Death Studies

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/udst20

COVID-19 severity, self-efficacy, knowledge,

preventive behaviors, and mental health in Turkey

Murat Yıldırım & Abdurrahim Güler

To cite this article: Murat Yıldırım & Abdurrahim Güler (2020): COVID-19 severity, self-
efficacy, knowledge, preventive behaviors, and mental health in Turkey, Death Studies, DOI:
10.1080/07481187.2020.1793434

To link to this article: https://doi.org/10.1080/07481187.2020.1793434

Published online: 16 Jul 2020.

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DEATH STUDIES
https://doi.org/10.1080/07481187.2020.1793434

COVID-19 severity, self-efficacy, knowledge, preventive behaviors, and

mental health in Turkey
Murat Yıldırıma,b €lerc
and Abdurrahim Gu
a
Department of Psychology, Ag rı _Ibrahim Çeçen University, Ag
rı, Turkey; bDepartment Neuroscience, Psychology and Behaviour,
University of Leicester, Leicester, United Kingdom; cDepartment of Sociology, Ag rı _Ibrahim Çeçen University, Ag
rı, Turkey

ABSTRACT
This study tested whether the levels of coronavirus disease-2019 (COVID-19) severity, self-
efficacy, knowledge, and preventive behaviors predicted mental health. Participants were
3190 Turkish adults (50% women; M age ¼ 38.76, SD ¼ 10.43 years) who completed online
self-reported questionnaires. Most participants (55.11–64.42%) had inadequate knowledge
about COVID-19 and were highly engaged in preventive behaviors. COVID-19-related sever-
ity, self-efficacy, and preventive behaviors correlated with mental health. Regression analysis
showed that COVID-19 severity, self-efficacy, and preventive behaviors uniquely predicted
mental health over and above gender, age, and chronic diseases. Findings may underscore
the development of interventions aiming to improve mental health of individuals dur-
ing pandemic.

The novel coronavirus disease-2019 (COVID-19) has measures taken to reduce the negativity associated
been characterized as the first pandemic that caused with the virus, recent evidence suggests adverse psy-
by a coronavirus family virus and gained intense chological impacts of those measures on people’s
attention globally. Due to fast transmission pattern of mental health. This impact can be observed in differ-
this highly contagious disease, the incidence and mor- ent population groups such as patients infected with
tality rates are rapidly growing worldwide (Guan COVID-19, suspected cases, families and friends of
et al., 2020). As of 21 June 2020, over 8.8 million affected persons, health professionals caring for
laboratory-confirmed cases and more than 465.000 infected people, and the general public (Xiang et al.,
deaths with COVID-19 have been documented glo- 2020). Certain types of factors associated with the
bally (Center for Systems Science and Engineering, virus can increase the levels of mental health prob-
2020). With the rapid spread of COVID-19 outbreak, lems. For instance, bodily sensations (i.e. fever, cough-
people have been highly concerned by its spread, ing, vomiting, and shortness of breath), mandatory
severity, and tremendous negative effects on the pub- contact tracing, and 14 days’ quarantine could exacer-
lic health and society. Accordingly, it is necessary to bate psychological stress among people (Xiang et al.,
identify the psychological and behavioral factors asso- 2020). In their review study, Brooks et al. (2020)
ciated with mental health of individuals during documented available evidence about the impact of
COVID-19 pandemic. Here we aimed to investigate COVID-19-related measures on psychological health
the role of COVID-19-related severity, self-efficacy, of individuals. They found that such measures signifi-
knowledge, and preventive behaviors in the prediction cantly affect the experience of various mental health
of mental health during pandemic. problems including fear, anxiety, nervousness, bore-
With the advent of COVID-19, a wide range of dom, distress, depression, anger, indecisiveness, and
measures including self-isolation, mass quarantine, suicide ideation. Another study reported that patients
travel restriction, lock-down, and establishment of iso- with confirmed or suspected virus infection experience
lation units and hospitals have been implemented emotional trauma associated with the diagnosis, treat-
quickly to prevent the COVID-19 containment and ment, and prognosis resulting in provoking fear, anx-
mitigation across the globe (Rubin & Wessely, 2020; iety, depression, and insomnia (Lai et al., 2020; Lee
Xiang et al., 2020; Yıldırım et al., 2020). Despite all et al., 2007).

CONTACT Murat Yıldırım [email protected] rı _Ibrahim Çeçen University, Erzurum Yolu 4 Km 04100,
Department of Psychology, Ag
rı, Turkey.
Ag
ß 2020 Taylor & Francis Group, LLC
2 M. YILDIRIM AND A. GÜLER

Early knowledge and heightened awareness of the requires not only skills but also a strong belief in one’s
public is pivotal to cope with mental health problems ability to exert control over motivations and behaviors.
during outbreaks. Having adequate knowledge during People’s beliefs about their capabilities have direct
pandemics, people may perceive themselves at risk of influence on what they do, how much exertion they
infection which may in turn lead them to engage in push, and how long they resist to take precautionary
preventive behavior and eventually protect their men- actions (Bandura, 1990). Self-efficacy affects how people
tal health (Brug et al., 2004; Sadique et al., 2007; fell, think, and act regarding risk-taking behaviors
Yıldırım et al., 2020). Using various means of infor- (Wong & Yang, 2020). Previous research has reported
mation such as newspapers, TV, and government offi- significant associations between self-efficacy and mental
cials effectively are key to increase the public’s health (Abdel-Khalek & Lester, 2017; Hu et al., 2020),
awareness about infection and its consequences (van well-being (Fu et al., 2018; Yuksel et al., 2019). Existing
der Weerd et al., 2011). The knowledge about studies suggest that direct experience to outbreak
COVID-19 includes but not limited to the routes of increases self-efficacy, which in turn leads to engage-
transmission, risk and severity of infection, details on ment in precautionary actions (de Zwart et al., 2009).
symptoms, availability and effectiveness of vaccines Moreover, research showed that self-efficacy is an
for COVID-19, updates on confirmed cases and death, important element in promoting health-related inten-
potential treatment for infection, advise on preven- tions and behaviors (Sheeran et al., 2016).
tion, overseas experience in handling COVID-19, and Despite the recognition of increased mental health
information on outbreak in local area (Wang et al., problems during COVID-19 pandemic, very little is
2020). Recent studies documented that lack of know- known about related factors, including severity, self-
ledge about pandemic can worsen mental health by efficacy, knowledge, and preventive behaviours. To the
increasing stress, depression, and anxiety (Du et al., best of our knowledge, no earlier research has
2020; Wang et al., 2020). Having poor knowledge and addressed the associations between the COVID-19-
erroneous beliefs spreading by media such as related severity, self-efficacy, knowledge, preventive
“overwhelmed hospital,” “panic in epicentre” and behaviors, and mental health. Therefore, the aim of
“epidemic rumours” can influence mental health this study was to examine the associations between
adversely (Rosling & Rosling, 2003; Rubin & Wessely, COVID-19-related severity, self-efficacy, knowledge,
2020). Literature also suggests that mental health is preventive behaviors, and mental health among
related with information present about COVID-19 as Turkish adults when controlled for age, gender, and
false information can increase mental health problems medical conditions. In the light of this aim, we
(Wang et al., 2020). hypothesized that the severity, self-efficacy, knowledge,
The perceived threat of COVID-19 is expected to and preventive behaviors would uniquely predict men-
have a significant positive impact on preventive tal health over and above the effects of age, gender,
behaviors and mental health as it triggers people to and medical conditions.
prevent themselves against threats (Mukhtar, 2020).
People take necessary actions to engage in preventive Method
behaviors if they perceive high risk and severity of
diseases (Bandura, 1990), which can be heightened by Participants
increasing number of confirmed cases and deaths, The sample was composed of 3190 Turkish adults
rumors, and, strangeness. In this context, protection (50% males). They aged between 18 and 80 years with
motivation theory posits that public perception about a mean of 38.76 years (SD ¼ 10.43). Most of the par-
severity of disease is influenced by its physical damage ticipants were married (64.63%), university graduates
to health (Rogers, 1975). Moreover, ever-spreading (39.66%), without any chronic disease (81.47%), living
rumors, including downplayed or exacerbated, about with three or four people (53.19%), and living in city
the severity of disease are likely to affect psychological center (81.85%). Detailed participants’ demographic
health adversely (Roy et al., 2020). Previous research information is presented in Table 1.
showed that higher level of severity is related with
lack of knowledge about diseases causing decreased
Measures
mental health outcomes (de Zwart et al., 2009).
Self-efficacy is a general concept referring to the Knowledge
extent to which people believe they have the compe- Knowledge about COVID-19 was assessed with four
tency to cope with tasks or stressors (Bandura, 2006). It questions as presented in Table 2. Four questions
 DEATH STUDIES 3

Table 1. Participant characteristics (N ¼ 3190).

Variable Group n %
Gender Male 1595 50.00
Female 1595 50.00
Marital status Married 2068 64.83
Single 956 29.97
Widowed/separated 166 5.20
Living place City center 2611 81.85
County 485 15.20
Municipality 45 1.41
Village/town 49 1.54
Highest level of education High school and below 166 5.20
University 1265 39.66
Master 727 22.79
PhD 1032 32.35
Household member including you Living alone 380 11.91
2 585 18.34
3 853 26.74
4 845 26.49
5 or more 461 14.45
Unanswered 66 2.07
Having a chronic disease (e.g. diabetes, asthma) Yes 591 18.53
No 2599 81.47

Table 2. Knowledge about COVID-19.

Questions Answer n %
Have you ever heard about the COVID-19? Yes 1135 35.58
No 2055 64.42
Have you known what the COVID-19 is? Yes 1432 44.89
No 1758 55.11
Have you known the causes of COVID-19? Yes 1272 39.87
No 1918 60.13
Have you known the death rate for people infected by the COVID-19? Yes 1367 42.85
No 1823 57.15

were adopted from the Severe Acute Respiratory all to 10 ¼ very serious. A higher score refers to
Syndrome (SARS) Knowledge Questionnaire used by greater severity associated with COVID-19.
Brug et al. (2004). Each question was answered using
yes (1) or no (0) format. We computed a total Self-efficacy
COVID-19-related knowledge score by summing the A single item was used to assess the levels of self-effi-
correct answers to the questions ranging between 0 cacy related to COVID-19: “How confident are you
and 4. A higher score indicates greater knowledge that you can prevent getting COVID-19 in case of an
about COVID-19. outbreak” (de Zwart et al., 2009). The item was scored
by using a Likert-type response scale ranging from
1 ¼ not confident to 5 ¼ very confident. A higher
Preventive behaviors
score reflects higher self-efficacy
We assessed COVID-19 related preventive behaviors
by adapting items from the study of Brug et al. (2004)
Mental health
who assessed SARS-related precautionary behaviors.
A single item was used to assess the mental health of
There were 16 items scored by using a Likert-type
participants: “In general, would you say your mental
response scale ranging from 1 ¼ never to 5 ¼ always.
health is?” (Ahmad et al., 2014). The item was
A higher score presents greater engagement in pre-
answered by using a Likert-type response scale rang-
ventive behaviors against COVID-19.
ing from 1 ¼ poor to 5 ¼ excellent. A higher score
indicates better mental health.
Severity
A single item was used to measure the levels of sever-
Procedure
ity related to COVID-19: “How serious would it be
for you if you contract COVID-19 in the next year?” A university Ethics Committee approved the research
(de Zwart et al., 2009). The item was scored by using protocol of this study. Participants were recruited
a Likert-type response scale ranging from 1 ¼ not at through email and social networking sites.
4 M. YILDIRIM AND A. GÜLER

All potential participants were provided information Table 3. Descriptive statistics for each preventive behavior
about the study. They were fully informed regarding against COVID-19.
their rights to withdraw from the study at any time Preventive behaviors Min Max Mean SD
1. Wore a mask 1 5 4.74 0.72
point, anonymity and confidentiality of their answers. 2. Avoided travel on subways or buses 1 5 4.72 0.78
Participants were then asked to give their consent, 3. Avoided large gatherings of people 1 5 4.65 0.65
which was presented on the first page of online sur- 4. Avoided travel to COVID-19-infected areas 1 5 4.61 0.83
5. Took an herbal supplement 1 5 4.59 0.70
vey. Those who gave their consent were allowed to 6. Ate a balanced diet 1 5 4.58 0.99
complete a variety of web-based survey. Participants 7. Used disinfectants 1 5 4.58 0.70
8. Avoided travel by taxis 1 5 4.55 0.99
did not receive any financial compensation for their 9. Avoided shaking hands 1 5 4.47 1.02
involvement in the study. The data used in this study 10. Made sure to get sufficient sleep 1 5 4.30 0.94
11. Were more attentive to cleanliness 1 5 4.27 0.98
were part of a larger project aimed at investigating the 12. Avoided particular types of people 1 5 4.05 0.93
psychological impacts of COVID-19 on the psycho- 13. Washed hands more often 1 5 3.87 1.26
14. Exercised regularly 1 5 3.84 1.06
logical health of the general public in Turkey. 15. Avoided eating in “food centers” 1 5 2.92 1.45
16. Avoided eating in restaurants 1 5 2.81 1.23

Data analysis
preventive behaviors, wearing a mask, avoiding public
Data analysis included two sequential stages. The transportation, and avoiding public gathering were the
main descriptive statistics and Pearson correlation most frequently practiced preventive behaviors while
were first computed. Second, a hierarchical regression avoiding eating in restaurant and food centers, and
analysis was performed. We tested multivariate out- exercising regularly were the least.
liers by using Mahalanobis’ distance (p < 0.001) for all
variables. The analysis did not produce any multivari-
ate extreme values thereby no case was removed from Correlation matrix
the sample. We then explored the distribution of uni- The Pearson correlation matrix is presented in
variate variables by computing skewness and kurtosis Table 4. Females were more likely to report higher
statistics. Except for the kurtosis value of preventive levels of perceived severity of the infection and
behaviors, which can also be considered as acceptable, engagement in preventive behaviors. People with
none of the variables presented extreme skewness and chronic diseases were also more likely to report higher
kurtosis values falling outside the proposed threshold levels of severity, knowledge, and mental health, and
values of ±2, suggesting a normal distribution for the low levels of self-efficacy. Severity was negatively sig-
variables of interest (George, 2010). Data were ana- nificantly correlated with self-efficacy, knowledge, and
lyzed using the Statistical Package for the Social mental health, and positively significantly correlated
Sciences (SPSS) software program, version 24.0. with preventive behaviors. Self-efficacy was positively
significantly correlated with knowledge, preventive
Results behaviors, and mental health. Preventive behavior was
positively significantly correlated with mental health.
Knowledge about COVID-19 Knowledge was not correlated with preventive behav-
The frequency of participants’ knowledge about iors and mental health and consequently removed
COVID-19 is presented in Table 2. Approximately from the regression analysis.
two-thirds (64.4%) of the participants said they had
never heard about COVID-19. More than 55% of the Hierarchical regression analysis
participants have not known what COVID-19 is. Also,
most participants (60.1%) reported that they have not The results of hierarchical multiple regression analysis
known the causes of COVID-19. Furthermore, partici- are presented in Table 5. In the regression analysis,
pants (57.2%) were largely unaware of the death rate gender, chronic disease, and age were controlled in
for people infected by the virus. Step 1. Here, age and chronic disease showed statis-
tical significance in predicting mental health by
explaining 8% of the variance. Younger and healthy
Preventive behaviors against COVID-19
people account for variance in mental health. In Step
The frequency of participants’ engagement in prevent- 2, inclusion of the severity, self-efficacy, and prevent-
ive behaviors against COVID-19 is reported in ive behaviors caused a statistically significant change
Table 3. Although participants largely engaged in all in R2 in mental health (DR ¼ 0.9, p < 0.001). Severity
 DEATH STUDIES 5

Table 4. Descriptive statistics and correlations between variables (N ¼ 3190).

Variable Mean SD Skewness Kurtosis 1. 2. 3. 4. 5. 6. 7. 8.
1. Gender – – – – 1 –0.01 –0.21 0.10 0.03 –0.03 0.19 –0.01
2. Chronic disease – – – – 1 –0.12 –0.06 0.04 –0.07 –0.04 0.28
3. Age 38.76 10.43 0.36 –0.27 1 0.08 –0.08 –0.04 –0.01 –0.10
4. Severity 8.12 2.15 –1.13 0.73 1 –0.09 –0.11 0.22 –0.15
5. Self-efficacy 2.87 0.60 –0.78 1.79 1 0.05 0.18 0.24
6. Knowledge 1.63 1.68 0.30 –1.63 1 –0.00 0.00
7. Preventive behaviors 75.79 9.09 –1.65 5.40 1 0.16
8. Mental health 4.01 0.64 –0.31 0.53 1
p < 0.01; p < 0.05.

Table 5. Results of hierarchical regression analysis predicting mental health (N ¼ 3190).

Predictor B SE b t p
Step 1 F(3,3189) ¼ 95.48, r ¼ 0.29, r2 ¼ 0.08, p < 0.001
Gender –0.02 0.02 –0.02 –0.87 0.38
Age 0.00 0.00 –0.06 –3.71 0.00
Chronic disease 0.45 0.03 0.27 15.89 0.00
Step 2 F(6,3189) ¼107.53, r ¼ 0.41, r ¼ 0.17, Dr2 ¼ 0.09, p < 0.001
Severity –0.04 0.00 –0.15 –8.71 0.00
Self-efficacy 0.19 0.02 0.18 10.67 0.00
Preventive behaviors 0.01 0.00 0.17 9.97 0.00

negatively accounts for unique variance in mental mainly engaged in preventive behaviors to protect
health, while self-efficacy and preventive behaviors themselves from the virus. The most frequently
positively account for unique variance in men- practiced preventive behaviors included wearing a
tal health. mask, avoiding public transportation, and avoiding
public gathering. These results are consistent with
recently reported findings on preventive behaviors
Discussion
against COVID-19. For example, Yıldırım et al.
In this study, we investigated the associations between (2020) reported that avoiding public transportation
the COVID-19 related severity, self-efficacy, know- and frequent handwashing were among the most
ledge, preventive behaviors, and mental health among practiced preventive behaviors against COVID-19
a representative sample of general public in Turkey. among Turkish population.
As predicted, all the main study variables were signifi- We found that high levels of COVID-19-related
cantly associated with mental health severity, self-efficacy, and preventive behaviors could
except knowledge. predict a significant amount of variance in mental
The results showed that participants health over and above the effects of age, gender, and
(55.11–64.42%) had a lack of knowledge about chronic diseases. These results suggest that people
COVID-19. Given that the data collection was under- who have low perceived severity and high self-efficacy
taken during the initial stage of COVID-19 in Turkey, and engagement in preventive behaviors against
this result is indeed expected. This is in the line with COVID-19 have better mental health during times of
previous findings where healthcare workers reported crisis. Although these results require further investiga-
inadequate knowledge and attitudes about the previ- tions by considering the role of other variables that
ous infectious diseases of SARS and the Middle East may influence the relationship between the measured
respiratory syndrome (MERS; Althomairy et al., 2018; variables and mental health, it is fruitful in terms of
Deng et al., 2006). People also reported greater sever- filling the gap in the relevant literature. Only few
ity and lower self-efficacy related to COVID-19. This studies examined the relationship between severity,
shows that participants believed that it would be very self-efficacy, and mental health in the context of
serious for them if they contract COVID-19 and they COVID-19. Higher severity, and lower self-efficacy
also believed that their ability or capability is inad- were found to be related with poor mental health
equate to cope with the virus. Earlier works have (Yıldırım & G€ uler, 2020). Another study found a
reported that high self-efficacy can play a critical role negative relationship between general self-efficacy and
in promoting personal performance in the face of psychological distress during COVID-19 pandemic
adversity (Amini & Noroozi, 2018). (Shacham et al., 2020).
With regard to the preventive behaviors against The results of this study have important implica-
COVID-19, the findings showed that participants tions for research and practice. Our study is one of
6 M. YILDIRIM AND A. GÜLER

the first studies investigating the roles of perceived suggest that the levels of severity, self-efficacy, and
severity, self-efficacy, and preventive behaviors in pre- preventive behaviors related to COVID-19 are associ-
dicting mental health. The documented findings will ated with mental health above and beyond the effects
shed lights on psychological factors contributing to of demographic variables and health conditions. These
mental health. People should be informed about the findings along with the findings of previous studies
potential risk of COVID-19 through mass media to can help in developing and tailoring of interventions
increase their awareness about the virus. The results to enhance mental health of individuals.
of this study suggest that perceived severity and self-
efficacy were significant predictors of mental health.
Ethical approval
Mental health professionals may develop and imple-
ment online interventions aimed at improving the All procedures performed in studies involving human par-
individuals’ ability to deal with stressors during adver- ticipants were in accordance with the ethical standards of
the institutional and/or national research committee and
sity and reduce their perception of excessive severity with the 1964 Helsinki declaration and its later amendments
of any potential threats which have an adverse effect or comparable ethical standards. Consent was obtained
on mental health. Furthermore, our study identified _
from all participants included in the study. Agrı Ibrahim
preventive behaviors may be of importance in devel- Çeçen University Ethics Committee approved the
oping the level of mental health. Therefore, individu- study protocol.
als’ engagement in preventive behaviors and its
improvement by various strategies can be useful in Acknowledgment
terms of contributing to mental health.
We would like to thank all participants who contributed to
This study includes several basic limitations that
this study.
need to be acknowledged and addressed in future
studies. The most important limitation of this study
was the assessment of study variables (e.g. COVID- Disclosure statement
19-related severity, self-efficacy, mental health) by No potential conflict of interest was reported by
employing a single-item scale. Indeed, assessing men- the author(s).
tal health of individuals using a single-item scale for
providing general health indicators is commonly used
Author contributions
in epidemiological studies for the reduction of
respondents’ burden. Future studies should assess MY and AG contributed to the conception and design of
those variables by using multiple-item scales to pre- the study. MY and AG contributed to the acquisition of
data. MY contributed to the analysis and reporting of data.
sent more solid evidence regarding the predictive val- MY drafted the manuscript. Both authors approved the final
idity of psychological outcomes. Second, this study version of the manuscript.
was conducted using online survey. Thus, those with-
out internet access could not have been participated
in the study. Third, the data collection was exclusively ORCID
relied on participants’ self-report. Self-report measures Murat Yıldırım http://orcid.org/0000-0003-1089-1380
may lead to limitations due to certain types of biases Abdurrahim G€ uler http://orcid.org/0000-0002-0317-8221
including social desirability and introspective ability.
Finally, the data were cross-sectional, and conse- References
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