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Health consideration
The COVID-19 pandemic, which led to more than 120 million infections and 2.66 million deaths by March 16th, 2021, is the most severe public health crisis since the establishment of the World Health Organization (John Hopkins University, 2020). Given that it might take much longer than expected for effective vaccines to be widely available for containing the COVID-19 pandemic, the best strategy to reduce the transmission of SARS CoV-2 is through population-wide engagement in health protective behaviors, such as washing hands effectively and wearing face masks while going out (Michie et al., 2020b, 2020c; Ramirez-Valles et al., 2020). Therefore, it’s necessary for people to adopt health-protective behaviors as recommended by public health experts and authorities for infection control during the pandemic. However, research on health-protective behaviors during pandemics found that behavior change is a major challenge during pandemics of infectious diseases (Puterman et al., 2009; Rubin et al., 2010; Vartti et al., 2009). To combat this challenge, social and behavioral scientists advocated for more research to understand the factors that influence engagement in health protective behaviors and called for applying behavioral sciences into developing and implementing scalable public health strategies to promote health protective behaviors during the pandemic (Lunn et al., 2020; Michie et al., 2020a, 2020b, 2020c; Van Bavel et al., 2020).
One important factor that influences people’s engagement in health behaviors is implicit theories of health—people’s implicit understanding of the changeability of their health (Bunda and Busseri, 2019; Burnette, 2010). The concept on implicit theories of health was adapted from the research on implicit theories proposed by Chiu et al. (1997) and Dweck et al. (1995a, 1995b). Based on the research by Chiu et al. (1997) and Dweck et al. (1995a, 1995b), people’s implicit theories could be categorized as incremental versus entity theory: people who hold an incremental theory of a personal characteristic tend to believe that they can change that characteristic through their own efforts whereas those who hold an entity theory tend to believe that they cannot do much to change that characteristic.
During the past decade, researchers have adapted the research on implicit theories into the health domain. For example, researchers found that implicit theories of health predicted people’s engagement in health promoting behaviors, such that those held an incremental theory of health were more likely to engage in physical exercise and healthy eating than those holding an entity theory of health (Bunda and Busseri, 2019; Burnette, 2010; Burnette and Finkel, 2012; Ehrlinger et al., 2017; Orvidas et al., 2018; Thomas et al., 2019; Schreiber et al., 2020). Recent research also suggested that smokers held an incremental theory of smoking displayed stronger intention to quit in the future than those held an entity theory of smoking (Thai et al., 2020). However, it’s not clear how implicit theories of health influence people’s engagement in health-protective behaviors during pandemics of infectious diseases. The current research filled this gap by investigating the impact of implicit theories of health on people’s engagement in health-protective behaviors during the peak period of COVID-19 pandemic in China.
To further illuminate the underlying mechanism of the relationship between implicit theories of health and engagement in health protective behaviors during the COVID-19 pandemic, we also investigated the mediating effect of consideration of future consequences. Consideration of future consequences is a cognitive-motivational concept that describes people’s likelihood of considering future versus immediate consequences in decision making (Joireman et al., 2012; Strathman et al., 1994). Previous research demonstrated that those tended to consider future consequences were more likely to engage in health behaviors (e.g. exercise, healthy eating) than those tended to consider immediate consequences in decision making (Joireman et al., 2012; Strathman et al., 1994). Given that the health benefits of engaging in health behaviors usually manifest in the future, those hold an incremental theory of health would be more motivated to consider future consequences (e.g. reducing transmission of virus to others) of engaging in health-protective behaviors during pandemics.
Present research
The current research extended the research on implicit theories of health into the domain of health-protective behaviors during pandemics of infectious diseases. As people need to adopt health-protective behaviors during the pandemic to prevent themselves and others from infection and reduce the spread of the COVID-19 pandemic, we predicted that those who held an incremental theory of health would be more likely to engage in health-protective behaviors as recommended by public health authorities than those hold an entity theory of health. Besides, given that people who habitually consider future consequences of their behaviors are more likely to engage in health behaviors that would benefit themselves in the future than those who tend to focus on immediate consequences of behaviors, we hypothesized that consideration of future (versus immediate) consequences could be one pathway through which implicit theories of health influence their likelihood of engaging in health-protective behaviors during the peak period of the COVID-19 pandemic in China.
Method
Participants
The research team prepared the survey using an online survey platform (www.wjx.com), which is similar to Qualtrics, and then distributed it through social media during the peak period of the COVID-19 pandemic in China. In total, 391 Chinese completed the survey. One participant was excluded from the sample because of unrealistic data on age, leaving 390 valid responses in the final analyses. Most of the participants are female (69.5%). The age of participants ranges from 17 to 69 (Mage = 33.28 years, SD = 10.26). About half (49.7%) of the participants are married, half are unmarried (48.2%), 2.1% divorced or widowed. The participants have a relatively higher education level than the general population; most of them have a bachelor’s degree or above (96.1%).
Measures and procedures
Implicit Theories of Health
We measured participants’ implicit theories of health using the Lay Theories of Health scale developed by Bunda and Busseri (2019). The scale measures entity versus incremental theory of health with six items. Sample items include “I can’t change whether I’m in good health or bad health.” (entity theory of health), “I can change even my basic level of health considerably.” (incremental theory of health). Participants responded to the items on a six-point Likert scale (1 = strongly agree, 6 = strongly disagree). After reverse-coding items on incremental theory of health, participants’ responses were averaged as an index of incremental theory of health. A higher score indicates a higher level of incremental theory of health. Cronbach’s α = 0.74 for the scale in the current study.
Health-protective Behaviors
Health protective behaviors were measured with fifteen questions adapted from previous research on engagement in health protective behaviors during the SARS pandemic (Brug et al., 2004; Puterman et al., 2009; Vartti et al., 2009). Eleven items of the measure were behaviors advocated by public health authorities for infection control, such as “Wearing a face mask while going out” and “Washing hands with soap or hand sanitizers,” the remaining four items are general health behaviors as a healthy lifestyle such as “Eating a healthy diet,” “Being physically active.” Participants reported their engagement of each of the fifteen health-protective behaviors since the outbreak of the pandemic using a six-point Likert scale (1 = never, 6 = engage in the behavior every day). Consistent results were found when engagement of health-protective behaviors was analyzed as two categories, HPB-pandemic and HPB-lifestyle, or analyzed as one composite. Therefore, we reported the results using engagement of health-protective behaviors as one composite. Cronbach’s α = 0.78 for the whole measure of engagement in health-protective behaviors in the current study.
Consideration of future consequences
The Consideration of Future Consequences Scale was developed by Joireman and colleagues with two subscales, one tapping consideration of immediate consequences (CFC-Immediate) and the other measuring consideration of future consequences (CFC-Future) (Joireman et al., 2012). Sample items include “I consider how things might be in the future, and try to influence those things with my day to day behavior.” (CFC-Future), “I only act to satisfy immediate concerns, figuring the future will take care of itself.” (CFC-Immediate). Participants responded to the statements using a 7-point Likert scale (1 = not like me at all, 7 = very much like me). Participants’ responses to CFC-Immediate and CFC-Future were averaged and treated as two dimensions of consideration of future consequences. Cronbach’s α = 0.80 and 0.87 for CFC-Immediate and CFC-Future, respectively, in this study.
Finally, participants answered questions about demographic questions, including age, gender, marital status, and education level. This research received ethical clearance from the Ethical Committee of authors’ hosted institution.
Data analyses strategy
We used correlational analyses to describe the relationships between key variables included in this study and used regression analysis to explore the predictors of engagement in health protective behaviors during the COVID-19 pandemic. We conducted mediational analyses to explore whether consideration of future consequences mediated the relationship between implicit theories of health and people’s engagement in health protective behaviors by using Preacher and Hayes’s (2008) Process macro.
Data sharing statement
De-identified individual participant data (including data dictionaries) is available in this study. After de-identification, individual participant data that underlie the results reported in this article (text, tables, figures) will be shared. Moreover, statistical analysis plan, analytic codes that has been used for the analyzes will also be available on FigShare.
Results
Descriptive statistics
Correlation analyses indicated that age weakly correlated with engagement in health-protective behaviors and CFC-Future, suggesting that older people tend to be more proactive in engaging in health-protective behaviors. People’ incremental theory of health significantly correlated with their engagement in health-protective behaviors and likelihood of consideration of future consequences (CFC-Future), but negatively correlated with their likelihood of considering immediate consequences (CFC-Immediate). People’s likelihood of considering future consequences (CFC-Future) also significantly correlated with participants’ engagement in health-protective behaviors (See Table 1). These results suggest that implicit theories of health and consideration of future consequences are important psychological factors that influence people’s likelihood of engaging in health protective behaviors during the COVID-19 pandemic.
Table 1. Descriptive statistics and correlations between key variables.
Predictors of health protective behaviors
Regression analyses revealed that gender, education level, implicit theories of health, and CFC-Future were significant predictors of people’s engagement in health protective behaviors. There were no significant interactions between implicit theories of health and consideration of future consequences (CFC-Future or CFC-Immediate). These results suggested that female participants, those with a higher level of incremental theory of health, and those who are more likely to consider future consequences while making decisions were more likely to engage in health protective behaviors during the COVID-19 pandemic. However, those with higher education levels were less likely to engage in health protective behaviors during the COVID-19 pandemic (See Table 2).
Table 2. Predictors of engagement inf health protective behaviors during COVID-19.
Mediational analyses
First, we conducted a mediation analysis with implicit theories of health as the independent variable, people’s engagement in health protective behaviors as the dependent variable, and CFC-Future as the mediator. The indirect effect of implicit theories of health on engagement in health protective behaviors through CFC-Future was significant, B = 0.054, p < 0.001. Bootstrapping analysis revealed that the 95% bias-corrected CI [0.030, 0.093] did not include zero. The Sobel test confirmed the mediation effect by CFC-Future, Z = 3.55, p = 0.001. Therefore, CFC-Future significantly mediated the relationship between implicit theories of health and engagement in health protective behaviors (see Figure 1).1
