)6.20 ± 0.99.78 .5663.35 ± 0.92.59 .7123.90 ± 0.63.31 .906
      Chungcheong59 (32.8)6.25 ± 0.993.19 ± 0.903.78 ± 0.55
      Gwanwon21 (11.7)5.95 ± 1.023.24 ± 0.893.82 ± 0.49
      Gyeongsang27 (15.0)6.41 ± 0.573.37 ± 0.883.88 ± 0.49
      Jeonra16 (8.9)6.00 ± 1.153.44 ± 0.963.88 ± 0.66
      Others14 (7.7)6.36 ± 0.933.57 ± 0.853.77 ± 0.54
      a p < .001,
      b p < .05.
      Table 2 shows the frequency of preventive health behaviour and the mean scores of every variable. The highest score was for “I wear a face mask when I go out” at 98.3%. The lowest scoring item was “I avoid the use of public transportation” at 63.9%. The mean scores of risk communication, anxiety, perception of influence of information (self and others), and participatory behaviour (preventive health behaviour, information sharing behaviour, and participatory behaviour intention) were 3.78 (out of 5), 2.25 (out of 4), 5.78, 5.81 (out of 7), 6.22 (out of 7), 3.31 (out of 5), and 3.84 (out of 5) points, respectively. Finally, regarding the perception of influence, the difference between the score of perceived influence on oneself and the influence of perceived score on others was -0.03, indicating that the pandemic would affect others a little more than the self.
      Table 2Frequency of preventive health behaviour and levels of major variables (n = 180).
      Items% of yesMeanSD
      I go out less frequently91.3
      I wear a mask when I go out98.3
      I wash hands more often than usual97.2
      I use hand sanitiser/disinfectant in public places92.8
      I avoid people with cough85.0
      I avoid visiting public places, such as restaurants and theatres92.8
      I avoid using public transportation, such as buses and subway63.9
      Total88.8
      Variables
      Risk communication3.780.65
      Anxiety2.250.47
      Perception of influence of information on oneself (1)5.780.82
      Perception of influence of information on others (2)5.810.90
      The predominance of perception of influence of information (1-2)-0.030.95
      Participatory behaviour (preventive health behaviour)6.220.95
      Participatory behaviour (information sharing behaviour)3.310.90
      Participatory behaviour (participative behaviour intention)3.840.56
      Table 3 shows the relationships between risk communication, anxiety, perception of influence of information, and participatory behaviour (preventive health behaviour, information sharing behaviour, and participatory behaviour intention). The anxiety level was negatively correlated to perceiving information to influence oneself (p = .002) and preventive health behaviour (p = .025). Perceiving information to influence oneself was positively correlated to perceiving information to influence others (p < .001), preventive health behaviour (p = .003), information sharing behaviour (p < .001), and participatory behaviour intention (p < .001). Perceiving information to influence others was positively correlated to information sharing behaviour (p = .008) and participatory behaviour intention (p = .031). Preventive health behaviour was positively correlated to information sharing behaviour (p < .001) and participatory behaviour intention (p < .001). Information sharing behaviour was positively correlated to participatory behaviour intention (p < .001).
      Table 3Correlation between risk communication, anxiety, perception of influence of information, and participatory behaviour (n = 180).
      Variables123456
      r / p
      Anxiety 2.06
      .437
      Perception of influence of information on oneself 3.13-.23
      .097.002
      p < .05.
      Perception of influence of information on others 4.04-.12.58
      .603.109<.001
      p < .001,
      Participatory behaviour (preventive health behaviour) 5.05-.17.22.07
      .471.025
      p < .05.
      .003
      p < .05.
      .384
      Participatory behaviour (information sharing behaviour) 6.01-.11.30.20.25
      .958.134<.001
      p < .001,
      .008
      p < .05.
      .001
      p < .05.
      Participatory behaviour (participatory behaviour intention) 7.13-.09.39.16.30.49
      .093.215<.001
      p < .001,
      .031
      p < .05.
      <.001
      p < .001,
      <.001
      p < .001,
      a p < .001,
      b p < .05.
      To determine the impact of participants’ risk of communication, anxiety, and perception of influence of information on participatory behaviour in relation to COVID-19, we performed a stepwise multiple regression Table 4. shows the results.
      Table 4Results of multiple regression (n = 180).
      VariablesBSEβtp
      Preventive health behaviourConstant1.330.7118.66<.001R2 = .06 Adj. R2 = .06 F = 9.34 p =.003
      Perception of influence of information on oneself0.040.01.223.06.003
      Information sharing behaviourConstant1.400.463.05.003R2 = .09 Adj. R2 = .09 F = 17.65 p <.001
      Perception of influence of information on oneself0.330.08.304.20<.001
      Participatory behaviour intentionConstant2.290.287.03<.001R2 = .15Adj. R2 = .15 F = 31.93 p <.001
      Perception of influence of information on oneself0.270.05.395.65<.001
      Perceiving information to influence oneself (β = .22, p = .003) was a significant factor for preventive behaviour under participatory behaviour. The influence of information on oneself explained 6.0% of preventive health behaviour under participatory behaviour. This was identified as the only influencing factor on information sharing behaviour and participatory behaviour intention at 9% and 15%, respectively.

      5. Discussion

      The purpose of this study was to investigate the factors influencing nursing students’ participatory behaviour in COVID-19. Specially, we examined the association between risk communication, anxiety, perception of influence of information, and participatory behaviour.
      Preventive health behaviour and information sharing behaviour levels of this study were higher compared to the aforementioned study related to MERS in Korea (
      • Park H.
      • Kim S.
      • Yang J.
      The effects of exposure to MERS information and issue involvement on perceived information influence, disease prevention and information sharing.
      ). The score of participatory behaviour intention was also higher than participatory behaviour intention related to AI and radioactive waste in
      • Sung H.J.
      The influence of cultural biases on risk perception, risk communication perception and participatory behavior intention- comparison of two risk issues; AI (Avian Influenza) infection and Radioactive Waste [Unpublished master’s thesis].
      . The average frequency of seven items in this study was higher than another Korean study (
      • Park H.
      • Kim S.
      • Yang J.
      The effects of exposure to MERS information and issue involvement on perceived information influence, disease prevention and information sharing.
      ) on MERS but lower than a previous study (
      • Taghrir M.H.
      • Borazjani R.
      • Shiraly R.
      COVID-19 and Iranian medical students: a survey on their related-knowledge, preventive behaviors and risk perception.
      ) related to COVID-19 involving Iranian medical students. “Behaviors pertaining to avoiding public transportation and efforts to avoid people with a cough” were more frequent than
      • Park H.
      • Kim S.
      • Yang J.
      The effects of exposure to MERS information and issue involvement on perceived information influence, disease prevention and information sharing.
      , but lower compared to
      • Taghrir M.H.
      • Borazjani R.
      • Shiraly R.
      COVID-19 and Iranian medical students: a survey on their related-knowledge, preventive behaviors and risk perception.
      . “Wearing a face mask” was the most common preventive health behaviour in this study, scoring much higher than the MERS outbreak (
      • Park H.
      • Kim S.
      • Yang J.
      The effects of exposure to MERS information and issue involvement on perceived information influence, disease prevention and information sharing.
      ). The difference in preventive health behaviour of subjects may result from difference of culture, and characteristics of risk communication provided. Though risk communication is essential for public health campaigns (
      • Vos S.C.
      • Sutton J.
      • Yu Y.
      • Renshaw S.L.
      • Olson M.K.
      • Gibson C.B.
      • et al.
      Retweeting risk communication: the role of threat and efficacy.
      ), the ways it is applied may vary from country to country and situation to situation. The frequency of participation in preventive health behaviour of the subjects in this study was also relatively higher in the items emphasised by risk communication. In other words, even if risk communication does not predict preventive health behaviour statistically significantly in this study, it is necessary to explore the effects of risk communication in various environments.
      There was no statistically significant difference in the level of participatory activities among the subjects of this study, but contrary to expectations, the score of preventive health behaviour was higher in freshmen. Participants in previous studies answered that the sources of information related to COVID-19 were mainly official advice from the mass media rather than school education (
      • Taghrir M.H.
      • Borazjani R.
      • Shiraly R.
      COVID-19 and Iranian medical students: a survey on their related-knowledge, preventive behaviors and risk perception.
      ;
      • Yuan T.
      • Liu H.
      • Li X.D.
      • Liu H.R.
      Factors affecting infection control behaviors to prevent COVID-19: an online survey of nursing students in Anhui, China in March and April 2020.
      ). It is inferred that there was little effect by school education. In the study in which knowledge, practice, attitude, and e-health literacy were identified as predictors of preventive behaviour of Chinese nursing students, the level of freshmen was higher than that of seniors in other factors except knowledge (
      • Yuan T.
      • Liu H.
      • Li X.D.
      • Liu H.R.
      Factors affecting infection control behaviors to prevent COVID-19: an online survey of nursing students in Anhui, China in March and April 2020.
      ). The public is known to be more compliant with official advice when anxiety grows due to ignorance of novel threats (
      • Rubin G.J.
      • Amlôt R.
      • Page L.
      • Wessely S.
      Public perceptions, anxiety, and behaviour change in relation to the swine flu outbreak: Cross sectional telephone survey.
      ). In other words, it is possible that freshmen perceived their lack of disease-related knowledge and responded more sensitively to risk communication emphasising preventive actions.
      However, COVID-19 is a public health emergency that threatens routine capabilities in the international community (
      • Lee M.
      • You M.
      Psychological and behavioral responses in South Korea during the early stages of coronavirus disease 2019 (COVID-19).
      ). The emergence of public health emergencies such as COVID-19 will be repeated for mankind. Therefore, the nursing curriculum should consider fostering human resources who can prevent and manage public health emergencies.
      Another interesting outcome was that risk communication did not correlate to any participatory behaviour. Anxiety had a significant negative correlation only in preventive behaviour. Iranian medical students’ risk perception was similar to the result of negative correlation with preventive behaviour, and it differed from previous studies (
      • Rubin G.J.
      • Amlôt R.
      • Page L.
      • Wessely S.
      Public perceptions, anxiety, and behaviour change in relation to the swine flu outbreak: Cross sectional telephone survey.
      ;
      • Song H.R.
      • Kim W.J.
      Effects of risk information component of media and knowledge on risk controllability - focusing on infectious disease.
      ;
      • Lim M.J.
      • Tun Z.M.
      • Kumar V.
      • Quaye S.E.D.
      • Offeddu V.
      • Cook A.R.
      • et al.
      Population anxiety and positive behaviour change during the COVID-19 epidemic: cross-sectional surveys in Singapore, China and Italy.
      ). Found that public behaviour and anxiety level toward COVID-19 can be changed as they receive sufficient information to control the spread of the infection. These may aid the impact of risk communication campaigns by demonstrating that, while COVID-19 is highly contagious, it can be controlled through preventive behaviour. In other words, continuing to provide risk communication to the public would be desirable from a long-term perspective because it helps their psychological stability.
      Most importantly, the study indicated that perceiving information to influence oneself was the only predictor of preventive health behaviour, information sharing behaviour, and participatory behaviour intention. These results differ from studies that suggest that the level of risk communication or anxiety predicts MERS-related participatory behaviour (
      • Kim O.
      • Oh J.H.
      • Lee K.H.
      The convergence study on anxiety, knowledge, infection possibility, preventive possibility and preventive behavior level of MERS in nursing students.
      ;
      • Park H.
      • Kim S.
      • Yang J.
      The effects of exposure to MERS information and issue involvement on perceived information influence, disease prevention and information sharing.
      ). Rather, it is a similar context to studies that risk perception affects COVID-19-related participatory behaviour (
      • Lee M.
      • You M.
      Psychological and behavioral responses in South Korea during the early stages of coronavirus disease 2019 (COVID-19).
      ) and changes in participatory behaviour related to swine flu (
      • Rubin G.J.
      • Amlôt R.
      • Page L.
      • Wessely S.
      Public perceptions, anxiety, and behaviour change in relation to the swine flu outbreak: Cross sectional telephone survey.
      ). However, the concept of perception in these studies does not distinguish in detail, so additional investigation is required for comparison.
      The finding of the study predicted that the more subjects perceive that COVID-19 has a greater impact on themselves, the more participatory behaviour will increase. COVID-19-related risk communication produced in Korea is classified as a public interest message to overcome the pandemic by promoting preventive health behaviour of the public (
      • Holmes B.J.
      Communicating about emerging infectious disease: the importance of research.
      ;
      • Perloff R.M.
      Third-person effect research: a critical review and synthesis.
      ) stated that the public has a bias that, when evaluating the impact of a message, if it is a message of public interest, it will have a greater effect on them than others. Strategies for establishing effective risk communication will need to begin with identifying context or mechanisms between them.
      A key takeway from this study is that Korea's adequate management of COVID-19 risk communication mitigated nursing students’ anxiety and facilitated the adoption of preventive behaviour. Finally, when risk communication demonstrates the seriousness of the disease and its potential effect on the self, it can be the most impactful regarding behavioural changes. In a pandemic situation, preventive health behaviour for oneself is also a pro-social behaviour that indirectly helps others. In addition, factors that threaten the health of others eventually affect one's own safety. Therefore, nursing students should not only actively participate in preventive health behaviours that protect themselves, but also pay attention to issues that affect the health of others. The nursing education should also be prepared to cope with the pandemic situation with a macroscopic perspective.

      5.1 Limitations

      This study has several limitations. First, convenience sampling was used to recruit nursing students from six Korean provinces. Though the varied locations made the study more representative of the country, the generalisability to other countries or populations might be limited, particularly those with a different value system such as the United States where the culture is one of individualism.
      Second, data were collected through cross-sectional design during a 2-week period in April 2020. Consequently, we could not explore the relationship between time and risk communication, anxiety, perceived influence, and preventive behaviour. Moreover, the passage of time has implications for COVID-19 phases, and this may suggest that the confounding variables of this study have not been fully considered. Finally, although acceptable instruments were employed to measure study variables, the generalisation of the findings needs to be prudent due to the biased self-reporting and use of multiple instruments primarily adopted in Korea. Therefore, repeated research using more sophisticated and detailed tools for populations in various environments is necessary.

      6. Conclusion

      Our findings indicated that the perception that information that applies to oneself could be crucial in encouraging the public to engage in prosocial behaviours that helps control pandemics. We recommend that the perspective of the perception of influence must be reflected in the creation of risk communication that encourages people's participatory behaviour.

      Authorship contribution statement

      Woo CH: Conceptualisation and Methodology, Data curation, Formal analysis, Funding acquisition, Investigation, Project administration, Supervision, Roles/Writing - original draft, Writing - review & editing. Park JY: Data curation, Formal analysis, Investigation, Validation, Visualisation, Roles/Writing - original draft, Writing - review & editing. Joe SY: Resources, Software, Roles/Writing - original draft, Writing - review & editing.

      Funding

      This study was supported by the National Research Foundation of Korea Grant funded by the Korean Ministry of Science and ICT [grant number NRF-2018R1C1B6002021 ]. The funding body had no role in the study design, data collection, writing or publication of this study.

      Ethical statement

      This study was approved by the ethics committee of Konyang University's Institutional Review Board (Approval No: KYU-2020-042-02; Date of approval: 22 April, 2020). Informed consent was obtained from each participant.

      Conflict of interest

      The authors state they have no conflict of interest to declare.

      Acknowledgements

      None.

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