Psychosocial indicators of individual behavior during COVID-19: Delphi approach

The study addresses the inconsistent effectiveness of COVID-19 control measures in Arab countries despite extensive policies and enforcement. It argues that early prevention strategies largely ignored individual social and psychological characteristics, applying one-size-fits-all policies and underestimating factors like social pressures, rumors, fear, and anxiety. The research gap identified is the absence of a combined exploration of social and psychological indicators predicting preventive behaviors. The main research question is: Which psychosocial indicators in Arab countries contribute to individual adherence to preventive behavior during COVID-19? The study’s importance lies in informing decision-makers about psychosocial determinants that can improve adherence to health guidelines during pandemics.

Theoretical framework integrates health behavior theories to explain preventive behavior: (1) Health Belief Model emphasizes perceived susceptibility and severity, benefits, barriers, cues to action, and self-efficacy as drivers of adherence to measures like masking and distancing. (2) Social Engineering Theory focuses on modifying environments (e.g., curfews, travel bans, temperature checks) to induce positive health behavior, sometimes outperforming individual-level programs. (3) Theory of Planned Behavior posits that behavioral, normative, and control beliefs shape intentions and behavior; during COVID-19, perceived social isolation, fear, and discrimination affected adherence. Contextual factors in Arab countries include shared religious and sociocultural norms, varying economic conditions (high-income Gulf vs. middle/low-income states), and structural barriers (reliance on daily labor, limited social support and internet access). Studies show varying adherence to masking, social distancing, hygiene, and food handling practices across Arab countries, highlighting socio-economic and cultural determinants that may facilitate or hinder compliance.

Design: Two-step qualitative study comprising a scoping review and a multi-round Delphi survey. Scoping review: Non-systematic scoping across international (APA PsycNet, Google Scholar, PubMed) and Arab databases (Dar Al-Mandumah, Al-Manhal) using keywords related to COVID-19, preventive behavior, psychological, social, indicators, health, society. Initial records identified: 3,886 (academic journals n=3359; ebooks n=384; books n=28; magazines n=24; reports n=17). After screening, 250 journal records remained; 149 addressed psychological indicators, 101 social indicators; 28 studies explicitly examined psychosocial indicators. From the literature, 24 psychosocial indicators (12 social, 12 psychological) were formulated for the Delphi instrument. Delphi procedure: Three online rounds conducted via email using a structured questionnaire with 24 items rated on a 1–5 Likert scale (1=Little important to 5=Most important). Consensus criterion: average absolute deviation from the median less than one point on the five-point scale (±10%). Round 1 gathered initial ratings; Round 2 provided feedback summaries to reduce variability; indicators lacking consensus after Round 2 were considered for elimination in Round 3. Panel recruitment: Non-probability sampling of experts in human behavior (≥20 years experience) from nine Arab countries (Saudi Arabia, Egypt, Tunisia, Algeria, Kuwait, Jordan, Yemen, Syria, Sudan). Of 27 invited experts, 19 completed all three rounds. Anonymity and confidentiality were assured; informed consent obtained. Data analysis: Quantitative summaries (average, median, deviation, min-max) assessed consensus strength; qualitative synthesis conducted after each round to minimize bias from individual opinions. Ethics: Approved by NAUSS Standing Committee on Ethics (Decision No. 3/2/20; 22/7/20).

- From the 24 proposed indicators, consensus was achieved after three Delphi rounds on 9 indicators (5 social, 4 psychological). - Social indicators with consensus and average ratings: Belief System (5.0), Income Status (4.9), Family Commitment (4.0), Faith (4.0), Kinship System (3.9). - Psychological indicators with consensus and average ratings: Self-Efficacy (5.0), Perception of Hazard (4.5), Motivation (4.5), Stigma (4.2). - The belief system and self-efficacy received the highest average ratings (5.0). - Consensus was not reached for the remaining indicators, sometimes due to minor rating differences and at other times due to wide variability, indicating areas for further research. - Contextual insights: economic constraints, strong family and kinship ties, and religious beliefs significantly shape adherence; threat perception, motivation, and stigma influence preventive behaviors.

The findings directly address the research question by identifying nine psychosocial indicators that predict adherence to COVID-19 preventive behaviors in Arab contexts. They underscore that both individual psychological determinants (e.g., self-efficacy, risk perception, motivation, stigma) and social determinants (e.g., belief systems, faith, family and kinship ties, economic status) are critical. This supports integrating health behavior theories (HBM, TPB) with culturally informed approaches. The results suggest interventions should be tailored to the Arab sociocultural fabric: leveraging family-based messaging and religious values, addressing economic barriers for low-income groups, and actively countering stigma to improve help-seeking and adherence. The study contributes a region-specific evidence base for designing equitable, inclusive public health strategies that complement structural measures with psychosocial components, potentially increasing compliance and reducing resistance to guidelines.

The study identified and achieved expert consensus on nine psychosocial indicators (five social and four psychological) that influence COVID-19 preventive behaviors in Arab countries, with belief system and self-efficacy rated highest. Using a scoping review to derive indicators and a three-round Delphi process to validate them, the research provides a foundational framework for culturally sensitive pandemic interventions. Since consensus was not reached for all 24 indicators, future research should test and refine these indicators across different pandemics and contexts, incorporate multi-layered community and individual factors, and further develop concepts such as community efficacy to enhance collective responsibility and adherence.

- Delphi method relies on expert judgment, which may introduce instability or variability in ratings despite efforts to assemble an interdisciplinary panel. - The study did not collect or analyze demographic profiles (e.g., age, gender, education) as potential predictors of preventive behavior, limiting generalizability and specificity. - Online data collection, while enabling participation during mobility restrictions, may limit depth of interaction typical of in-person methods. - Some indicators failed to reach consensus, indicating uncertainty about their relative importance and the need for further empirical validation.